Trial lawyers rely on medical records to be accurate. Sometimes, however, a patient will ask to amend medical records. Federal law governs the process to both request and amend medical records.
A patient has a right to request an amendment to a medical record. The written request must be signed and dated. The request should be directed to the provider who created that record. The request must identify the part of the record to be amended and specify how it should be amended.
A provider has a right to decide whether to amend the medical record or not. A provider must either act on the request within 60 days or provide written notice and the reason for the delay.
A provider may agree to amend a record if it is not accurate or complete. A provider who agrees to amend medical records should note in the record, “Per the patient’s request, the record is amended as follows” and then make any appropriate changes. The amendment should be signed and dated. The provider should also try to provide the amendment to others who may have received the pre-amendment records.
If a request is denied, the provider must send a denial written in plain language (not technical medical terms) and:
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