Accessing Medical Records |
Julia Del Gatto
For a variety of reasons, you may one day need copies of your medical records from treating physicians, hospitals or other health care providers.
Like most other records and documents that record your personal information, such as school transcripts and records, motor vehicle owner and operator abstracts, military service records and even criminal and arrest records, you have a right to access and obtain copies of your medical records. But, how do you access them?
You may have heard you have a right under federal law to access your medical records. The Federal Privacy Act of 1974 regulates the handling of health-care information by federal agencies. Which means you have a right to access those medical records in the custody of a federal agency.
In addition, new privacy regulations issued by the federal Department of Health and Human Services require health care plans, doctors, hospitals, clinics, nursing homes and other covered entities to provide you access to your medical records within 30 days.
The state law in the medical service provider's location tells you how to access your medical records. If you live in Iowa, but want medical records regarding an operation you had in a hospital in New York, you will have to consult New York's law to learn how to access your records. You can do a search by state or area of law. Most can be found under a section using a keyword such as "health."
Obtaining a copy of your medical records isn't as easy as showing up at your doctor's office or the hospital's front desk with a hand full of quarters to photocopy them. There are a few things you should be aware of and a few simple procedures you can follow to make it easier to get a copy of your medical records.
What to Ask For
"Medical records" is a general term for all, any, some or only a part of the documentation you may want. Many times a patient's hospital record will reflect the mandatory reports for services and procedures performed by third-party providers. (Anesthesia, private nurse, specialists/consultants, special therapies, etc.) But the hospital record may not contain a complete copy of that provider's own detailed records which may include their notes, charts, observations, etc. A chiropractor's records may contain a detailed summary report from an MRI diagnostician, but not necessarily the films and charts. The treating physician's records will contain any prescriptions written for a patient, but not the pharmacist's records of a patient's history of consultations (that log book you sign when you pick up your prescription) containing complaints of side effects and other drug interactions. These records may have to be requested separately from that service provider.
Where to Get Your Medical Records
A large hospital or a busy medical practice can handle a countless number of patients. So finding out exactly who to ask can be as easy as turning to your phone book. Call your doctor's office or hospital patient information representative and ask who to address your request to. Many large medical practices and hospitals employ a service to maintain and archive records or have a separate department (not always located at the same address as the hospital or physician's office) A request to "Hospital, Main St, Town, NY" can result in delays until it gets (if ever) on the right desk.
Requesting Medical Records
Even if you can be accommodated on the same day by visiting the provider in person, you most likely will have to sign a release verifying that a copy was provided to you. So once you find out who and where to get your records from, your best bet would be to write a letter requesting your records.
Include with your request:
- Your exact, correctly spelled name and/or any other names you may have been known as, especially at the time you received treatment
- Your social security number
- Date of birth
- Your patient number, if you know it. Patients often have billing statements, but their account number isn't always their patient number.
If the patient is an infant, the parent or legal guardian should make the request and sign it.
Specify the date or period of time of treatment and the nature of the treatment if you only want records regarding an isolated occurrence. Some providers, unless directed otherwise, will send records for every cold and sniffle the patient has had since she was born. Maybe you want all that, maybe you don't.
You can also include a list of specific records you want in order to avoid being charged for items you have no need for. In your letter of request, you can write:
- "a full and complete copy of all medical records in your possession, including but not limited to," or
- "a full and complete copy of only those records as follows"
To a treating physician you might include:
- itemized billing statements and receipts
- office and staff journal, diary and notes
- prescription records
- laboratory tests and evaluation reports
- X-Ray and/or MRI films
- X-Ray and/or MRI reports
- vaccination records
- hospital in-patient visits and treatment records
- CAT, EEG, EKG, NMR, fetal monitor or other
- diagnostic tracings and studies
To a hospital or clinic, you can add:
- admitting records
- anesthesiologist's records
- emergency room records
- dietitian's records
- discharge records
- nurse's cardex
- out-patient records
- pathology reports
- pre- and/or post- operative reports
- therapy records
Be aware: Medical records aren't going to arrive overnight. Yours is not the only request a provider receives. Priority may be given to certain requests for records, such as a specialist needing them for a critical patient.
What It'll Cost
Check your state statutes. For example, here in New York, our Public Health Chapter 45; Title II; sec. 18; 2. (e) states: "The provider may impose a reasonable charge for all inspections and copies, not exceeding the costs incurred by such provider. However, the reasonable charge for paper copies shall not exceed seventy-five cents per page. A qualified person shall not be denied access to patient information solely because of inability to pay."
Believe it or not, many providers even charge less. You can also phone the provider's patient record's clerk and ask. But the clerk will only be able to tell you the per page charge. In your letter of request, ask that you be notified of the total charge upon completion by either telephone or by notation on an enclosed self addressed stamped post card. Then send that amount as instructed.
Is It Easy?
The most common difficulties I've encountered when requesting medical records on behalf of a client usually boiled down to simple errors such as:
- Illegible handwriting
- Vague instructions as to what is being requested
- Non-payment of the copying fees
- The patient's identification is incorrect
- The patient hasn't signed a consent in order to allow the release of his or her medical records to another party, including their own attorney.
Related Web Links:
National Coalition for Patient's Rights
Health Insurance Association of America
Health and Human Services Info On Medical Record Privacy
Privacy Rights Clearinghouse