What is Medical Records?
The terms medical record, health record and medical chart are used somewhat interchangeably to describe the systematic documentation of a single patient’s medical history and care across time within one particular health care provider’s jurisdiction
How to Request Your Medical Records
Most practices or facilities will ask you to fill out a form to request your medical records. This request form can usually be collected at the office or delivered by fax, postal service, or email.
If the office doesn’t have a form, you can write a letter to make your request. Be sure to include:
Your name
Social Security number
Date of birth
Address and phone number
Email address
The list of records being requested
The dates of service
Delivery option (fax, post, email, in person)
Signature
Once the request has been made, you may have to wait a while before the records are actually received. State laws vary but typically require delivery within 30 to 60 days. Be sure to keep a copy of the original request, and contact your state’s Department of Health if you fail to receive the documents after repeated attempts.
Cost of Service
Be aware that you may have to pay for the cost of your medical records if you want them delivered on paper, by fax, or via electronic media. While the price can vary, it must be reasonable.4
Moreover, you are entitled to the records even if you haven’t paid the healthcare provider or facility for the procedure involved. The records cannot be withheld for non-payment, and you cannot be charged an exorbitant fee to compensate for the non-payment of services. If monies are owing, the healthcare provider or facility can pursue avenues for collection, such as legal action or a debt collection service.Costs for Copies of Your Medical Records
For a Healthcare Provider No Longer in Practice
If your healthcare provider retires or is no longer in practice, all medical records must still be maintained under the law. This pertains even if a healthcare provider has died or dissolves the practice without a sale.
Under the law, the medical records should be transferred to another healthcare provider that agrees to accept the responsibility.6 If a provider cannot be found, the records may be archived with a reputable commercial storage firm.
Similarly, if your healthcare provider has left the practice but the practice is still operating, your records must be maintained by the remaining members. If the practice was sold, the new practice will be responsible for the maintenance of the records and be liable if the records are lost or mishandled.
Tracking down your records can sometimes be a challenge, particularly if a healthcare provider’s office was closed with no forwarding details. In this instance, there are several things you can do:
Contact your state or local medical society. Many of these organizations require annual registration, they will most likely have the latest contact information.
Speak with your health insurance company. If the healthcare provider is still an approved provider, your insurer will have contact details.
Contact any hospital where your healthcare provider made rounds. Hospitals require healthcare providers to undergo a formal process to obtain hospital privileges. Human resource departments will usually have details on file.
If all else fails, you may need to reconstruct your file by contacting the various labs, hospital, or specialists you used. Your health insurers, both past and present, can provide you with the details of any claims made on your behalf.
Correcting Errors
Once you’ve obtained a copy of your medical records, review them carefully. If you find errors or omissions, you will want to have them corrected immediately to ensure that they don’t compromise your future care.
Most providers will agree to correct factual errors or track down reports that should have been maintained in your file.
However, this does not extend to differences of opinions for which your healthcare provider has the right to express a medical opinion. This includes notes regarding contributing factors to an illness (such as alcoholism or HIV) that you would rather not have in your medical records. Altering or omitting the records would not only be ethically problematic, it could subject the healthcare provider to legal action.
With that being said, if you believe that the refusal of a correction is unjust or places you in harm’s way, submit a complaint to the OCR detailing the dispute. They can review the evidence and decide if the correction is warranted.