Slideshow: Requesting Your Medical Records

This slideshow walks patients through a typical release of information request.

Your Fundamental Right to Your Health Information

The government and groups like GetYourHealthData, in their quest to empower patients to seek out their own records, frequently remind consumers of what HIPAA does for patients. In terms of accessing their own records, the US Department of Health and Human Services’ Office for Civil Rights (OCR) issued guidance reminding patients that they can:

  • Ask to see and get a copy of their health records from most doctors, hospitals, and other providers such as pharmacies, long-term care facilities, and health plans
  • Get either paper, or if records are kept electronically, an electriconic copy of their records
  • Have their provider or health or health plan send their records to another entity for treatment, payment, or operations purposes

The Record Request Process

To request your records, start by contacting or visiting your provider’s health information management (HIM) department—sometimes called the medical records department. Bring a government-issued photo ID and be prepared to sign a patient access request form to verify you are the person requesting the information. 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. Individual state laws may also dictate how quickly a facility must fulfill a request.

What You Are Entitled to Receive

The Privacy Rule requires a covered entity to provide the individual with access to their protected health information (PHI) in the form and format requested, if readily producible in that form and format, or if not, in a readable hard copy form or other form and format as agreed to by the covered entity and individual. The scope of the information patients can obtain, per what’s known as the “designated record set,” includes medical records; billing and payment records; insurance information; clinical laboratory test results (including genomic information generated by a clinical laboratory); wellness and disease management program files; and clinical case notes.

Personal Representative

If a person wishes to allow someone other than themselves to have access to their health records, they can designate a “personal representative.” These personal representatives are specifically defined to be the parties that make healthcare decisions for a patient under state law. If a person has been given medical power of attorney for an individual, they have the right to request access to another person’s medical records. The person asking for access on another person’s behalf may be required to fill out a request form or make the request in writing.

Is There a Fee?

It depends, based on the state where you live, whether the records being requested are held electronically, and how elaborate the request is. According to the most recent HIPAA guidance:

  • Patients should not be charged a fee for patient portal access through certified electronic health records (EHRs).
  • There cannot not be “per page” fees for electronic copies.
  • There cannot not be “surprise” fees; providers must inform an individual in advance of the approximate fee that may be charged.

Setting Up a Patient Portal

If a healthcare provider has an EHR, they may also offer a patient portal. Patients typically find out about the portal from their physician, a physician’s office staff, a nurse, or from their physician’s front office staff. Once a portal is set up a patient has access to their payment information; to medication refill requests; immunization history; diagnostic test reports; lab results; and discharge instructions. Some facilities use palm scanners to keep patient records secure. Palm scanning is a patient identification technology that’s 100 times more secure than finger prints. When a patient scans their hand with the machine, it can call up their records.

Why You Should Request Your Records

Medical record sharing and exchanging doesn’t happen as readily or easily as many patients think. Requesting, collecting, and checking records for accuracy can help people with chronic conditions keep their whole care team on the same page. Keeping, or having accessible on-line and up-to-date copies of your health information will prevent redundant care, like repeat tests, and give all your physicians essential information about your health. An educated patient is a healthier patient.

Tips for Requesting Your Records

Indicate if your request is urgent—some providers can’t always speed up the record retrieval process, but some will try. And, when possible, make your request well before you need the documents (between five and 15 days out). A common flaw with HIPAA is that covered entities will cite HIPAA as a reason to avoid giving a patient their records due to laziness or ignorance to the law. If this happens, you can report the provider to the Department of Health and Human Services’ Office for Civil Rights (OCR) and file a complaint.

 

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2 Comments

  1. Minor records – behavioral health records, prenatal records; how do we address this for release of information to third party requests other than the patient?

    Expired Notary on guardianship of minor?

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  2. My husband is trying to get his Explanation of Benefits paper for his Chemo and Radiation no one seems to know where we get this information we tried the hospital VA Social Security

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