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MEDICAL
RECORDS: Can I See Them or Not?
Author: Lisa Copen
I was to see the surgeon about the broken tendon in my hand and
so was handed a large folder containing my medical records to
take with me to the other side of the hospital. It was the first
time I was pleased to have to wait to see the physician. I
skimmed the records as quickly as I could, shocked at the large
amount of information that I had s condition which was omitted
from the records He had dismissed my most recently complaints of
pain from active rheumatoid arthritis as "likely caused by
stress of breaking up with boyfriend." I now knew where I
stood with this doctor, based on his scrawled inaccurate
descriptions of our visits.
The nurse appeared and witnessed me reading my documents and in
exasperation claimed, "You're not supposed to be reading
that!" grabbing the folder out of my hand.
"They're my records," I said, "I don't understand
why I can't."
"You just can't," she flustered. "It's not
ethical."
She was wrong.
CAN I GET A COPY OF MY MEDICAL RECORDS? Usually. Most states
allow patients to review their medical information, but some
states don't address the issue at all. Some may place
restrictions on the information you can get, for example,
psychiatric information is most difficult to receive.
IS THE INFORMATION MINE? Technically, the documents belong to
whoever made them, but in most cases the information about you
belongs to you. Contact the you State Department of Health to
find out your rights in your state. The number is in your local
yellow pages or at the FDA web site at:
www.fda.gov/oca/sthealth.htm.
Even in states where the law is restrictive or unclear, many
medical providers will provide your records to you anyway,
according to the American Health Information Management
Association, the "keepers" of the nation's health
records. If
you received care in a federal medical facility, you have a
right to access your record under the federal Privacy Act of
1974 (5USC Section 552a).
HOW DO I REQUEST A COPY OF MY RECORDS? Ask your doctor's staff,
hospital records clerk or other appropriate person for a patient
authorization form that allows the release of information. You
can also write a letter, just be sure to include the following
information: + Your full name and date of birth, date of
treatment + Name and address of the person or facility to which
disclosure is to be made + The specific kind and amount of
information to be disclosed, such as laboratory results, X-rays
or the doctor's notes on your chart. + The purpose of the
request, for example, "continuing care" or
"insurance." + Your
signature and the date
IS THERE A CHARGE? It's likely you will be charged $.25 to $.50
per page, however, you can request specific information to help
keep the costs down. Your request cannot be denied even if you
still owe your doctor money for appointments. If you are
collecting them for a third-party, keep a copy for yourself so
you don't have to pay for them in the future.
WHAT IF I DON'T AGREE WITH THE INFORMATION OR AM DENIED ACCESS?
The American Health Information Management Association has a
sample for called "Request for Correction/ Amendment of
Health
Information" that you can complete and file at
http://www.ahima.org/consumer/index.html
. You can also locate
your local state disclosure laws at the Health Privacy Project
at http://www.healthprivacy.org
.
About the author:
Lisa Copen is the founder of Rest Ministries, a Christian
organization that serves people who live with chronic illness or
pain. Living with rheumatoid arthritis and fibromyalgia, she is
a speaker/author and the coordinator of National Invisible
Chronic Illness Awareness Week. Her latest resource, "A
Woman's
Health Resource Journal" has been called, "a
disability lawyer's
dream." http://www.womanshealthjournal.com
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