How to Request Your Medical Records

If you’ve never requested your medical records from your doctor or hospital before, the process can seem complicated. However, understanding the law and the basic requirements will ease the process.

The Record Request Process

The basic process for requesting a medical record is similar across states and provider types. Whether requesting your personal medical records from a doctor’s office or a hospital, in Hawaii or Ohio, the federal law known as HIPAA applies. HIPAA entitles every person the right to access his or her medical records, receive copies of them, and request amendments to them.

State laws, however, can add variations to the exact process for requesting records and how much facilities can charge for fulfilling them.

In addition, individual doctors’ offices and hospitals may have their own policies. These cannot contradict federal and state law, but they can add variation in the request process between facilities.

The laws and policies can add complexity, but their end goal is the same—to ensure a person’s sensitive health information remains private.

Janet Mohlenhoff, RHIA, CCS, is the manager of health information services at Richmond University Medical Center based in Staten Island, NY. Her department is in charge of fulfilling records request.

“We are not trying to be a stumbling block,” she says.”[We’re] trying to best protect the information, because this is highly confidential information and we have to be very careful about releasing it correctly.”

“You wouldn’t want this information in the wrong hands,” she says.

To ensure information is released according to the owner’s wishes, facilities are required to verify the identity of the requestor and confirm that he or she is authorized to access or transfer the records.

Complete an Authorization Form

To request your records, start by contacting or visiting your provider’s health information management (HIM) department—sometimes called the medical records or health information services department. Smaller doctor’s offices may not have an HIM department, so ask to speak to the administrative staff in charge of releasing patient records.

The first step will be completing an “authorization for disclosure of protected health information” form.

A growing number of healthcare facilities offer their authorization forms online so they can be completed ahead of time. Some facilities allow patients to mail or e-mail the form if requesting certain record services, such as transferring records to another provider or payer covered by HIPAA.

If you are having the records sent to another person, you will need to provide their name and contact information.

For example, a patient requesting that his or her medical records from a recent hospital stay be sent to a new physician would have to provide the physician’s full name, address, and fax number or secure e-mail address.

A completed and signed authorization form is mandatory for all record releases. An incomplete or unsigned request will not be fulfilled.

Select Your Records

The authorization form also will ask what specific information you would like to have copied.
Knowing exactly what records you want or need can be difficult. Patients who are unsure can ask an HIM professional to help them narrow down their requests, according to Jennifer Miller, MHIS, RHIA, director of HIM and compliance officer at Loma Linda University Healthcare, based in Loma Linda, CA.

A medical record can often be hundreds of pages long, so being selective is important. If you don’t know the records you want, knowing what you want them for can help an HIM professional guide you to the proper documents.

In the case of especially sensitive records, such behavioral health and HIV/STD records, state law may require additional authorization. For example, in New York, an authorization has to explicitly state that the patient wants the facility to release records containing information on an HIV diagnosis or treatment. Most authorization forms have a section that addresses this type of request, and it must be filled out by the patient or their proxy if those records are requested.

Increasingly patients have the ability to request the format in which they would like to receive their records. For facilities using an electronic health record system, the medical record may be available on CD, DVD, USB flash drive, or sent via secure e-mail.

Additionally, larger facilities are increasingly creating Web-based portals that allow patients direct access to their information.

It is important to note that patients have a right to a copy of their record, not the original. The original record belongs to the healthcare facility. It is a document they must maintain for legal and business purposes.

Bring a Photo ID

If requesting records in person, you will be required to show a valid government-issued photo ID at either the time of their request or when picking up the record.

If you are picking up another person’s records, you will require additional legal documents and information to demonstrate your right to access records on another’s behalf, Miller says. Be certain to ask about these requirements in advance.

How Long Will It Take?

Fulfilling record requests can take time, so plan ahead and don’t expect to receive your records the day you request them.

In fact, HIPAA allows providers 30 days to complete a record request. It also allows a single 30-day extension, but the facility must explain the cause of the delay.

