One of the most responsible and useful steps a smart patient can take is to obtain copies of her medical records whenever she visits a doctor for any type of medical problem, even for well visits and check-ups.
According to federal law, we have the right to get copies of most medical records, whether they are paper copies, or electronic health records. Doctors' notes, medical test results, lab reports and billing information must be supplied to us if we ask properly.
The federal law that addresses our medical records is called HIPAA (pronounced HIP-a), the Health Information Portability Accountability Act. These rules mostly address privacy issues, but are so extensive that many healthcare providers are still confused about how to enforce them. That confusion sometimes makes it difficult for us to get our records, even when we are entitled to them.
Who May Request Medical Records and Who Must Share Them
If you want to obtain medical records, then:
- You must be the patient, or the parent or guardian of the patient for whom you seek records.
- If you are not the patient, parent or guardian, then you must obtain written permission from the patient, sometimes using the form the provider gives you. Caregivers or advocates may be able to access records if the patient has provided written permission to the provider.
- The US Department of Health and Human Services provides good background information for understanding who may, or may not, have access to a patient's records.
Providers, including doctors, hospitals, labs and other medical practitioners are required to keep most adult medical records for six years or more, although this varies by the state where the records are stored. In most states, children's records must be kept for three to 10 years beyond age 18 or 21. If you seek older records, contact the provider to see if they are available.
Providers are required to share any notes or records they have created themselves, or any test results for which they have copies. They are also required to share any information provided to them about you by another doctor if that information was used for the diagnosis and/or treatment being discussed with you.
Diagnostic lab test records, for such tests as blood tests, CT scans, x-rays, mammograms or others, should be requested from the doctor who ordered them, or your primary care physician. In most states, the lab will not provide them to you directly.
If you seek hospital records or records from any other medical facility, you'll want to request them directly from that facility.
Be aware that you may be denied access to some records, usually related to mental health records. If a provider believes that letting you look at your medical records can endanger your physical health, your request may be refused. They cannot deny you access just because they think you will be upset, unless they believe that upset will lead to an attempt to physically harm yourself. If you are refused, the provider must make that clear, in writing.
A note about privacy: Many patients believe they or their designees are the only people who can obtain copies of their records. In fact, there are many others who can gain access to your medical records without your permission.
You may also be interested in:
- Learning how much it will cost to get copies of your medical records, and/or
- What to do if you need to get records from a doctor who is no longer in practice.