Get a Copy of Your Medical Records

Getting your medical records released to you sounds confusing, but the process is fairly straight forward. It can be somewhat lengthy, as gathering the needed forms and information takes time, but if you stay patient and follow protocol you can smoothly receive the records you need if you live in the U.S.. Some of this may be applicable elsewhere in the world.

Steps

Learning about Medical Records

  1. Know who can request medical records. Medical records often contain highly sensitive and private information. Only specific individuals have access to your medical records.
    • States vary in procedures and policy in regards to handing out medical records, as do individual hospitals. However, federal law dictates that an individual has the right to access his or her medical records, make copies, and request amendments. For the most part, only you and your doctor have the right to access your medical records.[1]
    • In rare cases, you might need to obtain someone else's records. You will need a direct authorization signed by the patient. If the patient is incapacitated, legal documents will be needed to waive the signature. However, protocol for requesting someone else's records is a subject of debate and confusion in the medical community. If you need someone else's medical records for any reason, discuss the issue with an attorney to figure out the procedures necessary to obtaining that information.[1]
    • Married couples do not have the right to one another's medical records and signed authorization is needed to obtain a spouse's records. Parents usually have access to the medical records of children under 18 but there are some exceptions. If, for example, a child is over 12 some states allow records regarding reproductive health and sexual history to remain confidential.[1]
  2. Gather the necessary material. To obtain your records, you need certain materials. Make sure you know you have all the necessary paperwork filled out before beginning the process of requesting records.
    • Your healthcare provider's Health Information Management Department (HIM) can provide you with the authorization form specific to your hospital. This will need to be filled out in full.[1]
    • Information included in the authorization form varies from state to state and hospital to hospital. However, most forms ask for your address, date of birth, social security number, and phone number. You will also probably have to provide the dates you received treatment, what documents you want released, and your reasons for requesting the records.[2]
    • Many hospitals, in order to speed up the process, allow the authorization form to be filled out online. Check if this is an option at your hospital if completing the forms online is more convenient for you.[1]
    • When you go in to request your records, you will need a photo ID.[1]
  3. Figure out what fees, if any, you need to pay. Fees vary from hospital to hospital, but there is specific protocol when it comes to charging for records. Be aware of this to avoid paying unlawful fees.
    • Hospitals do have the right to charge fees for medical records. However, these fees are limited to the costs of the labor required to obtain the records. In other words, your hospital cannot use your records to make a profit.[1]
    • Usually, a hospital will charge a fee based on the number of pages in your records. There is a cap as to how much this fee is that varies from state to state. In New York, it's 75 cents a page and in California it's 25. Know what the maximum price per page is in your state and make sure you're not being overcharged. You can usually find this information on the Department of Health's website.[1] To avoid these fees, ask your doctor to send the last SOAP Note from your final visit, or if you are in the hospital, request the discharge summaries that were dictated by your physician.

Obtaining Your Records

  1. Know what documents to request. On the authorization form, you will be asked to select what kind of records you want. If you're unfamiliar with medical terminology, this can be confusing. However, for patients, the following forms are most useful for tracking medical history and transferring doctors.
    • Initial history and physical examination
    • Any consultation reports conducted by specialists. Consultation reports review the patient's history, explain their medical needs, and lay out the reason another physician's advise is being requested.[3]
    • Operative reports, which document the details of a surgery
    • Test results
    • Medication lists
    • Discharge reports, which include the dates you were dismissed from a hospital and any at home care your provider recommended[4]
  2. Decide how you want to receive your records. You have a variety of options when it comes to receiving your medical records. Paper copies are what is generally requested, but you can request digital copies as well. If your hospital uses electronic records system, you can get your records in the form of a CD or USB drive. You can also have your information sent through email. Figure out what is most convenient for you and then make the request.[4]
  3. Be prepared to wait. Receiving your medical records takes time. It is not a same day process and you should be aware of waiting periods.
    • Legally, your provider has to send you your records within 30 days of your initial request. They may be able to apply for a one time 30 day extension, but must explain the cause of this delay[4]
    • Most facilities will not take 30 days and, on average, the waiting time is 5 to 10 days.[4]
    • If you need your records because you are switching doctors or for insurance purposes, keep the waiting period in mind. Plan ahead and request your records well ahead of time.[4]

Knowing Your Rights

  1. Know your HIPAA Rights. HIPAA is the Health Information Portability and Accountability Act. You should be informed of your HIPAA rights when you start treatment with a new doctor, such as when you are admitted to a hospital or when you see a doctor for the first time. In general, HIPAA gives you the right to access your medical information and keep it private. This means that you have the right to:[5]
    • ask for a copy of your medical records.
    • request corrections to your medical records.
    • be notified about how your information may be used or shared.
    • decide how your information may be used.
    • get a report on how your information was used.
    • file a complaint if you think your information is not being handled properly.
  2. Know you are entitled to your medical records. You are entitled to your medical records. This is federal law and a hospital cannot withhold records for any reason, including delinquent payment. As stated, hospitals can charge for paper but they cannot charge a searching fee. If a facility tries to refuse to release your records, or demands a hefty sum of money for their release, talk to an attorney. Refusal to release medical records is rare, but does sometimes occur. Understand this is illegal.[6]
  3. Understand what information doctors can withhold. While you are legally entitled to most medical records, a doctor has the legal right to refuse to release certain documents regarding your medical history. These documents include:
    • Personal notes
    • Information regarding a minor over the age of 12, if the minor objects
    • Any information the physician believes will cause substantial harm to you or others
    • Information obtained from other physicians
    • Substance abuse records or mental health records[6]
  4. Appeal a refusal, if necessary. In some cases, you might want or need certain information a doctor can legally refuse to release. If, for example, you're transferring to a specialist a doctor's personal notes and observations can provide your new physician important insight into your condition. There is an appeal process if your provider refuses to release certain records.
    • Regulations vary from state to state. Most states require you file a written appeal, citing your reasons for needing the information, to the Department of Health. Your provider must then submit an explanation for his or her refusal.[6]
    • A judge or committee decides whether or not the information should be released. If you win your appeal, your provider must legally release the documents. If you lose the appeal, the decision is final.[6]

Tips

  • Once at hand, make sure to organize your medical records by date or record type in a binder or a digital tool. Most patients prefer to keep them organized by date. Use sticky notes to clearly set the date and record type on each record, so you won't have to look for them on the record every time. A lot of online and mobile tools can help you do it easily, including backup, for free or at low cost.
  • If you have had the provider for a long period of time, it might be cost effective to give him or her date parameters as medical records can be thousands of pages long if you've had lengthy hospital stays or prolonged illnesses. Request a few months worth of information rather than a few years.

Related Articles

Sources and Citations

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 http://journal.ahima.org/2012/03/01/how-to-request-your-medical-records/
  2. ↑ https://www.aurorahealthcare.org/patients-visitors/medical-records
  3. ↑ http://www.dummies.com/how-to/content/medical-transcription-the-sections-of-a-consultati.html
  4. ↑ 4.0 4.1 4.2 4.3 4.4 http://health.usnews.com/health-news/patient-advice/articles/2014/06/05/how-to-get-access-to-your-hospital-records
  5. ↑ http://www.hhs.gov/hipaa/for-individuals/guidance-materials-for-consumers/index.html
  6. ↑ 6.0 6.1 6.2 6.3 https://www.health.ny.gov/publications/1443/
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