DAL/DRS: 10-06: Access to Medical Records
July 13, 2010
The purpose of this correspondence is to provide specific information contained in regulation and statute regarding access to medical records.
In accordance with Sections 17 and 18 of the Public Health Law, Section 415.3 of Title 10 Health of the New York Compilation of Codes, Rules and Regulations, and Section 483.10 of Title 42 Code of Federal Regulations, nursing home providers are obligated upon request to supply a copy of a medical record to a qualified person. The qualified person includes the resident, their legal representative, guardian or individual holding a valid Power of Attorney for a resident who specifically directs the provision of records, reports and statements. The use of a completed HIPAA Form #960 is considered a legal request for the record. Additionally, a qualified person can indicate that the copy request be sent to a third party directly. In the case of denial of access to a medical record, Form DOH-1989 must be completed and supplied to the requestor, even if the request is being denied only in part.
A facility or its contracted copy service is allowed to charge no more than seventy-five cents per page for paper copies of the record. The only exception to this law is for applicable taxes and the cost of actual postage. If the cost of producing the record is actually less than seventy-five cents per page, you are expected to charge the lower cost.
A requestor (or their legal representative) cannot be denied access to the medical record due to inability to pay. The requestor can be asked to submit supporting documentation for such a claim. However, it is the Department's expectation that all nursing home providers have a process in place to handle requests.
We acknowledge that most facilities are currently operating in compliance with the laws/regulations. This overview will serve to assist in the identification of areas where your facility may need to make changes.
Jacqueline Pappalardi, Director
Division of Residential Services