INDIVIDUAL PATIENT RECORD RIGHTS

Indiana law and federal law (HIPAA) require patient access to and copies of medical records to patients. This is the mirror image of preventing unauthorized disclosure and access. The failure to properly respond to patient requests for medical record copies is one of the fastest growing areas of complaint made about doctors to consumer and medical licensing boards.

Indiana law requires all health records (except mental health records and a few others) be supplied to a patient on written request. This includes copies of patient x-rays, eyeglass and contact prescription information and similar information. For anyone eighteen (18) years and older who provides this request or a written consent for release to a third party, you must release the information. You may only withhold the information if you make a reasonable determination that the information, if released, is likely to be detrimental to the physical or mental health of the patient or is likely to cause the patient harm. A “policy” or simply feeling the patient should not see their records is insufficient. These requests do not apply to inpatient requests.

Copying fees may be charged but cannot exceed the amount set by rule by the Indiana Department of Insurance. This currently allows for a cost of $1 per page (for first 10, 50¢ per pages 11-50 and 25¢ for pages 51+ plus actual postage/mailing costs. A labor fee of $20 and a certification fee of $20 may be charged. You may also charge a $10 expedite fee if you provide the records within two (2) working days of the receipt of a written request. Note that these are the maximum fees and you may charge less or nothing as your business model dictates.

In my experience, patients are extremely irritated by the policy of some medical providers to provide other doctors copies of patient medical records for free but to charge the patient a fee for their own records. I recommend that you carefully review this policy and determine whether the amount recovered from patients justifies the extreme bad will created by such a policy.

HIPAA also requires that patients be given access to their medical records. In addition, HIPAA provides a right to insert information or request correction of information upon patient records.

In general terms, if you comply with Indiana law on patient record requests and in addition, allow patients to make reasonable insertions in their patients records which are then kept in your records and copied and transferred to others upon appropriate request, you will be in general compliance with Indiana and HIPAA patient record release requirements.

HIPAA also requires you to account for all patient record releases so you must keep track and keep reasonable records showing every transmission of the patient medical data whether to a payor for payment purposes or to other physicians, to law enforcement, as a result of a subpoena or as a result of a patient request.

However, there are many conditional requests and exceptions such as inpatient records, mental health records, communicable disease records that require special attention.

This newsletter is edited by Paul Wallace, a member of the American Bar Association Healthcare Law Section who has been representing physicians and healthcare practices for 30 years. Mr. Wallace assists physicians in health practices in contract items, federal legal compliance, creation of practice entities, estate and wealth planning and similar issues.

Please feel free to call if you have any questions about this newsletter or any other matter.