Dr refuses to give me copy of my full medical records. Help!

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Latest post 07-04-2011 9:46 AM by ClydesMom. 16 replies.
  • 07-03-2011 10:49 AM

    • Johntr7
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    Dr refuses to give me copy of my full medical records. Help!

    The doctor, a psychologist, gave me a report explaing my scores but not a full report including the scores I obtained during the evaluation. She says that I am not qualified to interpret them. She also says that by law she is not allowed to release them to patients. I called an attorney and he says that the Dr is violating the law by not releasing the full records, since they are not part of her personal notes and whether I can interpret them or not is not her problem.

    A random lawyer I contacted offered to write a letter to the Dr. explaining the law to her, for the amount of $500, but I would rather not spend that amount of money on a letter that might or might not yield the desired results.

    Is it possible to sue because of a violation of hipaa law? Do I need to call the federal/state agency in charge of hipaa and ask them how to proceed? Or do I just need to file a complaint with the APA/licensure board? And will a complaint with these boards actually help me obtain the full records?

    Also, I already talked to the person in charge of the clinic but he says that the doctor in question is sort of like a contractor who shows up to do testing and her records are her records.

    Can someone offer me some guidance?

     

    By the way, if I end up suing or paying a laywer to intervene, can I sue the Dr for the amount of money I wasted on lawyers?

  • 07-03-2011 12:05 PM In reply to

    Re: Dr refuses to give me copy of my full medical records. Help!

    Johntr7:
    I called an attorney and he says that the Dr is violating the law by not releasing the full records

    Call the attorney back and ask him for the statute number.

    Then you can look it up and write your own letter, quoting the statute.

    You can also file a complaint with whatever state agency licenses her. But read the statute first.

    • The right of the people 
    • to keep and bear arms,
    • shall not be infringed.
  • 07-03-2011 2:36 PM In reply to

    • DOCAR
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    Re: Dr refuses to give me copy of my full medical records. Help!

    Is it pissible to sue because of a violation of hipaa law?

    No, even if the law applied in this situation, there is no private cause of action under hipaa.

    Can I sue the Dr. for the amount of money I wasted on lawyers?

    No.  besides, if the lawyer got you the result you were seeking, it was not wasted.

  • 07-03-2011 2:53 PM In reply to

    Re: Dr refuses to give me copy of my full medical records. Help!

    I don't believe HIPAA applies here.  That is normally about releases of medical information outside the requirements.  You have a refusal to release the records.

    Contact the agency in your state that regulates this profession and ask that agency what rights you may have.  At a minimum they might refer you to the proper law or another agency.

     

  • 07-03-2011 3:16 PM In reply to

    • cbg
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    Re: Dr refuses to give me copy of my full medical records. Help!

    I am absolutely not an expert in this area so feel free to correct me if I am wrong. But I seem to remember there being something that exempts psychological information from the law that requires a medical professional to release records to the patient. IF I am right, and I am not saying that I am (ClydesMom may know) then the doctor is, in this particular instances, within his/her rights to withhold the info.

  • 07-03-2011 3:52 PM In reply to

    • Drew
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    Re: Dr refuses to give me copy of my full medical records. Help!

    Did you make a written request for same?  Do so.  Samples letters for MA are on line. 

    Mental health records may or may not be a special case in MA.



  • 07-03-2011 6:18 PM In reply to

    • Johntr7
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    Re: Dr refuses to give me copy of my full medical records. Help!

    I haven't made a written request.

     

    Can you show me those "sample letters for MA"?

     

    Also, would it make a difference if I get the letter notarized?

  • 07-03-2011 6:35 PM In reply to

    Re: Dr refuses to give me copy of my full medical records. Help!

    Johntr7:
    A random lawyer I contacted offered to write a letter to the Dr. explaining the law to her, for the amount of $500, but I would rather not spend that amount of money on a letter that might or might not yield the desired results.

    The money would be wasted. That attorney probably had not read the details of HIPAA when he made that offer. While you do have a right to most medical records that a health care provider has about you, that does not extend to "psychotherapy notes." This is explained on the U.S. Department of Health and Human Services (HHS) web page about your medical records. The relevant portion of it states this:

    "You do not have the right to access a provider’s psychotherapy notes.  Psychotherapy notes are notes taken by a mental health professional during a conversation with the patient and kept separate from the patient’s medical and billing records."

    Johntr7:
    Is it possible to sue because of a violation of hipaa law? Do I need to call the federal/state agency in charge of hipaa and ask them how to proceed?

    If there was a violation of HIPAA here, your remedy is to file a complaint to the Civil Rights division of HHS. HIPAA does not provide a civil remedy for you for violations, meaning you cannot sue for money damages.

  • 07-03-2011 7:03 PM In reply to

    • Drew
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    Re: Dr refuses to give me copy of my full medical records. Help!

    Not my area of any compeency---but I'd not agree that test scores are among the Drs personal notes- as to mental health issues---. (I've been on otherside of the coin where mental health professionals failed to observe confidential nature of records under PA state law )

    Also MA has its own laws ((I've not read them) as to medical records and my read is you are entitled to teh more favorable to you of the two.  Mass General laws Section 111 and 112.  Topic discussed at Gerogetown Edu cira 2005.



