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Patient Medical Records Requests

Wondering what to do if a patient requests their medical records? Here's help!

Patients have the right to access their healthcare records, with only a few exceptions. If you receive a request for medical records from a patient, don't panic - and don't alter your records. With all requests for records, you are encouraged to check with a local attorney or the state dental association to understand your state's requirements. Below we have provided some general guidance on how to handle patient requests for medical records.

There can be many reasons for a patient to request their records. Regardless of the reason, it is crucial to give the request the necessary time and attention as required by state and federal laws. If a patient or their attorney with their signed "authorization" (or any other third party with a signed authorization) requests records, you must provide the complete record typically within 30 days. However, original records should never be released, except when required by court order, subpoena, or a government agency; true, exact, and accurate copies of dental files should be made and released to the patient.

Please review the information below to learn more about handling patient records requests.

Should I require patient records requests to be in writing?
Yes.
How should I send the records?
It is important to always verify the receiver and their address before sending any information. If the information is being sent on paper, it should be sent via certified mail with a return receipt requested. If you maintain electronic health records, you can provide a readable electronic copy on a USB drive or any other electronic medium.
Can I send the records via email?
It is generally recommended that a copy of the records be mailed using certified mail with a return receipt requested or any “traceable” shipping method, for instance, UPS, FedEx, or USPS Priority Mail. However, if a patient requests that their information be sent via email, but end-to-end encryption cannot be guaranteed, you must inform the patient about the lack of encryption and the potential risks. If the patient still wishes to proceed with email transmission, you must comply with their request.
Is it necessary to obtain explicit permission (authorization) from the patient for every transfer of their medical records?
In general, dental records can only be released with the patient's authorization, except when the patient requests their own records. However, some states may require the use of their approved authorization form. It's recommended to check with your local attorney or the state dental association regarding this matter.

There are two exceptions where authorization is not required. The first is when the records are sent to another healthcare provider for treatment purposes, and the second is when the records are sent to an insurance company for payment processing. However, it's important to only release the minimum necessary information for the intended purpose. It's also worth noting that some states may have specific requirements in this area, so it's best to consult with your local attorney or your state dental association.
How should I document the process of sending the records?
Keep a record of where and to whom the records were sent and copies of all authorizations.
Can I withhold the records if the patient has an outstanding balance?
We advise NO, despite what your state’s statutes may say.
What should I do if I receive a request with the proper authorization from an attorney, a subpoena, or a government agency?
To ensure compliance with the request, please contact DentistCare, A ProAssurance Program. We will provide guidance and assistance throughout the process.
Can I make changes to records after receiving a records request, such as amendments, additions, or redactions?
Our advice is NO, even if they are incomplete, have inaccuracies, or irreverent or subjective comments. 
May I share medical records with a family member or legal guardian of a patient?
Yes, if prior authorization has been provided. If not, then state law determines who is authorized to act as a personal representative, legal guardian, or parent for an incompetent adult or minor. Seeking advice from a local attorney is strongly recommended in such cases.
What if a patient's dental record contains sensitive information, such as their HIV status, mental health conditions, or substance abuse history?
It is recommended to seek advice from a local attorney before releasing any such information.
Can I charge to copy and transmit records?
State and federal laws generally outline this information, but for specific guidance, we suggest contacting a local attorney or the state dental association.

Disclaimer: The information contained on this page does not constitute legal advice, it is for general informational purposes only and is prepared from a risk management perspective to aid in reducing professional liability exposure. You are encouraged to consult with your personal attorney for legal advice, as specific legal requirements may vary from state to state. Specific states and licensing boards may have stricter requirements.