Whether you have a complicated illness, or receive routine care, your health history is a crucial part of your health puzzle. If you are seeing a new doctor or moving to a new location, getting copies of your medical records is key to receiving good medical care. Of course, you want each of your doctors to see your entire health history, including past illnesses, tests and associated results, medications prescribed and other key facts. Clearly, doctors can struggle to diagnose and treat patients when they do not have access to a complete set of records. Additionally, it’s important to periodically review your records to make sure they don’t contain mistakes. So, how do you get copies of your medical records?
Where are your medical records?
Unfortunately, your medical records are likely scattered among various doctors’ offices and hospitals, making it hard to track down and receive a complete set of records. Old paper records, which often never become digitized, may be gathering dust in your doctors’ filing cabinets and hospital records departments.
If your doctors use EHRs, you should easily find appointment notes and test results through the portal used by each doctor and hospital. However, sending digital records from one provider to another is not always easy since many EHRs don’t talk to each other. And older EHR systems can be quite hard to access.
What about older records?
It’s possible that providers you used in the past might not have your records. Federal and state law dictates how long doctors, hospitals and other providers must keep medical records. Often they must keep records for 7-10 years after a patient’s last visit. Those treating children are usually required to keep the records until the child is 21 years old. You can learn about your state by searching for “how long does a medical provider need to keep records” and your state.
Clearly, if your records are old, paper files, there is a chance they have been destroyed. However, the widespread use of EHRs increases the chance that your records will be maintained.
You have a legal right to get copies of your medical records.
Even though it might not always be easy, you are legally allowed to access and obtain copies of most of your medical records, according to the HIPAA law enacted in 1996. Whether your records are digital or in paper files, this law provides patients with access to a broad range of health information, including the following:
- Clinical notes and records that the provider created him/herself
- Test results, including:
- Blood work
- Genetic tests
- Results from imaging tests, such as x-rays and MRIs
- Screening tests, such as mammograms and colonoscopies
- Wellness and disease management notes, including information used to make decisions about diagnoses and treatments
- Billing and payment records
- Insurance information
However, medical providers are not required to create new information upon record requests, such as “explanatory materials or analyses“, that does not already exist in the patient’s records.
New laws will make getting your records even easier.
On March 9, 2020, the Department of Health and Human Services (HHS) released updated rules that require healthcare providers, payers and health IT vendors to make it easy for patients to access and share their medical records. The changes outlined in this 1,500+ page documents will require time and money to implement, so don’t expect any quick improvements.
And, as you might expect, there is controversy over implementation issues. The new rules require payers and providers to use standard APIs that would allow outside apps to connect with EHR systems so patients can easily load their medical information onto apps. Although many providers already follow these standards, some hospitals and health IT companies are concerned that this could lead to privacy concerns. So, before you use an app to store your health data, make sure you know what exactly information you are sharing and what privacy protections you are agreeing to.
Which records can providers deny access to?
Although the law allows you to access and obtain most of your medical records, there are some medical records that providers can legally withhold from sharing. Firstly, providers are not required to share information that is not related to a particular patient’s care, such as general quality assessment records and those related to business planning and development.
Additionally, HIPPA outlines 2 categories of records for which patients can be denied access:
- The personal notes of a mental health care provider which document or analyze the contents of a patient’s counseling session. These notes are generally kept separate from the rest of the patient’s medical record.
- Information compiled in reasonable anticipation of, or for use in, a civil, criminal, or administrative lawsuit or proceeding.
It’s worth noting that a doctor cannot deny a patient request for records due to concern that the information may hurt the patient’s feelings. However, providers can deny access if they think releasing the information may lead patients to harm themselves or others.
Lastly, if a doctor is denying access, he/she must provide a written denial.
Who has the right to access your medical records?
Of course, as a patient you can access and obtain your own records. Similarly, parents and patient guardians can access to the patient’s records. Additionally, patient’s authorized representatives, such as caregivers or advocates (with written permission from the patient) can access the patient’s records.
Additionally, other individuals and organizations may have the right to access your records, including your primary care doctor, your health insurance company, hospitals, labs, and nursing homes.
Whether you want to have them for your personal use, or you want to share your medical records with a new provider, you likely need to make a formal request. And don’t be surprised if you face some resistance. Some doctor’s offices refuse to mail or email records to patients due to concerns about privacy.
Moreover, HIPAA regulations protect patient privacy, but the extensive rules can be confusing. This can make it hard to get your medical records – even when you are legally entitled to obtain them. However, it is possible to get your records – most of the time.
And don’t think that EHRs make this process seamless. Sending digital records from one provider to another is not always easy since many EHRs don’t talk to each other. And older EHR systems can be quite hard to access. But, you you may be able to print a hard copy of your EHR records, if desired.