Most facilities, however, do not require that much time—many can fulfill a request in five to 10 days. Individual state laws may also dictate how quickly a facility must fulfill a request.

Fulfilling requests takes time because facilities receive many of them and processing them requires individual review. Large hospitals can get thousands of record requests a month from patients, providers, insurers, attorneys, law enforcement, and other entities, explains Anne Tegen, MHA, HRM, the director of HIM at Children’s Hospitals and Clinics of Minnesota, based in Minneapolis, MN.

Once received, each of these requests requires personal attention. Processing a record request is much more difficult than pressing print on a computer screen or walking a chart to the copy machine, says Colleen Goethals, MS, RHIA, FAHIMA, a release of information and HIM consultant with Midwest Medical Records Association, based in Schaumburg, IL.

For each request, staff  must validate a requestor’s authorization signature with a signature in the medical record; locate records; select the requested documents; review the record to ensure the authorization is valid for the release all requested information (such as HIV testing, substance abuse treatment, or behavioral health records); and then prepare and send the request.

Is There a Fee?

Facilities have the right to charge fees to offset the labor involved in copying and assembling records.
Maximum fees vary widely between states. In New York, the maximum fee a facility can charge is 75 cents per page; in California it is 25 cents per page. Georgetown University’s Center on Medical Records Rights and Privacy offers a complete list of state-specific record release laws and fees.

Facilities charge different rates, also, although none may exceed the maximum set by their state law.
Oftentimes facilities will waive the fee if the information is being sent to another provider for use in care. However, the same facility may charge a fee if the patient requests a personal copy of the record.

Still other facilities do not charge for copies at all, or only charge for requests that exceed a set page limit, according Goethals. She advises requesting information on fees before submitting a record request.

When the records are ready, HIM departments will either transfer the record to the requested healthcare provider through e-mail, fax, or mail, or they will alert the requestor that the physical copies are ready for pickup.

The Value of Requesting Your Records

There are many good reasons to request a copy of your medical records. Physicians don’t always share complete patient information or exchange a patient’s health records, so if a patient is seeing a new provider it is beneficial to ensure a copy of their record is sent to the new physician, Tegen says. Also, it is beneficial for patients or caregivers dealing with multiple doctors and facilities to have all medical records in one place, which can then be used by providers to ensure thorough care.

Reviewing your record is an important way to ensure your provider has complete, correct, and up-to-date information, such as your known allergies. If you find information in your record that is incorrect or that you disagree with, contact the provider’s HIM department.

Finally, it can be good for your health to keep a copy of your medical records, Goethals says. She advises people to be an advocate for their own healthcare by tracking their preventative care and treatment. Keeping an up-to-date copy of your health information will prevent redundant care, like repeat tests, and give all your physicians essential information about your health.

“Even when patients are well, it is nice to know their immunization history, allergies, and have certain other pieces of information,” Miller says. “So by viewing or accessing copies of their records, they are able to be better informed on their healthcare.”

Special Cases: Requesting Someone Else’s Records

Requesting another person’s records is a different process from requesting your own, and it has its own requirements.

Facilities will not release a patient’s records to someone else without a direct authorization signed by the patient. If the patient is incapacitated or deemed incompetent, legal documents must be drawn up and presented at the HIM department before another person can access the records.

Healthcare proxy is a big source of confusion, says Mohlenhoff says. Documents such as powers of attorney grant different rights at different stages. Some expire at the patient’s death, and others only become effective at that point. Some may not be effective when the patient reaches “diminished capacity” and is in the greatest need of assistance managing his or her records.

The issue of diminished capacity “is an important consideration,” Miller says. “You can word your advance directives and powers of attorney to prevent [a spouse or caregiver] having to wait for diminished capacity.”

For more information, read “Sorting out Advance Directives.”

Deceased Patient Records

The process and requirements change again when a person seeks to access the records of a deceased person. The rights conveyed by a healthcare proxy or power of attorney expire upon a patient’s death, and only an executor of the estate can gain access to records.

For more information, see “Who Has Rights to a Deceased Patient’s Records?”

Parental and Spousal Rights

Married couples do not have an automatic right to one another’s records.

