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How to Gather and Keep Medical Records

As a medical professional for 40 years, I have been able to see what works and does not work in the medical system. Passing that knowledge

how-to-gather-medical-records

Why Should I Keep My Medical Records?

Reviewing your medical records is not only a smart thing to do, but it is your right. It allows to you see if there are any updates to your records that may need to be done. It also allows you to make corrections to your records. You can also discuss with your physician any questions that you may have regarding test results or prescriptions.

If you move to another area or state, you will often ask your previous physician to send your records to a new provider. But you have no say over what is sent. So having your own medical records means that your new medical provider will have a better understanding what is going on with your health.

If you are visiting a new specialist or a physician whom you have never seen before, they may only have a limited amount of information on your situation. You want to make sure that he/she has all the information they need to make a decision for your healthcare.

Other reasons to get your medical records include:

  • If you are going to a new provider (doctor) Or facility. For example, if you are having a new x-ray of your chest, the facility may want the old x-ray to compare with the old one
  • If you go to multiple specialists, the information may not always be shared. Soi having copies on hand in a journal format, will be beneficial when you have an appointment.
  • Some doctors are able to access information from a system while others may not. Several of my doctors can see information from the hospital system. But others may not have that access. I when I have an appointment, I always ask, did you get the blood work or test from.......? You want them to have all the information to make correct decisions for your health.
  • Mistakes happen. You want to be sure that the information in your records is correct and accurate.
  • You can have conversation on any reports or test results with your physician or health care provider
how-to-gather-medical-records

How Do I Get My Medical Records?

Remember, it is your right under the Health Insurance Portability and Accountability Act (HIPPA) to see and get copies of your medical records. Or share it with a third party,

More and more physicians and providers use an electronic program called a patient portal. This is a secure website through your doctor or provider's office. Not all do have it, but those that do, have specific information that you can access and print out for your own use. Just like most secure websites, you will need to provide a username and a password.

Things like recent doctor's visits, discharge summaries, lab and test results, medications, immunizations and allergies are often available.

You may have several patient portals for each of the physicians and hospitals that you visit

how-to-gather-medical-records

What Does HIPPA Say About My Medical Records?

HIPPA is the government rules or laws that govern your medical records. It says what your rights are regarding your records-both electronic and written.

The first thing that you should know is that only you or your personal representative have the right to access your medical records. Your personal representative can be named several ways; state law may affect this process.If a person can make health care decisions for you using a health care power of attorney, the person is your personal representative.

The personal representative of a child is usually the child's parent or guardian.In cases where a custody decree exists, the personal representative is the parent(s) who can make health care decisions for the child under the custody decree.

No doctor can send your records to any other doctor without your permission.

A physician cannot deny your records to you because you have not paid your bills. He/she may level a reasonable fee for copying or mailing your personal records.

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Who Can Get My Medical Records?

Of course you as the patient have the right to your medical records. Others who can obtain your records include:

  • A third party who is designated to obtain your records
  • A person who has the legal designation by you to act in your behalf to make medical decisions for you
  • An executor of an estate can obtain a deceased persons records. They may have to petition a court to do so

For records on your minor child, check with the facility or your state law. If a child is 18 years old or older, he/she has complete control over the medical records, even if you are providing the medical insurance.

For records of married individuals, you will either need to be the designated person to make health care decisions by that person. Or the person can request that you ask if their behalf.

Steps To Obtain Your Medical Records

Getting your medical records should not be complicated or taxing if you follow systematic steps to get them. You often will need a photo ID to obtain your records.

  1. Call the facility or provider's office to get the information on their requirements. Sometimes that information on their requirements are on their websites. Contact the medical records department if they have one. They will be able to explain the procedures.
  2. Check the patient portal if your provider or facility has one. You may be able to access information and print it depending on the portal set up.
  3. Complete a patient access form to obtain your records. Often these forms can be done ahead of time on the internet or in an email. This is often done online if you are requesting records to be transferred to another provider. The form will require you to state the records or specific information that you need. The more information that you give on the form, the faster your request will be filled.
  4. Indicate to the facility the urgency of your request. If you have a specific time frame that you need these records, explain your needs.
  5. In the case of especially sensitive records such as behavioral, substance abuse, or HIV records, You may have to fill out an additional form.
  6. You will need to provide the name, address and phone number/fax number of the person/ facility that you want the records to be sent.
  7. An authorization form must be signed and validated.
  8. Personal representatives can act in place of the patient if they if they are defined as the person to make health care decisions under state law.
  9. You can request a format such as CD, DVD, Flash or sent by secure email.

More Tips On Getting Your Medical Records

Many facilities have a form that must be filled out in order to get your medical records. But you may not know if they do or not before you get there, unless you phone ahead.

If You Phone Ahead

  1. Ask for the medical records department
  2. Explain that you want to obtain your medical records
  3. Give the dates or the type of medical records you want to obtain
  4. Ask if there is a fee to obtain the records
  5. Ask what types of identification is required
  6. Ask if they have a form to fill out or do you need to supply a letter of request
  7. Ask if a spouse or caregiver can pick up the records

More On Your Rights To Obtain Your Medical Records

how-to-gather-medical-records

How Long Will It Take To Obtain My Records?

