WHAT IF: I receive a request for records?
Part 1

WHAT IF: I Receive a Request for Records? Part 1 and 2

What is a request for records?

A Request for Records is a formal request for copies of documents in your possession. This 2 part “What If?” deals with documents held by private healthcare practitioners and private healthcare establishments, for example doctors in private practice and private hospitals. Different rules apply when documents are requested from public health establishments.

Read this in conjunction with Part 2.

What is a healthcare record?

A health record is any relevant record made by a healthcare provider during the rendering of health services. This includes but is not limited to:

  1. Handwritten notes;
  2. Notes taken by another practitioner such as a referralnote;
  3. Lab reports and other documents generated by a laboratory;
  4. Audiovisual records such as photographs or x-rays.

A health record contains unaltered information about a patient’s health and healthcare which is recorded and created by the healthcare provider or under the provider’s instruction

Who do the records belong to?

A patient’s records created and held by a healthcare provider are the property of the healthcare provider and are protected by the patient’s right to privacy. Patients may be entitled to their records. However, the records belong to the practitioner and must be requested formally.

Who can request records?

People other than a patient may in certain circumstances request a patient’s medical records, for example family members, attorneys, the police or a medical scheme. None of these parties have an automatic right of access to the patient’s medical records. Even police need proper authorization to access records. Patients may consent under certain circumstances to the disclosure of their records, for example consenting to a medical schemes’ request for records. Court orders ordering the provision of records should generally be complied with. See part 2 of “What if I receive a Request for records” on the specific requirements of a request for records.

What to do first?

  1. Check who the request is from, either the patient or representative of the patient;
  2. If the request is from a representative of the patient ensure there is a copy of the patient’s ID and a consent form signed by the patient;
  3. Confirm that you treated the patient;
  4. Check which documents they have requested and for what reason;
  5. Confirm that you have the records which have been requested;
  6. Inform Natmed immediately by doing the following:
    • Log in to Natmed.mobi, and register the request and upload a copy of the request to the system.
    • Call the legal helpline on 0824 628 633 for assistance with the next steps.

What is next?

We will assess the request for records and assist you in responding to it.

The insurer may decide to involve attorneys at this stage depending on the circumstances. These attorneys may contact you to set up a meeting to discuss the legal process and the possible outcomes. The attorneys will need to be provided with all the patient’s records and a report from you prior to this meeting.

If there is a claim, we will assist you by notifying the relevant insurer to check whether the claim is covered by the insurance contract.

Part 2

What is a request for records?

A Request for Records is a formal request for copies of documents in your possession. This 2 part “What If?” deals with documents held by private healthcare practitioners and private healthcare establishments, for example doctors in private practice and private hospitals. Different rules apply when documents are requested from public health establishments. Read in conjunction with Part 1.

How can records be requested?

Records must be requested for a legitimate reason and in the prescribed form. For instance, records can be requested by patients wishing to make a claim against a healthcare provider. Sometimes records may be provided voluntarily, although your insurance policy must be checked to determine whether there are any restrictions in the policy relating to the provision of records, and notification obligations. Some documents can be requested via legal processes like records requested under the Promotion of Access to Information Act (PAIA) or through a subpoena (see “What if I receive a subpoena”).

The most common method to request records is through the mechanism available to private persons to request records from a private body, via the Promotion of Access to Information Act (PAIA).

PAIA prescribes the way in which a person can go about requesting records, these requirements can be found in section 53 of the act and are as follows:

  1. A clear description of the desired records;
  2. A clear description of who is requesting the records;
  3. Indicate how they would like to receive the records;
  4. Indicate where the records should be sent;
  5. Identify the right the requester is seeking to exercise or protect;
  6. Explain how the access to the records would assist in exercising or protecting that right;
  7. If the request is made on behalf of someone else, such as an attorney on behalf of a patient, then a consent form must be signed and must accompany the request.

If the request is granted then the healthcare provider must inform the requester of this and send the records in the form and the method asked for. The healthcare provider is required to send all records unaltered to the requester. If it is found at a later stage that not all records were sent, the healthcare provider must inform the requester as soon as reasonably possible.

Attorneys often use PAIA requests to access records in cases where a patient has come to them for legal advice. A request for records does not necessarily mean that a patient is contemplating legal action against you - it may mean that they are investigating a certain circumstance such as the cause of a birth defect on a third-party claim for example against a negligent driver. If court proceedings are already underway (for example a Summons was served relating to a claim) then the court process will determine how and when records will be provided, usually through the formal process of Discovery.

What is next?

We will assess the request for records and assist you in responding to it.

The insurer may decide to involve attorneys at this stage depending on the circumstances. These attorneys may contact you to set up a meeting to discuss the legal process and the possible outcomes. The attorneys will need to be provided with all the patient’s records and a report from you prior to this meeting.

If there is a claim, we will assist you by notifying the relevant insurer to check whether the claim is covered by the insurance contract.

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