States vary in procedures and policy in regards to handing out medical records, as do individual hospitals. However, federal law dictates that an individual has the right to access his or her medical records, make copies, and request amendments. For the most part, only you and your doctor have the right to access your medical records. In rare cases, you might need to obtain someone else’s records. You will need a direct authorization signed by the patient. If the patient is incapacitated, legal documents will be needed to waive the signature. However, protocol for requesting someone else’s records is a subject of debate and confusion in the medical community. If you need someone else’s medical records for any reason, discuss the issue with an attorney to figure out the procedures necessary to obtaining that information. Married couples do not have the right to one another’s medical records and signed authorization is needed to obtain a spouse’s records. Parents usually have access to the medical records of children under 18 but there are some exceptions. If, for example, a child is over 12 some states allow records regarding reproductive health and sexual history to remain confidential.
Your healthcare provider’s Health Information Management Department (HIM) can provide you with the authorization form specific to your hospital. This will need to be filled out in full. Information included in the authorization form varies from state to state and hospital to hospital. However, most forms ask for your address, date of birth, social security number, and phone number. You will also probably have to provide the dates you received treatment, what documents you want released, and your reasons for requesting the records. [1] X Research source Many hospitals, in order to speed up the process, allow the authorization form to be filled out online. Check if this is an option at your hospital if completing the forms online is more convenient for you. When you go in to request your records, you will need a photo ID.
Hospitals do have the right to charge fees for medical records. However, these fees are limited to the costs of the labor required to obtain the records. In other words, your hospital cannot use your records to make a profit. Usually, a hospital will charge a fee based on the number of pages in your records. There is a cap as to how much this fee is that varies from state to state. In New York, it’s 75 cents a page and in California it’s 25. Know what the maximum price per page is in your state and make sure you’re not being overcharged. You can usually find this information on the Department of Health’s website. To avoid these fees, ask your doctor to send the last SOAP Note from your final visit, or if you are in the hospital, request the discharge summaries that were dictated by your physician.
Initial history and physical examination Any consultation reports conducted by specialists. Consultation reports review the patient’s history, explain their medical needs, and lay out the reason another physician’s advise is being requested. [2] X Research source Operative reports, which document the details of a surgery Test results Medication lists Discharge reports, which include the dates you were dismissed from a hospital and any at home care your provider recommended[3] X Research source
Legally, your provider has to send you your records within 30 days of your initial request. They may be able to apply for a one time 30 day extension, but must explain the cause of this delay[5] X Research source Most facilities will not take 30 days and, on average, the waiting time is 5 to 10 days. [6] X Research source If you need your records because you are switching doctors or for insurance purposes, keep the waiting period in mind. Plan ahead and request your records well ahead of time. [7] X Research source
ask for a copy of your medical records. request corrections to your medical records. be notified about how your information may be used or shared. decide how your information may be used. get a report on how your information was used. file a complaint if you think your information is not being handled properly.
Personal notes Information regarding a minor over the age of 12, if the minor objects Any information the physician believes will cause substantial harm to you or others Information obtained from other physicians Substance abuse records or mental health records[10] X Research source
Regulations vary from state to state. Most states require you file a written appeal, citing your reasons for needing the information, to the Department of Health. Your provider must then submit an explanation for his or her refusal. [11] X Research source A judge or committee decides whether or not the information should be released. If you win your appeal, your provider must legally release the documents. If you lose the appeal, the decision is final. [12] X Research source
