How to Get Copies of Your Medical Records

Process, Cost and Patients' Rights to Their Medical Records

Some medical records are still found in folders, kept on paper.
RezaEstakhrian/Getty Images

Reviewing your medical records is your right, and it is a wise thing to every time you visit a doctor. Unless you are in a health care system that gives you access to your electronic medical record, you will have to make a request for copies of your medical record. 

According to federal law, you have the right to get copies of most of your medical records, whether they are paper copies or electronic health records.

Doctors' notes, medical test results, lab reports, and billing information must be supplied to you if you ask properly.

The federal law that addresses access to our medical records is called HIPAA (pronounced HIP-a), the Health Insurance Portability Accountability Act. These rules mostly address privacy issues but are so extensive that many healthcare providers are still confused about how to enforce them. That confusion sometimes makes it difficult for your to get your records, even when you are entitled to them.

Who May Request Their Medical Records

If you want to get copies of your medical records, then:

  • You must be the patient or the parent or guardian of the patient whose records are being requested.
  • If you are not the patient, parent or guardian, then you must obtain written permission from the patient, sometimes using the form the provider gives you. Caregivers or advocates may be able to access records if the patient has provided written permission to the provider.
  • The US Department of Health and Human Services provides good background information for understanding who may, or may not, have access to a patient's records.

 Many patients believe they or their designees are the only people who can obtain copies of their records. In fact, there are many others who can gain access to your medical records without your permission.

Which Health Care Providers Have Your Medical Records

Providers, including doctors, hospitals, labs, and other medical practitioners are required to keep most adult medical records for six years or more, although this varies by the state where the records are stored. In most states, children's records must be kept for three to 10 years beyond age 18 or 21. If you seek older records, contact the provider to see if they are available.

  • Providers are required to share any notes or records they have created themselves or any test results for which they have copies. They are also required to share any information provided to them about you by another doctor if that information was used for the diagnosis and/or treatment being discussed with you.
  • Diagnostic lab test records, for such tests as blood tests, CT scans, x-rays, mammograms, or others, should be requested from the doctor who ordered them, or your primary care physician. However, as of 2014, you can request these results directly from the lab.
  • If you seek hospital records or records from any other medical facility, you'll want to request them directly from that facility.

Records That Providers Don't Have to Share With You

Be aware that you may be denied access to some records, usually related to mental health records.

If a provider believes that letting you look at your medical records can endanger your physical health, your request may be refused. They cannot deny you access just because they think you will be upset unless they believe that upset will lead to an attempt to physically harm yourself.  If you are refused, the provider must make that clear in writing.

These types of records and circumstances include:

  • Psychotherapy notes.
  • Information compiled for use in a lawsuit.
  • Records that are not in a designated record set.
  • Records that might endanger life and safety.
  • If the record includes mention of another person and your access to the record may cause harm to that person.
  • If the record has information from a source promised confidentiality and your request would reveal that source.
  • If you are in prison and requesting your records from the correctional institution and releasing the record might have a negative impact on the safety, health, custody, or rehabilitation of yourself, other inmates, or correctional employees.
  • If the information you are requesting is part of a research project and you consented that the records wouldn't be divulged while the project is still in progress, you might not be able to get that record until the project is completed.

How Much Does It Cost to Get Your Records?

You may have to pay for the medical records copies you want to be delivered on paper, by fax, or electronic media. The price will vary due to several factors. But you only have to pay a reasonable charge for providing the record. You can still be provided your record if you haven't paid for the medical services provided.

How to Request Your Medical Records

Most practices and facilities ask you to fill out a form to request your records. Call the provider's office and request a copy of the form. They should be able to deliver it to you by fax, email, or postal mail, or you may pick it up from the doctor's office.

If the doctor's office doesn't have a specific form, you may write a letter to make your request. Include this information:

  • Your name, including your maiden name (if applicable)
  • Social Security number
  • Date of birth
  • Address and phone number
  • Email address
  • Record(s) being requested
  • Date(s) of service (months and years under the doctor's care)
  • Signature
  • Delivery option (pick up, fax, email, etc.)

What if Your Doctor Is No Longer in Practice?

Doctors don't stay in practice forever. Just like the rest of us, they change jobs, retire, move, or even die. The steps to take to get your medical records depend on what happened to your doctor's practice and records after they left.

  • Practice Still in Operation: If your doctor has left, but the practice is still operating, your records should be available through the practice. Follow the same protocol to request your medical records as if the doctor was still working in that practice.
  • If the Practice Was Sold: If your doctor's practice was combined with or purchased by another practice, then the new practice entity will still have your records. This applies even if your doctor is no longer there or if a group of doctors bought the practice. Follow the same protocol to obtain your medical records as if the doctor was still working there.
  • If the Practice Is Out of Business: If your doctor's practice closes and is no longer in business, you have three possible resources: 
    • First, contact your local medical society. You may be able to look up the phone number online or in the phone book. You may also find the contact information you need through your state's medical society. Someone at the medical society should be able to let you know what became of your doctor's practice. It is possible that they can find out where the doctor's records are being housed. They may also be able to tell you how to get medical record copies if the procedure varies from standard practice.
    • If your local medical society doesn't have the information you need, contact your state medical society association. Again, a search for your state's association should give you results.
    • Finally, if none of these possibilities work out, contact the hospitals in your area. Doctors must go through a formal process to be granted privileges to treat patients at a hospital, and many doctors do so at some point in their career. You can contact a department such as surgery or internal medicine, or Human Resources. They may know where the records for their patients treated by that doctor are being kept or be able to direct you to the appropriate department.

Keep in mind that when your records have been housed elsewhere, they will be difficult to retrieve unless they are among the minority of records that have already been transferred to an electronic health record. For that reason, you very likely will be charged for the copies you want.

What Happens Next

Once you have made the request, you may have to wait for awhile before you get the records. State laws regulate how quickly those records must be supplied to a patient. In some states, you'll be given access to review them in the doctor's office immediately but may have to wait between 10 to 60 days to obtain your own copies. Other states require access within 30 days. Those time frames may sometimes be extended if circumstances warrant.

What if You Are Denied Access to Your Records?

There is a protocol and complaint system to follow if you are denied access or copies of your medical records. Take those steps if you think your denial was not appropriate.

If You Find Something Wrong With Your Medical Records

Once you've obtained copies of your records, be sure to review them carefully. If you find errors, you'll want to correct them immediately to be sure they cannot affect any future diagnoses or treatment you may receive. You have the right under HIPAA to request that your medical or billing records are amended to correct inaccurate or incomplete information. Providers usually agree to correct factual inaccuracies. But if it is a difference of opinion, your provider isn't required to amend the record. If your request for an amendment isn't granted, HIPAA allows you to add a statement of disagreement to your record.

A Word From Verywell

Knowing what is in your medical record is part of taking an active role in your health care. If you have electronic access to your medical record, be sure to review it after every appointment, well care visit or treatment. Besides giving you information about your health, it is a chance to clear up errors or to discuss anything that isn't clear with your doctor.

Sources:

CLIA Program and HIPAA Privacy Rule; Patients' Access to Test Reports, Final Rule, Federal Register Vol. 79, No. 25, February 6, 2014.

Your Medical Records. U.S. Department of Health and Human Services. https://www.hhs.gov/hipaa/for-individuals/medical-records/index.html

Continue Reading