A health record is a written account of everything related to your health. It may include:
- Prescription medications
- Notes from doctor's appointments
- Lab tests
- Other treatments prescribed
Why You May Need Your Medical Records
You may want your medical record for personal curiosity, to have a copy in case it's needed, or to send information to your new doctor. As a caretaker for someone else, you may request their record for similar reasons. Other reasons you may want your health record include:
- Sharing information with family members
- Coordinating health care between several practitioners
- Checking your information to make sure it is accurate
- Making sure you don't repeat any tests or procedures
- Sharing children's health information with schools, camps, or other places that might request it
How to Request Your Health Records
These days, it's easier than ever to access your health record through an online portal or mobile application. Some doctor's offices, though, may still use paper files. Either way, most medical practitioners in the U.S. are legally obligated to give you your medical record when you request it. But they may all have a different requesting procedure. Here are a few ways you can look up your medical record or find out what the requesting procedure is.
Step 1: Check your online patient portal, if you have one. If you have an online patient portal with the hospital or medical clinic you frequent, some of the information you would like may be readily available to access and print out, like details about prescriptions or immunizations. Your patient portal may also have a specific area where you can request your full medical record.
Step 2: Check your doctor's website. If you visit a medical practice, your doctor may have details on how to request your medical record on their website.
Step 3: Call or e-mail your doctor directly. By doing so, you can ask how you can request your health record.
Step 4: Fill out a form. Many doctors have a form you can fill out either online or on paper to request your health record. This form may include:
- Your name, date of birth, and record number or the same information of the person whose medical record you're requesting on their behalf.
- The doctor or clinic within the practice you need information from.
- The range of dates you would like information from.
- The type of information you would like to see on the record.
- Where the records should be sent.
- Why you want the medical records, though according to HIPAA, the law that ensures your access to your medical records, you don't have to provide a reason.
- The amount of time you permit to share the records.
- If there's a certain date you would like the records by.
- Your signature, the date you signed the form, and your relationship to the person (if it is not you).
- Legal paperwork proving your legal right to access the health record.
Step 5: Follow your provider's instructions for how to submit the form. They may require e-mail, mail, or in-person submission. If you submit in person, be sure to bring a photo ID just in case.
Step 6: Pay the fee. Your doctor can only charge a "reasonable fee" for making paper or electronic copies of your health record and mailing it to you, according to federal law.
Even though you may have to pay a small fee to get your records, your doctor can't deny your request due to outstanding medical bills.
Step 7: Wait up to 30 days for your doctor to release the records and send them to you. According to federal law, if it's going to take longer than that, your doctor needs to let you know and tell you why.
How to Change Your Medical Records
If something isn't right in your health record, you can request a change. Mistakes can include anything from a wrong address to an incorrect diagnosis in the health record.
To request a change, contact your doctor and ask them about their specific procedure. If your doctor's office doesn't have a specific form to fill out to request a correction, write them a letter including the following:
- Your information including name, address, and phone number
- The doctor's information
- The date of service that needs to be requested
- A description of what you want to have corrected
- A copy of the medical record where you found the mistake
- Your signature
Your provider then has 60 days to respond to your request. They may approve your request and update your medical record.
They can also deny your request. In this case, they must tell you why. You can respond to the denial to dispute it or you can request that your doctor include a copy of the denial in your medical record.
All About HIPAA
HIPAA is a federal U.S. law that ensures all people have the right to access their medical records. It also controls who can see or share your medical records.
The only information you don't have a right to access under HIPAA are notes taken by a provider during a psychotherapy session. These are separate from your medical record. Your psychotherapist needs your permission to disclose most types of information from these notes.
Entities that must follow HIPAA include insurance plans, most healthcare providers, health centers that process data, and business associates of the aforementioned places, like lawyers and IT teams.
Entities that are not covered by HIPAA include:
- Life insurers
- Places of work
- State agencies
- Law enforcement
- Workers compensation providers
Providers who must follow HIPAA are obligated to:
- Allow you to access your health records
- Allow you to correct your health records
- Tell you if and how they share your health information
- Allow you to decide if you would like your health data shared for research or marketing
- Allow you to file a complaint with your provider
- Safeguard your information to try to prevent unauthorized people from seeing it
- Train employees to protect your health record
Children age 17 and younger need a parent or guardian to request their health or medical records. Adults age 18 and older can request their records themselves and don't have to share them with anyone, including their parents.