Finally, if you want copies of lab tests or records from a hospital stay, it might be easier to try to get the records directly from the lab or hospital, instead of from your doctor.
How to request your medical records.
Contact your provider or organization and ask them how you can get copies of your medical records and/or how to send your records to another provider. Most doctor’s offices, hospitals, labs and other providers require you to fill out a form to request your medical records. If they don’t have a form, ask what information you must provide to get your records.
And don’t expect your records to immediately appear. Although state laws vary, typical delivery time frame is within 30-60 days of the request.
When possible, keep a copy of your original request, until you receive the documents (or have confirmation that your new provider received the information).
What if your doctor denies your request?
If you don’t receive the requested records after repeated attempts, contact your state’s Department of Health. You can find your state’s office by searching for “Department of Health” and the name of your state.
Additionally, if you feel your provider is unfairly denying you access to your medical records, you can file a complaint with the Office for Civil Rights (OCR) at the Department of Health and Human Services. If the OCR believes your complaint is justified, they will direct the provider to take corrective action. They can also enforce a settlement if they believe the denial caused patient harm. Note that you must file a complaint within 180 days of when you knew that the act or omission occurred. File your complaint here.
Furthermore, the HIPAA regulations prohibit any retaliations against anyone filing a complaint, such as denying services or increasing fees. You should notify OCR immediately if you think a provider is retaliating in any manner.
Finally, you can also file a complaint with OCR if your confidential medical information was inappropriately shared or breached.
What if your doctor is no longer practicing medicine?
If your doctor leaves or sells his/her practice, retires, or dies, you should still be able to get your records. But it might be a bit trickier. In these scenarios, the law requires medical records be transferred to another doctor who agrees to take responsibility for the records. If there is no provider willing to take the records, they can be stored with a secure, reputable storage company. Even death doesn’t get a doctor off the hook – the doctor’s estate must keep the records or transfer them to a willing doctor.
You might find it difficult to locate your records if your doctor no longer practices in the office you saw him/her. But, there are a few people and places you can reach out to:
- Your doctor’s partners who are still in practice.
- A health information or medical records manager at the hospital where your doctor practiced.
- The local medical society in your community.
- Your state’s medical association.
- Your state’s department of health.
Additionally, you can call your health insurance company to see if your doctor is an approved provider in another location. If so, your insurance company can give you their new contact information.
Still can’t get the information you need?
If these steps don’t lead to your records, do some digging and gather the records piece by piece. Contact the labs, specialists, testing sites, hospitals, and specialists you used. If you need help creating this list (and who wouldn’t?), talk to your health insurance company. They can likely provide you with the details of any claims filed on your behalf. Warning – this could be a slow, frustrating process – but if you need specific information, you likely will be able to find it.
Finally, even if you owe money to the provider, the law still entitles you to copies of your records.
The importance of reviewing your records.
If your medical records contain mistakes, including mistakes regarding diagnosis, tests, and medications, this misinformation will travel with you if no one makes corrections. And this can lead to dangerous be a frustrating, and dangerous, problem. So, take the time to regularly review your medical records, both your current and older records. And notify your provider when you notice an error – the sooner the better. If your provider refuses to make a correction that you think is needed, or one that you think may place you in danger, submit a complaint to the OCR.
However, you should understand that doctors can, and should, express medical opinions in your record, even if you don’t like what it says. For example, you cannot ask a doctor to remove a note in your record about something you don’t want shared, such as alcoholism or drug use, if he/she thinks it may contribute to an illness or health concern.
For more information on problems with EHRs, read:
Old paper records can be tricky.
If you find your old paper records, you may face another kind of struggle. Old records may require decoding notoriously difficult doctor’s handwriting and/or cryptic lab results. Patients and doctors can find it quite difficult to decipher the information.
Start planning now – before you need copies of your medical records.
To make your life easier in the future:
- Maintain a running list of each doctor you have seen, including what years you were under his/her care. It may seem obvious now, but in 15 years it will probably be hard to remember the name of the cardiologist who did your stress test.
- Record important medical milestones, including surgeries, hospitalizations, MRIs, CT scans and other important tests, and immunizations. Record when and where each “event” occurred; include the name of the doctor(s) involved, and a few details regarding findings and outcome. Keep this information together electronically, or in a notebook or file folder.
- Ask your doctor to print out summary notes from each appointment. Read these for accuracy and let the doctor know if you notice a discrepancy. Keep all of these notes in a file or scan them and save them on your computer.
- Get copies of test results, including discs with results of scans, and keep them in a safe place.
For more information related to medical records, read the following posts:
- Why Take Detailed Notes at Doctor Appointments?
- The Benefits of OpenNotes.
- Should You Record Conversations with Your Doctors During Your Medical Appointments?
- Understanding Medical Information Is Harder Than Most Realize.
- Keeping Your Medical Information Organized Is Easier Than You Think.