Requesting your medical records from your doctor or hospital may seem complicated. But, it is your right to review your medical records and be updated about the vital information. Traditionally medical records were maintained by your healthcare provider. In recent years the trend has changed; the patient is taking responsibility for storing and preserving his/her own medical records.
The basic procedure for requesting medical records across all states fall under the federal law referred to as HIPAA ( Health Insurance Portability and Accountability Act ). According to HIPAA, every person has the right to access his or her medical records and receive copies of them.
To request the medical records, you need to visit your healthcare provider’s office or speak to the administrative staff in charge. Some hospitals offer online medical records through their website. For this, you need an online access as a patient where you can get your test results, list of medications, and other medical history.
Under HIPAA, the federal law regarding medical information storage and access, you can request copies of your full medical records from all your healthcare providers. This can be done in person or by written request. It may be possible to do so over the phone, depending on whether your healthcare provider feels that is an appropriate level of proof of identity.
Bring an appropriate ID– When you are requesting your medical records in person, you need to show a valid government-issued photo ID. If you need another person’s medical records, you need to bring some additional legal documents to show your rights to access someone else’s documents. Ask about these formalities in advance.
Most of the time, you need to fill the form for requesting your records. If there is no such form, you can make a written request. Make sure to include:
- Your name, including your maiden name (if applicable)
- Social Security number
- Date of birth
- Address and phone number
- Date(s) of service (months and years under the doctor’s care)
- List of records you need
- The delivery format you need
- Your signature
Remember that each healthcare provider stores records documenting the healthcare they provided. If you have used multiple physicians or have a complex medical history, you will have to contact all of these healthcare providers to have a complete medical record history.
What to do if you have trouble
Most of the healthcare providers are aware of the federal law HIPAA. But still, if you encounter any issue with healthcare administrators, refer them to this federal document, which may help.
If you have made a written request and received no response, then call your healthcare provider’s office. If they confirm receiving your request but haven’t done anything then see the provider’s “Notice of Privacy Practices.” It should include the contact information for a privacy official who can help. And remember, healthcare providers have 30 days to gather and provide copies of your medical records, so make sure you’ve allowed enough time. If you feel your rights to access your health information in a timely fashion have been violated, you can file a complaint with the U.S. Department of Health & Human Services; just make sure to file the complaint within 180 days.
Special instructions for veterans’ medical and health records
Various military and government agencies hold veteran and military medical records. Each branch has some additional policies concerning these records. It may seem complicated as military medical records are treated differently, whether they are related to outpatient medical services or treatment requiring a hospital stay. So, you need to check-in at least two places, for complete military medical records history:
- Since 1960, hospital inpatient records only have been maintained in the Official Military Personnel File (OMPF) at the National Personnel Records Center (NPRC). NPRC has kept these records in bulk retired each year by the creating hospital, rather than with each personnel file. Therefore, most of these hospital inpatient records are filed by the name of the hospital in which the service member was treated. As such, the NPRC needs the name of the hospital, month (if known), and year of treatment, as well as the veteran’s name and Social Security or service number, to locate these clinical records.
- Health records covering the outpatient, dental, and mental health treatment that former members received while in military service are stored in a different location. Health records include induction and separation of the physical examinations, as well as routine medical care (doctor/dental visits, lab tests, etc.) when the patient was not admitted to a hospital. Military medical records and hospitalization records from the Department of Veterans Affairs (VA) are not included in these medical records. In general, those discharged from military service after 1979 will find their service medical records at the Department of Veterans Affairs.
Benefits of Getting Your Medical Records
When you have access to your health records, it enables you to keep track of your healthcare. Your health records keep you up to date with your current health detains. Mainly there are three important benefits of getting your medical records:
- It saves you time. When you have the history of all the tests already performed, your health care provider can avoid performing the same tests again. This will save you time as well as money.
- It keeps you prepared for medical emergencies. During such emergencies, your medical records come handy to review and decide on the best possible treatment.
- It keeps you informed. You will feel empowered knowing all your health info. You can also check if any errors, and can get it corrected.
Choose what information you want from your medical records
A medical record can have a lot of information. Knowing exactly what information you need can help you to narrow down your search. If you don’t know which documents you need, then take professional help to get the proper materials. You can limit your request for medical records to a specific time period if you want. You can also ask for papers of a particular condition or specialist, but you may run the risk of missing vital information.
While doctors can’t charge any fee for providing your medical records, but they can charge a reasonable amount for copying and printing your documents. If you have a long or complicated medical history, the fees can add up.
Medical records that can be provided include:
- The initial history and physical examination from the doctor.
- Consultation reports from specialists, as well as any notes.
- Operative reports.
- Test results, especially those used to track chronic conditions or showing meaningful test results such as x-rays, biopsies, and blood tests.
- Current medication list.
- Discharge summary if you were hospitalized.
Records that may get denied:
- Psychotherapy notes.
- Information that could endanger the physical safety of the patient or another person.
- Information compiled for use in a lawsuit.
- Information that is part of a research project while it is still in progress.
- If your request for information would reveal the identity of a source that was promised confidentiality.
Certain medical information such as HIV/STD records may require further authorization in addition to your initial request. If your healthcare provider denies your request, they have to document that denial and the reason for it. You have the right to review and appeal that denial. During such appeal, a healthcare professional who was not involved in the initial denial decision will review the decision and determine whether or not to grant you access.
Who Has Your Medical Records
In general, any healthcare provider you have seen has to keep medical records about you and provide access or a copy when requested. There is no federal law specifying how long a doctor needs to keep a patient’s medical history. But instead, every state has its own holding period, which ranges between 7 to 10 years.
If you have moved or have changed health care providers, it’s a good idea to request your medical records. Contact your healthcare provider to see if the medical records you want are available. Your medical records can be accessed through doctors, hospitals, labs, or any other medical establishments you visited. You may get access to your medical records through a patient portal, which is an electronic health record, but it only has few summary notes.
Who Can Request Your Medical Records
HIPAA regulations are designed to protect your privacy, and sometimes, because of this, you may find it challenging to obtain your records.
According to HIPAA, you can request your medical records if;
- You are the patient or the patient’s parent or guardian.
- You are the caregiver having written permission from the patient.
The other groups that can sometimes access your health records are;
- Employers, life insurers, and some school districts can view some records.
- Government agencies, such as Medicare or the Social Security Administration, may have the authorization to examine your medical records to establish eligibility for certain programs.
- Your electronic patient records can be released if ordered by a court or by health agencies or law enforcement agencies with a valid subpoena or legal order, and may be required in certain situations. In most states, medical records showing treatment for gunshot wounds, for medical treatment related to sexual attacks, and for cases where domestic violence is suspected, must be submitted to the proper authorities.
- Your healthcare providers may also release medical records without your written authorization in the following circumstances, among others: to insurance companies for purposes of processing health insurance coverage; to professional societies and research organizations who are reviewing health care providers or doing medical research; to employers if they are evaluating workers compensation claims.
How to fix mistakes on your medical records
If there are errors in your medical record, then you can write a letter to the healthcare administrator outlining those errors and the needed corrections. Mentions your name, date, social security number, and other vital information, then staple a copy of the page that contains an error. The provider must respond and act on your request within 60 days.
Having your medical record is as essential as taking the right treatment for your health condition. Always review your health record and make needed corrections. By actively participating in your medical record review, you can be well informed and up to date about your health condition.