How can you effectively handle records requests from patients or their representatives?

1 Know the legal requirements

The first step is to familiarize yourself with the legal requirements that apply to your practice and the type of records request you receive. For example, HIPAA gives patients the right to inspect and obtain a copy of their own medical records, as well as request corrections or amendments. However, there are some exceptions, such as psychotherapy notes, information compiled for legal proceedings, or information that may endanger the patient or others. HITECH also gives patients the right to request an electronic copy of their records or have them sent to another person or entity. You should also be aware of any state laws that may impose additional obligations or restrictions on records requests, such as fees, time limits, or consent forms.

2 Verify the identity and authority of the requester

The second step is to verify the identity and authority of the person or entity requesting the records. You should ask for proof of identification, such as a driver's license or passport, and check if they have a valid authorization form signed by the patient or their legal representative. The authorization form should specify the records to be disclosed, the purpose of the disclosure, the recipient of the disclosure, and the expiration date of the authorization. You should also verify if the requester has a legal right to access the records, such as a parent, guardian, spouse, executor, attorney, or court order. If you have any doubts or concerns, you should consult with your supervisor or legal counsel before releasing the records.

3 Respond to the request promptly and accurately

The third step is to respond to the request promptly and accurately. You should acknowledge the request within a reasonable time frame and inform the requester of any fees, delays, or denials that may apply. You should also ensure that you provide the records in the format and manner requested, unless it is impractical or impossible to do so. You should also ensure that you redact or withhold any information that is not authorized or required to be disclosed, such as other patients' names, sensitive diagnoses, or irrelevant details. You should also keep a record of the request and the response, including the date, time, name, address, phone number, email, and fax number of the requester, the records disclosed, and the fees charged.

6 Communicate with the patients and the requesters

The sixth step is to communicate with the patients and the requesters effectively and respectfully. You should inform the patients of their rights and responsibilities regarding their records and encourage them to review and update their records regularly. You should also explain the process and the fees involved in records requests and answer any questions or concerns they may have. You should also communicate with the requesters in a clear, courteous, and professional manner and provide them with the records they need in a timely and accurate fashion. You should also follow up with them to ensure that they are satisfied with the service and the records they received.

7 Here’s what else to consider

This is a space to share examples, stories, or insights that don’t fit into any of the previous sections. What else would you like to add?