Understanding the Process, Costs, and Your Rights
Reviewing your medical records is not only the smart thing to do, it’s your right. It allows you to update any information that may be vital to your care or to query your doctor about prescriptions or test results that are missing or incorrect.Historically, medical records were kept and maintained by the primary care provider. In recent years, a trend has emerged that has seen patients taking responsibility for the storage and maintenance of their own medical records.
Unless you are in a health care system which provides you access to your electronic medical records (EMR), you will need to take steps a request for copies for yourself.According to the Health insurance Portability and Accounting Act (HIPAA) of 1996, you have the right to obtain copies of most of your medical records, whether they are maintained electronicallyor on paper. These include doctor’s notes, medical test results, lab reports, and billing information.
Illustration by Joshua Seong. © Verywell, 2019.
Who May Request Medical Records
While designed to protect your privacy, HIPAA regulations are so extensive that many providers are still confused about how to enforce them. This can sometimes make it difficult to obtain your records, even if you are fully entitled to them.According to HIPAA, you have the right to request medical records if:
- You are the patient or the parent or guardian of the patient whose records are being requested.
- If you are a caregiver or advocate who has obtained written permission from the patient. In some cases, the health care provider will provide you a form that the patient must complete.
Many people assume that only they or their designees can obtain copies of their medical records. Under the law, there are other individuals or organizations who may also have the right.This not only includes your primary care physician but third-party covered entities to whom you may have knowingly or unknowingly granted the right when signing a patient intake or registration form. These not only include medical practitioners but organizations like insurance companies, hospitals, labs, nursing homes, rehabilitation centers, and billing providers.
Today, some people are even requesting their medical information be shared with mobile apps (such as those that monitor your heart health or diabetes). Under HIPAA, you have the right to request this with the understanding that the doctor who releases the information is not responsible for how the mobile app provider uses or secures your information.To this end, it is in your interest to read any medical registration or intake document to fully understand the rights you are granting and with whom your information may be shared.
Which Records Can Be Provided and Which Denied
Although you have a right to most of your medical records, there are some that healthcare providers can withhold. Note that the age of a particular set of records also can affect the ability to obtain them: Most providers, including doctors, hospitals, and labs, are required to keep adult medical records for at least six years, although this can vary by state. Depending on the state, a child’s records must be kept for three to 10 years beyond the age 18 or 21.
Among the various records you have the right to obtain:
Any notes or records that a provider has created themselves
Any diagnostic results for which a provider has copies including blood tests, X-rays, mammograms, genetic tests, biopsies, etc.
Any information provided by another doctor that was used to establish a diagnosis and/or direct treatment
If you’re seeking specific lab tests or hospital admission records, often it’s best to request them from the lab or hospital rather than your primary care provider. They are likely to be more complete and may even be kept for a longer period of time than a private medical practice.
Records Your Provider May Deny
There are records to which you may be denied access. These primarily involve mental health records for which the provider’s notes may be considered “impressions” rather than diagnoses. It has been argued that disclosure of these record may harm the doctor-patient relationship or be misconstrued when taken out of context.With that being said, a provider cannot deny your request because it might hurt your feelings. It can only be denied if the release of the information may compel you to harm yourself or others. If denied, the denial must be provided to you in writing.Under the law, the following may be reasonably withheld:
- Psychotherapy notes
- EMR records that are not in a “designated record set” (meaning those that do not pertain to your health but are used for quality assurance to improve patient care)
- Records that might endanger your life and safety
- Information compiled for use in a lawsuit
- Records that includes mention of another person who may be harmed by the release of the information
- Records that breach the confidentiality of a third-party who was promised confidentiality
- Records that may compromise your health, safety, custody, or rehabilitation if you are in prison (or those of other inmates or persons in the correctional facility)
- Records that are part of ongoing research that has not been completed
Many of these limitations are subject to broad interpretation.
If you feel you are being unfairly denied access to erf6opspecific medical records, you can file a complaint with the Office of Civil Rights (OCR) at the DHHS. You can do the same if your medical confidentiality has been breached.
If the OCR agrees that your complaint is justified, it will instruct the doctor or facility to take corrective action or enforce a settlement if actual harm was done. The complaint must be filed within 180 days of the violation.The law also prohibits retaliation on the part of the covered entity if a complaint is lodged, such as the termination of services or an increase in the cost of services.What to Do if You are Denied Access to Your Medical Records
How to Request Your Medical Records
Most practices or facilities will ask you to fill out a form to request your medical records. The forms can be usually be collected at the office or delivered by fax, postal service, or email,If the office doesn’t have a form, you can write a letter to make your request. Be sure to include:
- Your name
- Social Security number
- Date of birth
- Address and phone number
- Email address
- The list of records being requested
- The dates of service
- Delivery option (fax, post, email, in person)
Be aware that you may have to pay for the cost of your medical records if you want them delivered on paper, by fax, or via electronic media. While the price can vary, it must be reasonable.Moreover, you are entitled to the records even if you haven’t paid the doctor or facility for the procedure involved. The records cannot be withheld for non-payment, and you cannot be charged an exorbitant fee to compensate for the non-payment of services. If monies are owing, the doctor or facility can pursue avenues for collection, such as legal action or a debt collection service.
For a Doctor No Longer in Practice
If your doctor retires or is no longer in practice, all medical records must still be maintained under the law. This pertains even if a doctor has died or dissolves the practice without a sale.Under the law, the medical records should be transferred to another health care provider that agrees to accept the responsibility. If a provider cannot be found, the records may be archived with a reputable commercial storage firm.
Similarly, if your doctor has left the practice but the practice is still operating, your records must be maintained by the remaining members. If the practice was sold, the new practice will be responsible for the maintenance of the records and be liable if the records are lost or mishandled.Tracking down your records can sometimes be a challenge, particularly if a doctor’s office was closed with no forwarding details. In this instance, there are several things you can do:
- Contact your state or local medical society. Because many of these organizations require annual registration, they will most likely have the latest contact information.
- Speak with your health insurance company. If the doctor is still an approved provider, your insurer will have contact details.
- Contact any hospital where you doctor made rounds. Hospitals require doctors to undergo a formal process to obtain hospital privileges. Human resource departments will usually have details on file.
If all else fails, you may need to reconstruct your file by contacting the various labs, hospital, or specialists you used. Your health insurers, both past, and present can provide you with the details of any claims made on your behalf.
Once you’ve obtained a copy of your medical records, review them carefully. If you find errors or omissions, you will want to have them corrected immediately to ensure that they don’t compromise your future care.Most providers will agree to correct factual errors or track down reports that should have been maintained in your file.
However, this does not extend to differences of opinions for which your doctor has the right to express a medical opinion. This includes notes regarding contributing factors to an illness (such as alcoholism or HIV) that you would rather not have in your medical records. Altering or omitting the records would not only be ethically problematic, it could subject the doctor to legal action.With that being said, if you believe that that the refusal of a correction is unjust or places you in harm’s way, submit a complaint to the OCR detailing the dispute. They can review the evidence and decide if the correction is warranted.