Medical Records 101

There are steps that you can take to assist in maintaining confidentiality of your medical record. To start:

• Be aware of what information is being collected and by whom.
• Read the fine print before you authorize any release of information, even if it doesn't specifically say you authorize release of medical information -- this includes printed forms from insurance companies. The authorization should be specific about who is to receive your information, what information is to be released, and for what purpose. The authorization should specify for how long the authorization will be valid. If you don't like what you read, change it. For example, a general release may provide: "I authorize any physician, hospital or other medical provider to release to [insurer] any information regarding my medical history, symptoms, treatment, exam results or diagnosis. Change it to "I authorize my records with respect to (name and date of treatment) in the possession of (name of doctor, clinic or hospital) to be released to (insert name)." 
• Set privacy standards with your doctor. You can ask that notes for specific treatments that you consider sensitive information be kept separate from your general medical chart. This kind of request will keep that information from being sent to people or companies that don't need to know about it, particularly companies collecting claims information. You can also discuss with your doctor to whom certain information should or should not be disclosed.
  • The only information a doctor is obligated to disclose to a health insurer is a diagnosis-not a patient history.
  • If your insurer or anyone else asking for information needs additional information, they will ask your doctor for the information. Your doctor can contact you before releasing the information.
• Ask your doctor to be discreet when leaving messages on voice mail or answering machines.
  • Even if your voice mail isn't normally accessed by other people, someone may be standing there when you check your messages thinking they will all be run-of-the-mill.
  • Be sure your wishes regarding messages, particularly of notification of lab results are recorded on your medical chart-- and that your wishes are repeated to each new doctor you see.
• If you and your doctor communicate by e-mail:
  • Ask your doctor to be discreet and not include diagnoses or test results -- particularly if you receive your e-mails at work. It would be better if the e-mail only asked you to contact the doctor's office.
  • Don't use office e-mail for information about your health condition. Use a personal account instead.

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