If you call ahead to the facility, they will most likely advise you the length of time it will take to obtain your records. Of course, that will depend on the amount of records you are requesting. The larger the facility, the longer it may take to get your records. The average could be anywhere from 1-10 days.

Federal law (HIPPA law) requires that the request for records be fulfilled within 30 days. But the law also allows that they can have a 30 day extension if they explain to you the reason why.


how-to-gather-medical-records

What If A Provider Or Facility Denies Your Request For Medical Records

It does not often happen, but if your provider denies you request or does not respond within 30 days, there are actions that you can take.

If you have asked for your records several times and have either been denied or did not receive an answer at all, you can notify the Department of Health in the state where you live. You can get that information by typing "Department of Health in (whatever state you live in) in your favorite browser

Additionally, if you feel your provider is unfairly denying you access to your medical records, you can file a complaint with the Office for Civil Rights (OCR) at the Department of Health and Human Services. If the OCR believes your complaint is justified, they will direct the provider to take corrective action. They can also enforce a settlement if they believe the denial caused patient harm.

Note that you must file a complaint within 180 days of when you knew that the act or omission occurred. File your complaint here.

Furthermore, the HIPAA regulations prohibit any retaliations against anyone filing a complaint, such as denying services or increasing fees. You should notify OCR immediately if you think a provider is retaliating in any manner.

What Records May My Provider Deny To Me?

There are some records that may be denied to you. Some of these may include:

  • Psychotherapy notes
  • Any records that pertain to quality assurance
  • Records that could endanger your life or safety
  • Information compiled for a lawsuit
  • Records that includes mention of another person who may be harmed by the release of the information
  • Records that breach the confidentiality of a third-party who was promised confidentiality
  • Records that are part of ongoing research that has not been completed
  • Records that may compromise your health, safety, custody, or rehabilitation if you are in prison
how-to-gather-medical-records

Is There A Fee To Get My Medical Records?

Any facility or provider (doctor) can charge a fee for the labor involved in providing your medical records. But they cannot refuse your records But they cannot refuse your records to you if you have not paid for any services or treatment.

HIPPA laws (federal law) provide the limits that facilities or providers can charge. State laws cover the amounts that lawyers and other third parties can be charged.

Some facilities wave the fee, especially if the records are being sent to another doctor or facility.Some will not charge a fee up to a certain limit and then add on fees above their limit. Always ask the facility or provider what fees may be asked for so that you are prepared with the amount in hand.

how-to-gather-medical-records

What Should You Include In Your Personal Medical Records?

There are a few things that you should have in your personal medical records especially if you are starting out from scratch:

  1. The names, addresses, fax and phone of all of your health care providers
  2. The names and contact information for next of kin or caregiver
  3. The names and information about your insurance carriers
  4. Copies front and back of your health insurance cards
  5. A list of all your medications-that would include the name and dosage of all your medications. Several of my physicians have message lines where I call for refills. Having that information speeds things up when I need to make that call. Sometimes one of your doctors may order a new medication, but it is important for other providers to have that information. And of course, any new physician will need that information. Include any supplements and vitamins that you may be taking. Some of these may interact with medications. Create a list of all of your meds.
  6. Allergies-to foods, medication, etc
  7. Any medical devices that you use-hearing aids, glasses, oxygen, cpaps, etc.
  8. A list of any chronic medical conditions. You may be able to get this information from your physicians' portal. Most of that information will know. This information may also be on Xray reports too.
  9. A list of past medical procedures and surgeries. This is important information for your history, It gives any of your providers information about what has happened in the past and why. If you do not have that information, your insurance provider may be able to provide that information.
  10. Your most recent test results. If you go to a x-ray facility, you are entitled to copies of your information. Many hospitals have portals where you can get results as well as copies of your tests. Several location's where you have your blood drawn will also have these results.
  11. A list of immunizations. You can often get that information from a pharmacy if you have gotten these immunizations from them. Otherwise, ask for your information.
  12. Your family history. Ask family members what they remember about significant family members for information on past heath histories.
  13. Copies of any advanced directives or living wills

Final Thoughts On Personal Medical Records

While it may take a bit of time to collect all of your medical records, the benefits to you are truly significant. In an era of medical records being computerized, it is essential for you to make sure that each of your physicians that all the information that he/she needs to make about your health future.

Being a partner in your health and heath options means that you take a active role with your health care provider to make the best decisions for your heath now and in the future.

Become an active part of your future heath or for those that you care for and reap the results of a brighter future.

More Information About Your Medical Records

  • Access Memo
    A PDF that explains your rights on medical records

This content is accurate and true to the best of the author’s knowledge and does not substitute for diagnosis, prognosis, treatment, prescription, and/or dietary advice from a licensed health professional. Drugs, supplements, and natural remedies may have dangerous side effects. If pregnant or nursing, consult with a qualified provider on an individual basis. Seek immediate help if you are experiencing a medical emergency.

What Are Your Experiences Getting Your Medical Records?

Linda F Correa (author) from Spring Hill Florida on October 01, 2018:

Thank you for your kind words. I think it is important for everyone to understand their rights.

Cecil Kenmill from Osaka, Japan on September 29, 2018:

This is amazing! You really know you're stuff. This is life-saving information.

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