26 April 2012

accessing your medical records

The following was written for posting on a group site where contributors post concerns and comments about psychiatry, psychiatric treatment and the mental health/illness industry [call it as you see it]. Since the subject matter may have a more universal interest, I have co-posted it here as well.

I work as a human rights abuse investigator. Asking for copies of records is part of what I advise clients on as a component of the job. I do not personally have the resources to assist individual case requests between people and specific institutions, but I may be able to help walk you through the process you'll go through to get your records.

Each state has different rules related to seeking records but both state and federal [USA] laws allow for you to get copies of your records. Always ask for them in writing, so to have documentation as to when you made the inquiry.

Agencies and individual treaters may be legally allowed to charge you a per-page copying fee. If you are indigent or in a facility ask a public defender or a legal advocate for assistance in getting the fee waived. I'll talk about legal advocates later in this posting.

If you are writing to an institution, then write directly to Medical Records department. If you are writing to an individual treater, the request goes directly to the treater. Most medical records offices are permitted 30 to 45 days to get the records copied and to you.

You might be required to sign a waiver that states, since you are personally getting copies of the record, that the institution or treater releasing the record is no longer responsible for protecting the confidentiality of the material you obtain from them.

If you want to keep your records as confidential, ask an attorney, a clergy person, or another licensed clinician to obtain them on your behalf. People working in each of those occupations are generally obliged by law to keep confidential any records they obtain about a client or former client.

Every state in the USA has an office of Protection & Advocacy. if you have trouble getting records, you can contact them to help you. To find out where your state's P&A Office is check the links at the NAPAS website [ http://www.napas.org/ ]. NAPAS is the National Disability Rights Network for Protection & Advocacy.

In many states, the only legal limit placed on obtaining your records would be if the treating physician is willing to document ~ in writing ~ that the requesting party is going to become "...an imminent danger to oneself or others or would rapidly deteriorate in their clinical stability...". This is actually a rather tough standard to prove, so it is likely that you would be able to obtain your record.

If you are still in an inpatient setting, you may ask to see your records, but someone will be likely required to sit with you while you look at the chart. This can be handy if you want to seek specific information [clinical assessments and consultation reports, for example] without actually paying to get the record. It may be prudent to ask to see the record, so that you won't be paying for copies of pages that are irrelevant, unreadable or blank.

If you are asking for records related to a lawsuit, an agency or a physician is legally obliged to provide them. again, they still may be permitted to charge a fee for copying and getting them to you.

No comments:

Post a Comment