In the United States, the most basic rules governing access to a medical record dictate that only the patient and the healthcare providers directly involved in delivering care have the right to view the record. The patient, however, may grant consent for any person or entity to evaluate the record. The full rules regarding access and security for medical records are set forth under the guidelines of the Health Insurance Portability and Accountability Act (HIPAA). The rules become more complicated in special situations.
A covered entity may disclose records to facilitate treatment, payment, or health care operations, or if we have obtained authorization from the patient. However, when a covered entity discloses any medical information, it must make a reasonable effort to disclose only the minimum necessary information required to achieve its purpose. Whether records are for the patient’s personal use or being released to a third party by the patient, a Medical Release Form must be completed.
Once a Medical Release Form has been properly completed and returned to your provider, please allow 5 to 7 business days to process your request, as the information may not be onsite. Keep in mind, each health care facility in Ohio must maintain records for six (6) years from the date of discharge, documenting the patient’s needs and assessments and services rendered. Please contact the office to confirm your records still exist, if they exceed the legal required timeframe.
WHO OWNS MEDICAL RECORDS?
Medical records are the property of the medical provider (or facility) that prepares them. This includes films and tracings from diagnostic imaging procedures such as X-ray, CT, PET, MRI, ultrasound, etc. The patient has a right to view the originals, and to obtain copies. For a patient to obtain a copy of their record(s), PHS requires a release form to be completed along with a picture ID to be provided.
HOW DO I OBTAIN COPIES OF MY LAB RESULTS?
The health care professional who requested the test be performed is required to provide a copy of the results to the patient, if requested either orally or in writing. When the patient requests his/her lab results, the health care provider should provide the results to the patient within a “reasonable” time period after the results are received by the provider. Depending on the results of the tests, some physicians may want the patient to schedule an appointment to review and discuss the results and any follow-up testing or treatment that might be required. The test results cannot be released by the lab performing the test and must be released by the provider requesting the test(s).
HOW DO I GET MY MEDICAL RECORDS TRANSFERRED FROM MY PREVIOUS DOCTOR?
Transferring records between providers is considered a “professional courtesy” and is not covered by law. Most providers do not charge a fee for transferring records, but the law does not govern this practice so there is nothing to preclude them from charging a copying fee. There is also no time limit on transferring records.
If you want to insure that your new provider receives a copy of your medical records from your previous provider, you can write your previous provider requesting that a copy of your medical records be sent directly to you. When you receive your records, you can provide a copy of those records to any provider you choose. If you select this method, the provider must provide the records within 15 days of receipt of your request.
*NOTE: If requested of, Primary Health Solutions is only responsible for transferring records of Primary Health Solutions files. The patient will be responsible for obtaining previous providers records.
HOW CAN I CORRECT AN ERROR IN MY RECORDS?
The patient can write an “Addendum” to be placed in his or her medical file. The original information will not be removed, but the new information, signed and dated by the patient, will be placed in the file.