Medical records are the complete and detailed account of a patient’s health history, serving as the primary communication tool among all healthcare providers. Accurate documentation ensures continuity of care, meaning every provider involved has a clear understanding of past diagnoses, treatments, and medications. When records contain incomplete or incorrect information, it can lead to medical errors, such as receiving inappropriate treatment or an incorrect medication dosage, directly impacting patient safety. A formal, legal process exists to ensure these essential documents are corrected to reflect the truth of your health status.
Understanding the Right to Request Amendment
Patients have a legal right to request an amendment to their protected health information (PHI) if they believe it is inaccurate or incomplete. This right is codified under the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule, which gives individuals control over the integrity of their data. The request applies to the “designated record set,” which generally includes medical and billing records used by a provider or health plan to make decisions about a person. Covered information typically includes diagnosis and procedure entries, laboratory results, medication lists, and demographic details.
The right to request an amendment mandates that the provider must formally review the request, but it does not mean every change will be made. This process is intended to correct factual errors, such as an incorrect date of service, a wrong dosage amount, or a mistaken allergy listed in the record. The amendment process is not typically used to challenge a professional opinion or judgment recorded by a clinician, unless that judgment is based on a clear factual error. If the information was created by another healthcare entity, the provider may deny the request and direct you to the original source, unless that originator is no longer available.
Formal Steps for Submitting a Correction Request
The process for initiating a correction begins with identifying the precise location and nature of the error within your health record. You should obtain a copy of your records and clearly mark the specific entry or entries that you believe are incorrect. Identifying the date of service, the clinician who wrote the note, and the specific section or page number will make the review process easier.
The next step is to determine the correct party to contact, which is often the Privacy Officer or the Health Information Management (HIM) department. Providers typically require the request to be submitted in writing, either through a formal letter or by using a specific amendment request form supplied by the facility. This written request must clearly state your full name and date of birth, the exact information you want changed, and the reason why the current entry is inaccurate or incomplete.
You must also include the language you propose as the correction or addition to the record. Providing supporting materials, such as a discharge summary or a lab result that contradicts the record, strengthens your case. Before sending the request, make a complete copy of the entire submission, including the completed form, supporting documentation, and the date you sent it. Retaining this documentation is important for tracking the provider’s adherence to the required response timeline.
Provider Obligations After Receiving the Request
Once the provider receives your written amendment request, they must act on it within a specific time frame. The provider has up to 60 days to complete the review process and inform you of their decision in writing. If the provider determines they cannot complete the review within the initial 60 days, they may take an extension of up to 30 additional days. They must notify you in writing of this extension and provide a reason for the delay before the original 60-day deadline expires.
If the provider accepts your request, they must make the necessary correction or amendment to your record. The provider does not physically erase the original incorrect entry. Instead, they append the amendment or addendum to the record and link it to the original entry. You have the right to request that the provider make reasonable efforts to notify other relevant parties who may have received the incorrect information, such as your health plan or other specialists.
If the provider denies your amendment request, they must provide a written denial notice that clearly explains the reasons for the refusal. The notice must also inform you of your right to submit a written statement of disagreement to be included in your record. This statement, which the provider may impose a reasonable length limit on, then becomes part of your official medical documentation. The provider is required to include your statement of disagreement, or a summary of it, with any future disclosures of the disputed information.