  • 07-03-2011 8:24 PM In reply to

    Re: Dr refuses to give me copy of my full medical records. Help!

    Drew:
    Not my area of any compeency---but I'd not agree that test scores are among the Drs personal notes- as to mental health issues---.

    That depends on the test done. If the test is an evaluation based on talking with the patient, the exclusion would seem to me to apply.

    Drew:
    Also MA has its own laws ((I've not read them) as to medical records and my read is you are entitled to teh more favorable to you of the two.  Mass General laws Section 111 and 112.  Topic discussed at Gerogetown Edu cira 2005.

    I don't know where you got the idea Massachusetts law even applies. The poster's screen info says he's in California, and so far I see nothing where he's said that this took place in Massachusetts (or any other state than California for that matter).

  • 07-03-2011 9:02 PM In reply to

    • Johntr7
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    Re: Dr refuses to give me copy of my full medical records. Help!

    Taxagent:

    Drew:
    Not my area of any compeency---but I'd not agree that test scores are among the Drs personal notes- as to mental health issues---.

    That depends on the test done. If the test is an evaluation based on talking with the patient, the exclusion would seem to me to apply.

     

    The evaluation was based, for the most part, on talking to me. It wasn't a pen/paper evaluation. However, numerical scores were assigned, since the doctor told me the final score at the end of the evaluation and it's hard to imagine how she would have quantitated that final score without numerical subscores obtained on individual tasks. I want those subscores.

  • 07-04-2011 1:19 AM In reply to

    Re: Dr refuses to give me copy of my full medical records. Help!

    Johntr7:
    The evaluation was based, for the most part, on talking to me. It wasn't a pen/paper evaluation. However, numerical scores were assigned, since the doctor told me the final score at the end of the evaluation and it's hard to imagine how she would have quantitated that final score without numerical subscores obtained on individual tasks. I want those subscores.

    The actual regulation text says that the term "Psychotherapy notes means notes recorded (in any medium) by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session and that are separated from the rest of the individual's medical record. Psychotherapy notes excludes medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: Diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date." 45 C.F.R. § 164.501.

    As the regulation defines the covered material to be notes documenting or analyzing the contents of conversation during a private counseling session, but excludes the "results of clinical tests," it seems to me that where the test is based on talking to you, everything but the final result of the test (which you've been given already) appears to be within the definition of psychotherapy notes. The intermediate subscores seem to me to be part of the analysis that leads to the final test result, and thus those intermediate subscores would be covered as psychotherapy notes.  That's certainly what I'd expect the doctor to argue to HHS if it started enforcement proceedings against the doctor for failing to comply with the rule. It's certainly not crystal clear that you are entitled to this information at any rate. But you can, of course, complain to HHS and see what, if anything, comes of that.

  • 07-04-2011 8:31 AM In reply to

    • Johntr7
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    Re: Dr refuses to give me copy of my full medical records. Help!

    The actual regulation text says that the term "Psychotherapy notes means notes recorded (in any medium) by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session and that are separated from the rest of the individual's medical record. Psychotherapy notes excludes medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: Diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date." 45 C.F.R. § 164.501.

    I didn't receive psychotherapy. I received psychometric testing. It was a one-time meeting. I am not sure why the subscores would be considered part of "psychotherapy notes" since I did not receive counseling or therapy.

  • 07-04-2011 9:22 AM In reply to

    Re: Dr refuses to give me copy of my full medical records. Help!

    There is a time when a mental health care provider is permitted to with hold information and that is when they believe releasing it would be detrimental to the patient.  

    While it says "physician" the same would hold true for a treating clinical psychologist.  I got this information from the Calfornia Medical Board here:  http://www.medbd.ca.gov/consumer/access_records.html

    A physician may refuse a patient's request to see or copy his or her mental health records if the physician determines there is a substantial risk of significant adverse or detrimental consequences to the patient if such access were permitted, subject to the following conditions:

    • The physician must make a written record and include it in the patient's file, noting the date of the request and explaining the physician's reason for refusing to permit inspection or provide copies of the records, including a description of the specific adverse or detrimental consequences to the patient that the physician anticipates would occur if inspection or copying were permitted.
    • The physician must permit inspection or copying of the mental health records by a licensed physician, psychologist, marriage and family therapist, or clinical social worker designated by the patient. These health care providers must not then permit inspection or copying by the patient.
    • The physician must inform the patient of the physician's refusal to permit the patient to inspect or obtain copies of the requested records, and inform the patient of the right to require the physician to permit inspection by, or provide copies to, the health care professionals listed in the paragraph above. The physician must indicate in the mental health records of the patient whether the request was made to provide a copy of the records to another health care professional.

     

    My educated answer in the instance of the OP is that the treating clinician believes that there is no clinical reason to release the scores to the patient and/or that releasing them to the patient presents some reasonable risk of clinical harm.  The OP will need to demonstrate the need for having the information personally and that it presents no harm in releasing it to him and the clinician will be required to do so. 

    The lawyer(s) he consulted were only partially correct on the law. While health care providers are required to release records to a patient, under California law if the provider can provide a documented record that releasing them would cause substantial harm in the case of mental health patients, the provider does not have to release full records.  

    "That's just my opinion, then again I might be wrong."  Dennis Miller

     

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