Did you know a patient has the right to request an amendment to their medical record at no charge to them? Related to the HIPAA Privacy Rule of 2001, patients may make such a request.
As a provider, you can require the patient give a written request for the amendment. For documentation purposes the request should provide a reason the request for amendment is being made. It is then up to the provider to accept or decline the request within 60 days. If the provider needs more time, it could be extended for another 30 days. After a decision has been made, the patient must be notified of the outcome.
If the request is accepted, then the medical recorded must updated. Providers cannot delete anything from the medical record; only an amendment to the record can be made. Providers could also be penalized if there is any retaliation against the patient because of the request. It is important to send amended medical records to any providers that may be caring for the patient. Insurance companies could possibly need to be informed as well.
If the request is declined, the patient must be provided with a timely explanation and it must be in plain language. In the explanation, the patient must be given an option to submit a statement of disagreement. Along with the disagreement statement, the patient must also be given the appropriate phone numbers to call to express a complaint. The provider also may give the patient a rebuttal statement.
It is critical that the request of recordkeeping is kept. By ignoring the record amendment request, the provider will be in violation of HIPAA regulations. It is important for practices to have a policy for amendment requests.
KRHIO can provide support if your practice needs assistance understanding HIPAA regulations or requests. Contact us for more information.
Resources: AAPC Business Monthly December 2017