How to Correct Errors in Your Medical Records

Mistakes can affect your health care and outcomes

Nurse checking medical records

By law, you have the right to correct 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."

As medical records are transferred from paper to digital in particular, there are any number of mistakes that are being made. Your review and correction are definitely warranted.

The Proper Procedure

Once you have obtained and reviewed your medical records, you'll want to follow this procedure to amend any errors:

Determine the Extent of Correction

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.

Furthermore, problems with medical identity theft are on the rise, so information that regards payment, billing, or your personal identity should, in fact, be corrected.

Here are some scenarios to consider:

  • 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 and an inability to be contacted if needed.
  • 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.

Reach Out

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 mail a copy to you.

Make Copies

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 easily and be able to correct it. If they sent you a form to fill out, you can staple the copy to the form.

Outline the Issues

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 of 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.

Make More Copies

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.

Medical Information Bureau (MIB)

The Medical Information Bureau is an organization that supplies information to health insurers, life insurers, and other entities which have an 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.

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