It should also be noted that a HIPAA covered entity, including a physician, that uses an electronic record is now required to provide an electronic copy of the record if the patient requests that it be provided electronically. (The cost may be adjusted according to the Consumer Price Index.) Massachusetts law allows physicians not covered by HIPAA to charge a base fee of $15.00 for each request, as well as a copying charge of $0.50 per page for the first 100 pages, and $0.25 per page in excess of 100. The fee may not include the cost associated with searching for and retrieving the records. Under HIPAA a physician may only charge a “reasonable, cost-based fee,” which can only include the cost of copying (including supplies for and labor of copying) and postage, if the records are mailed. If the patient continues to request the entire record, the physician may make it available to either the patient’s attorney, with the patient’s consent, or to another psychotherapist, as designated by the patient. However, if, in the physician’s reasonable judgment, providing the entire medical record would adversely affect the patient’s well-being, the provider may provide a summary of the record.
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Physicians who are providing psychotherapy services should, when appropriate, provide full records to their patients. Physicians not covered by HIPAA must produce medical records in a “timely manner.” The Board has interpreted “timely manner” as being two to three weeks. In the case of a medical emergency or Social Security claims, records should be provided as soon as possible. A physician may extend the time for production once-for an additional 30 days by providing the requestor with a written statement of the reason(s) for the delay and the date by which the physician will produce the records. Under HIPAA a physician has 30 days to provide the patient or the patient’s representative with a copy of the requested medical records however, if the medical records are not maintained or are not accessible on-site, then a physician has 60 days to provide the records. Patients are entitled to a copy of their complete records, including records transferred from previous physicians. Health care providers must provide patients, upon request, with an opportunity to inspect their records, receive a copy of their records, or receive a copy of any previously completed report required for third party reimbursement. The records can be requested by a patient, the patient’s parent (if a minor) or legal guardian, or, with patient authorization, by another physician or any person authorized by the patient. Patients often assume that the original record belongs to them since the information in the medical record is about them however, the Board requires that a physician maintain the original to ensure that a patient’s medical history will be available to assist any future health care provider. A patient is entitled to inspect or receive a copy of his or her medical record, not the original.
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