How to Gather and Keep Medical Records
Why Should I Keep My Medical Records?
Reviewing your medical records is not only a smart thing to do, but it is your right. It allows to you see if there are any updates to your records that may need to be done. It also allows you to make corrections to your records. You can also discuss with your physician any questions that you may have regarding test results or prescriptions.
Other reasons to get your medical records include:
- If you are going to a new provider (doctor) Or facility. For example if you are having a new xray of your chest, the facility may want the old xray to compare with the old one
- If you go to multiple specialists, the information may not always be shared. Soi having copies on hand in a journal format, will be beneficial when you have an appointment.
What Records Must Be Kept By My Provider?
Any notes or records that a provider has created for 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
How Do I Get My Medical Records?
Remember, it is your right under the Health Insurance Portability and Accountability Act (HIPPA) to see and get copies of your medical records.or share it with a third party,
More and more physicians and providers use an electronic program called a patient portal. This is a secure website through your doctor or provider's office. Not all do have it, but those that do, have specific information that you can access and print out for your own use. Just like most secure websites, you will need to provide a user name and a password.
Things like recent doctor's visits, discharge summaries, lab and test results, medications, immunizations and allergies are often available.
You may have several patient portals for each of the physicians and hospitals that you visit
All records of your health care provider (physician) must be kept on an average of 6 years. That is the average, but it can vary from state to state. It is best to check your state laws if you have any concerns.For a child, their records must be kept from three to ten years beyond the age of 18-21 (again depending upon state laws
What Does HIPPA Say About My Medical Records?
HIPPA is the government rules or laws that govern your medical records. It says what your rights are regarding your records-both electronic and written.
The first thing that you should know is that only you or your personal representative have the right to access your medical records. Your personal representative can be named several ways; state law may affect this process.If a person can make health care decisions for you using a health care power of attorney, the person is your personal representative.
The personal representative of a child is usually the child's parent or guardian.In cases where a custody decree exists, the personal representative is the parent(s) who can make health care decisions for the child under the custody decree.
No doctor can send your records to any other doctor without your permission.
A physician cannot deny your records to you because you have not paid your bills. He/she may level a reasonable fee for copying or mailing your personal records.
Who Can Get My Medical Records?
Of course you as the patient have the right to your medical records. Others who can obtain your records include:
- A third party who is designated to obtain your records
- A person who has the legal designation by you to act in your behalf to make medical decisions for you
- An executor of an estate can obtain a deceased persons records.They may have to petition a court to do so. Learn more here.
For records on your minor child, check with the facility or your state law. If a child is 18 years old or older, he/she has complete control over the medical records, even if you are providing the medical insurance.
For records of married individuals, you will either need to be the designated person to make health care decisions by that person. Or the person can request that you ask if their behalf.
State laws vary as to how and procedures to obtain your medical records, You need to check with the requirements for the state where you reside in
Steps To Obtain Your Medical Records
Getting your medical records should not be complicated or taxing if you follow systematic steps to get them. You often will need a photo ID to obtain your records.
- Call the facility or provider's office to get the information on their requirements.Sometimes that information on their requirements are on their websites. Contact the medical records department if they have one. They will be able to explain the procedures.
- Check the patient portal if your provider or facility has one. You may be able to access information and print it depending on the portal set up.
- Complete a patient access form to obtain your records. Often these forms can be done ahead of time on the internet or in an email. This is often done online if you are requesting records to be transferred to another provider. The form will require you to state the records or specific information that you need. The more information that you give on the form, the faster your request will be filled.
- Indicate to the facility the urgency of your request. If you have a specific time frame that you need these records, explain your needs.
- In the case of especially sensitive records such as behavioral, substance abuse, or HIV records, You may have to fill out an additional form.
- You will need to provide the name, address and phone number/fax number of the person/ facility that you want the records to be sent.
- An authorization form must be signed and validated.
- Personal representatives can act in place of the patient if they if they are defined as the person to make health care decisions under state law.
- You can request a format such as CD, DVD, Flash or sent by secure email.
How Long Will It Take To Obtain My Records?
If you call ahead to the facility, they will most likely advise you the length of time it will take to obtain your records. Of course, that will depend on the amount of records you are requesting. The larger the facility, the longer it may take to get your records. The average could be anywhere from 1-10 days.
Federal law (HIPPA law) requires that the request for records be fulfilled within 30 days. But the law also allows that they can have a 30 day extension if they explain to you the reason why.
Sending A Third Party For Your Medical Records
If you need to send a person other than yourself to pick up medical records such as copies of xrays, lab tests, ect, check with the facility on what is necessary for that person to pick them up. Often, you will need to provide a request in your own handwriting stating who will be picking them up and giving them permission to do so,
What Records May My Provider Deny To Me?
There are some records that may be denied to you. Some of these may include:
- Psychotherapy notes
- Any records that pertain to quality assurance
- Records that could endanger your life or safety
- Information compiled for 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 are part of ongoing research that has not been completed
- Records that may compromise your health, safety, custody, or rehabilitation if you are in prison
You have the right to copies of your records. The healthcare facility or physician's office always will retain the original
Is There A Fee To Get My Medical Records?
Any facility or provider (doctor) can charge a fee for the labor involved in providing your medical records. But they cannot refuse your records But they cannot refuse your records to you if you have not paid for any services or treatment.
HIPPA laws (federal law) provide the limits that facilities or providers can charge. State laws cover the amounts that lawyers and other third parties can be charged.
Some facilities wave the fee, especially if the records are being sent to another doctor or facility.Some will not charge a fee up to a certain limit and then add on fees above their limit. Always ask the facility or provider what fees may be asked for so that you are prepared with the amount in hand.
More Information About Your Medical Records
- Access Memo
A PDF that explains your rights on medical records