“You can’t necessarily request your spouse’s records. You need an advance directive, a power of attorney, or you need your spouse to sign the authorization form for you,” Miller says. “Sometimes that can be seen as cumbersome; however, it is really meant to provide privacy of the information for the patient themselves.”

For example, one estranged spouse may try to access the other’s medical records, and some patients may choose to hide certain medical treatment or testing information from their spouse or parent. HIPAA grants adult patients the right to privacy from everyone—even spouses and parents, Goethals says.

In some instances parents do not have full access their child’s medical record. There are some privacy protections for minors.

Some state laws, such as in California, allow minors as young as 12 to keep reproductive, sexually transmitted disease, and behavioral health information private from their parents. The parents would require a signed authorization from the child in order to access those records, Miller explains.

This can be a confusing and contentious issue with parents who may receive a bill for medical services given to their child but are denied access to those records.

Children age 18 and older have complete control over their medical care and records, and parents require authorization to access their records. This is true even if the child’s care is paid for by the parents’ insurance.

 

TIPS FOR RECORD REQUESTS

Read online or call the facility’s HIM department for information specific to your request. This will give you time to collect the required information and documentation before you arrive. If you are requesting another person’s records, you can confirm in advance that you will have authorization.

Provide as much information as you can on the authorization form. This will speed up request processing by giving HIM professionals sufficient data to track down your records. If you have a common last name, provide extra information about yourself, such as your date of birth or the last four digits of your Social Security number.

Bring a valid government issued photo ID and all other required legal documents with you when you pick up a record request. HIM professionals by law must deny requests where the individual cannot prove his or her identity or his or her right to access the records.

Tell the HIM staff why you are requesting the record. HIM professionals can help ensure you receive the records you need—and not the ones you don’t. The set of records one should request for personal use, for example, can be different from the set of records sent to a doctor for continuing care. A person’s medical record can be hundreds of pages long, so requesting your entire record may be too much, especially if the facility charges a per-page fee for compiling and reproducing it.

Indicate if the request is urgent… Many facilities triage their record requests, putting the most time-sensitive and care-oriented requests first.

…but allow as much time as you can. Not all facilities honor rush requests, however; some fulfill orders in the order in which they were received. When possible, make your request well before you need  the documents (between five and 15 days out).

Don’t request your records before you leave the hospital. If you need records from your hospital stay sent to a physician for follow-on care, don’t request the transfer before you are discharged. This will ensure all of your records are sent, including the discharge summary.

22 Comments

  1. I would like to know how physician offices are handling the inquiries from a patient who during their visit wants a copy of the immunization record and or lab work or radiology report – are they obtaining a patient authorization?

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  2. If the release doesn’t have an expiration date on it how long is the release good for? (IE 60 or 90 days)

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  3. If a patient requests medical records from our office and in addition records from previous offices in which she was seen (that were transferred to us) Are we obligated to provide records from all the previous offices or can we refer the patient to the original office in which she was seen. I was under the impression that we could only release records from our own practice.
    Thank you.
    -Kim

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  4. Melissa:

    Check out this it might help you understand redisclosure of records from other medical offices. http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_042636.hcsp?dDocName=bok1_042636

    Generally if you have used the information to make health care decisions for the patient, it is considered part of your designated record set and you are able to release it. However, it is always best to suggest to the patient that they request the information from the originator as you do not know if the information you received is complete.

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  5. My 81 yr old father can not drive the 2 hr drive to his doctor anymore near their home on the lake. He requested his medical records in writing. He or anyone else can not read what was sent. He called the doctors office and they said they couldn’t type them up but would let him know. What are our rights getting these. He’s seen this doctor for over 15 yrs. And no there are no mental issues to hide from the patient so why will they not send something my father or family can read.

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  6. How long does a clinic need to house a childs medical record? I was told that it is 7 years after the child turns 18. Can someone verify this?

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  7. My doctore recently retired and sold his practice to another doctor. Would I request records of the retired doctor from the new doctor?

