There are many reasons why you might ask for copies of medical records for yourself or someone you care for, such as your child or other family member, ranging from curiosity to investigating a medical malpractice lawsuit. You have the right to access and obtain copies of your records.
Getting copies usually involves making a written request to your doctor or health care provider and paying copying fees. However, your medical record isn't found in just one file, so how do you draft your records request?
Keep this task simple and straightforward, and learn how to identify and ask for the exact records you want.
Defining Your Medical Record
Medical records is a general term for all, any, or some of your medical and patient information and documentation you may want. The files making up your complete medical record may come from doctors and other individual providers, hospitals, clinics or labs. They may be written or electronic.
You may need to contact multiple sources for records relating to a certain treatment, illness or accident. For example, many hospital records reflect the need for mandatory services and procedures performed by third-party providers, such as anesthesiologists, private nurses, and specialists or consultants. However, the hospital file may not include all of that provider's notes, charts or test results.
The scope of provider's records may not be complete, either. For example, a chiropractor's records may contain a detailed summary report from an MRI diagnostician, but possibly not the films and charts. A treating physician's records will contain any prescriptions written for a patient, but not the related pharmacy records.
Drafting Your Request
HIPAA (Health Insurance Portability and Accountability Act) and other laws reflect more detailed requirements for physicians to release this information. Here's what to include in your request:
1. Identify the patient, whether it's you or someone you represent, such as your child. Include your complete name, along with any alternate names, your social security number, birth date and patient number (which may be different from your account number).
2. Treatment date or date range, and the nature of treatment. Use this information to limit your request to a certain time, illness or incident. Otherwise, some providers may copy all records, and that may not be what you wanted or needed.
3. List specific records. You can ask for specific records to avoid charges for items you don't want or need. In your request, use phrases such as:
- "a full and complete copy of all medical records in your possession, including but not limited to (enter a description of the treatment or illness you want records for)," or
- "a full and complete copy of only those records as follows: (enter detailed list of the precise records you want, such as X-rays and diagnostic notes, as well as a description of the treatment or illness connected to the records)"
4. In a letter to a treating physician you may want to include a request for:
- Itemized billing statements and receipts
- Office and staff journal, diary and notes
- Prescription records
- Laboratory tests and evaluation reports
- X-Ray and/or MRI films
- X-Ray and/or MRI reports
- Vaccination records
- Hospital inpatient visits and treatment records
- CAT, EEG, EKG, NMR, fetal monitor or other test results
- Results of diagnostic tests
5. To a hospital or clinic, you may want to add a request for:
- Admitting records
- Anesthesiologist's records
- Emergency room records
- Dietitian's records
- Discharge records
- Nurse's Cardex
- Outpatient records
- Pathology reports
- Pre- and post-operative reports
- Therapy records
6. Arrange for payment and confirmation before completing your request. You may want to know the extent of the files to be copied and the final copy charges.
Don't expect copies of medical records overnight. Give a provider a reasonable time to respond to your request, such as ten days to two weeks. Priority may be given to certain requests, such as a specialist needing them for a critical patient. Your advance planning and effort pays off when you receive the records you expected with a minimum of delay or mistakes.
Questions for Your Attorney
- Does state law penalize a provider's failure or refusal to provide me access or copies of my medical records?
- Can I request someone else's medical records if I am that person's agent named in a durable power of attorney?
- Are there laws or rules on how long a provider must keep patient records? Are records storage and location regulated by state or federal law?