Medical Records 101

Thanks to federal law, you are entitled to a copy of your complete record - including the doctor's notes. Health care providers are permitted to charge for copying and mailing records. Some states have a statutory maximum charge that ranges from ten cents per page to one dollar per page. A facility or doctor may not make it financially impossible for a patient to exercise the right to medical records by charging an exorbitant charge for copying. To save money:

• If your records are in electronic format:
  • Find out if patients are given access to the database. If so, a pat ient I.D. and password is generally required.
  • If not,  you can ask that a copy of your medical record be e mailed to you, or that it be downloaded onto a disk. There is generally no copying charge if a record is sent electronically. The cost of a disk is minimal. 
• If your records are still on paper: you can request specific documents or summaries within your record rather than a copy of the entire record. For example, you can ask for the problem list, medication list, list of allergies, immunization record, most recent history, physical, consultations, operative reports, pathology reports, and/or hospital discharge summaries.
• If you have to ask for a copy of your record, make certain your request is to the right person or department. While you're identifying the person, obtain their extension number or direct phone number so you can follow-up easily.

Request/Authorization Forms

Most medical facilities have their own patient authorization form that allows for the release of information. If they have such a form, it is generally preferable to use it. In fact, some facilities will not provide you records unless you complete their form.

You may also simply write a letter asking for a copy of your records or requesting / authorizing the release of your records. The letter should contain the following information: (A sample letter follows)

• Your full name at time of treatment
• Dates of treatment for information being requested to the best of your recollection
• Date of birth
• Name and address of the person or facility to which disclosure is to be made
• The specific kind and amount of information to be disclosed, including laboratory results, other diagnostic tests including X-rays, and the doctor's notes
• You may wish to include the purpose of the request, for example, "continuing care" or "insurance" or "my own records"
• Your signature and the date of request
• There is no need to have your signature notarized

For a sample letter, click here. 

For details about regulations about charges in your state, see Georgetown University's Center for Medical Record Rights and Privacy at http://hpi.georgetown.edu/privacy/ .

• If you need to get a file from a medical institution and have difficulty gettng through to the right person or getting the file, ask for the patient advocate or president's office. They can likely get through on different phones or can send an internal message so help speed up the process.
• If a doctor refuses to give you or your representative a copy of your records, ask another doctor to get them for you. As a last resort, consider going to your state's regulatory authority. As a last resort, you can sue.

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