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  8. In California does a faxed or copied authorization have to say “copy is as valid as original”

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  9. @Cindy: Patient does not need to sign a release form to get copies during their visit, if the clinicians have the records readily available to copy. Some organizations may require the patient to fill a form out anyway just to have something on file showing they disclosed those recs to the patient, but not required technically.

    @David: Most releases are good for a year from date of signature

    @Melissa: you can disclose other offices records if you used them for medical decision making, but note to the patient the records you have may not be their complete record from those other offices. It’s also better for the patient to not have to go to several offices to get what they need if you have it all available.

    @Laura: Send in the release form, filled out and signed by your father, and ask the doctor’s office to mail the records to his home.

    @Robin: Depends on state law. Many organizations keep records for 10 years from last date of service. Others will keep records until patient hits 18 then 2-3 years afterwards (minimum is still 7-10 years from last date of service).

    @Ken: Generally the sale of a practice comes with the patients and their records. You should be able to obtain your records from the new doctor if he picked up where your previous doctor left off. This isn’t always the case.

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  10. I tried to look at my medical records at the local huge medical corporation. The idea was to look at the record and then request only the ones I needed. The nurses and medical records people refused, saying that the records were on their computers and they’re not going to let a mere patient to sit at their computer. They were very angry when I pointed out that state law allowed patients to see their medical records, and that I’d be happy to look at paper files if they don’t want me looking at their computers. They reused, saying that they don’t have any paper files – no, you can’t look at your records. Who cares about the laws?

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  11. My daughter wanted to get her results from lab work and an ultrasound but could not get it from the doctor’s office, she signed a release for me (an employee) to retrieve it from the medical record for her. I have now been placed on suspension pending investigation. Since a release was signed, what that illegal?

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  12. I am trying to get my 16 year old sons records from the hospital I took him too. He died january 9th 2013. Our local native american clinic sent a fax to get those records and they refused. I have two reasons to get them. One is for referance for another son who has the same condition and we as a family have some questions about the son that died.

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  13. When a patient picks up records in the HIM Department a picture ID is necessary. However, when it is mailed in we ask for the signature to be notarized to make sure we are sure of who is asking for records. I do not see anything regarding this in the article. Why would we except a mail in signature but have to have a picture ID if they pick up? Help!

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  14. How do I obtain my medical records from 2005 to current day

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  15. What is a Doctor has not sent two patients record ( my mother and I ) after 4 months? Do I have a right to themk?

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  16. I want to obtain my records from a previous physician that cared for me while I was pregnant in 2009, in Texas. How would I start that process?

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  17. I was wondering how releasing medical records to another clinic works. If another clinic is requesting medical records on a patient is a signed release required? How about if the patient has been reffered to this other practice? What if this patient was not reffered to another clinic and they are requesting records? Do I need to request a signed release to send these, or do I need to inform the patient and get verbal consent from them? Please help!

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  18. Hello;
    Is there a means of restricting information that a doctor releases? For example, I am leaving my primary care for another, I would like to prevent the previous physician from giving out my records after I leave.

    I also went to a chiropractor office, and found them to be seeking long term payment for services they called “super billing”. How do I restrict them from everything that they had me sign?

    Thank yo for answering these questions!
    Terry

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  19. Hi-We requested records on 8-29-2013. Never heard back. Filed a complaint on 12-1-2013 with the ORC. As of today, 3-5-2014, we have not received records or heard back from the ORC?? What next steps do we take? We believe our child’s medical records were looked at by neighbors, as a few work for the place our child receives medical care.

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  20. i’m looking for my birth parents

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  21. Can a patient use a notary to request Medical release to have their records tranferred to another Doctor?

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  22. My ENT retired a year ago. He referred me to a new Dr and told me that he would send my
    Medical records there. They have NOT received anything!
    I have had other health issues and didn’t contact the new Dr until recently.

    What do I do if I have no way to contact my Dr if he is retired????

    I am assuming. The records are being stored somewhere. By law they have to be kept for
    7 years.
    Any advise would be appreciated. Thank you.
    Thank you.

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