By law, you have the right to correct most errors you find in your medical records. Those corrections are referred to in the law as "amendments." The records themselves are called a "designated record set."
In particular, as medical records are transferred from paper to digital, electronic records, there are any number of mistakes that are being made. Your review and correction is definitely warranted.
1. Determine exactly what the error is and whether it needs correcting. Sometimes errors are simply typographical and may or may not require correction. However, any piece of information that will have an effect on your diagnosis, treatment, or ability to be contacted, whether it can affect you or your health today or in the future, should be corrected. Further, problems with medical identity theft are on the rise, so information that regards payment, billing or your personal identity should be corrected.
Here are some examples:
- If any medical test results, symptoms or treatment decisions are recorded incorrectly, they should be corrected immediately. Your care and future health could hinge on their accuracy.
- If your phone number is incorrect, you'll want to make sure it gets corrected immediately. Failure to do so will result in the wrong information being replicated.
- If the record says your appointment was at 2 p.m., but you never saw the doctor until 3:30 p.m., that may not have any bearing on your future health or billing information needs.
- If your doctor met with you for 45 minutes, but only a 10 minute appointment is recorded, then it probably does not need to be corrected. That would be up to the provider's office to correct. But if you had a 10 minute appointment, and a longer time period has been recorded, it may affect your billing and the amount of money you will have to pay. In that case, you may want to consider requesting an amendment to the record.
2. Contact the provider's or payer's office to ask if they have a form they require for making amendments to your medical records. If so, ask them to email, fax or postal mail a copy to you.
3. Make a copy of the record page(s) where the error(s) occur. If it's a simple correction, then you can strike one line through the incorrect information, and handwrite the correction. By doing it this way, the person in the provider's office will find it most easily and be able to correct it most easily. If they sent you a form to fill out, you may staple this copy to the form.
4. If the correction is more involved, you may need to write a letter outlining why you think it is wrong and what the correction is. If you do write a letter, make sure you include some basics, such as your name and the date of service in your letter, then staple your letter to the copy of the page that contains the error. Be concise, and write the correction exactly as you think it should be noted. The idea is to make it very easy for the provider's records person to amend your records.
5. Make a copy of each page you have put together to send to the provider: the form they sent you, any letters you have written, and any page you have written on. Mail, fax or deliver your amendment request in person.
What Happens Next?
The provider or facility must act on your request within 60 days, but may extend up to 30 days if they provide a reason to you in writing.
They are not required to make the change you request. In many cases, they will, because it will benefit both you and the provider. However, if they believe your request does not have merit, they can refuse to make the amendment. They must notify you of their decision in writing.
If they have refused to amend your records as per your request, you may submit a formal, written disagreement which must be added to your file.
If you feel as if your privacy has been violated during the process of requesting an amendment, the federal government provides a procedure for making a formal complaint on the U.S. Department of Health and Human Services website.
Correcting Records Kept by The Medical Information Bureau (MIB)
The Medical Information Bureau is an organization that supplies information to health insurers, life insurers, and other entities which have interest in a combination of your health information and credit information.
To correct your MIB records, follow the procedure they have outlined on their website. While it is basically the same procedure outlined above, their terminology is different, and they do provide phone numbers.