By Jen Wilding
In the healthcare world, almost everything is heavily documented since the Code of Federal Regulations (CFR) dictates that a lot of the who, what, when, where, and how much/how long gets properly recorded and retained. These records are generally referred to as your Medical Records and they contain more information about your health conditions and treatments than medical bills and insurance records. However, just because these records are tracked doesn’t mean everyone has instant access to view their own medical records. While you do have a legal right to access a copy of your records, by law, to obtain a viewable copy of your collected records, you have to make a specific request for this from your healthcare provider. Here, I will discuss steps to take to make that request and go over the benefits of requesting your records.
What information is included in your medical records?
Healthcare providers such as private practice doctors, specialists, and hospitals must document the following for your records: Your personal health history and current diagnoses, any congenital conditions, dates and times, injuries requiring treatment, any treatment that is issued/prescribed, surgeries, changes to treatments, medications, known allergies, medical assessments and recommendations, first aid records, immunizations, and lab tests and examination results (including Xray images and other imaging scans), and potentially more. These records are so important that even if your doctor were to retire or your local hospital shut down, they are required to transfer these records to another local facility where patient records can still be stored. Records can be a mix of electronic data (digital records) and paper records or images.
Ways you can request your records:
- Directly from a Hospital Patient’s Portal – If you’ve been given an account you can log into by your provider.
- By Online Form via the Provider website (if applicable)
- By Written Letter Request
- By Apps (ex: Apple’s HealthKit for limited record view – if compatible with your provider’s records system)
- In Person
- By Email (though this is not a very secure method)
Also, in some cases, a provider may assess you a minimal fee to cover the cost of the media required to make you records copies: such as paper/ink costs or fee for a CD or data drive. This is something to ask your provider about or to see if their website discloses this cost to prepare for covering that fee as part of your request. Often when a fee is assessed a way to pay by credit card is also offered.
Here’s the information your provider will usually need to get from you in order to honor your request: Your full name, your social security number, your date of birth, your address and phone number, your email address, the list of records being requested, the dates of service related to your request, your preferred delivery option (mail, package, in-person, digital files on data disk or data drive), your signature (if letter) and/or ID (if in person).
If you find this task a bit daunting or something you’d prefer to assign to someone else, you can search online for a reputable company to hire to obtain your records for you.
To request the medical records on behalf of a loved one, be ready to provide legal documentation that you are authorized to make the request and your ID to match your name as someone authorized to make the request. Example: If you are requesting medical records for a person you are caregiving for, many hospital portals allow the patient to designate a caregiver be allowed (added) to access their account and related medical record information. Otherwise, you may be asked to provide Medical Power of Attorney documentation as part of your request.
If you’re requesting the medical records of a deceased loved one, you may be asked for a copy of the death certificate, documents proving your relationship to the deceased, and your reason for making the request.
Should you have any questions about what specific information is required from your provider to complete the request, check their website or call them to ask. They are aware that HIPAA (Health Insurance Portability and Accountability Act) requires them to have a process in place to allow you access to these record copies. States differ on how long practitioners need to retain their records on you, however. HIPAA requires them to be retained for at least 6 years.
How Long It Takes to Get the Records
A physician has 30 days to honor your medical records request per HIPAA regulation. However, if the records are not kept onsite, they are granted an extra long grace period of 60 days to get the information to you.
If your request is not honored in the legally required time, you can file a formal complaint with the U.S. Department of Health and Human Services within 180 days of the time your provider’s violation of this requirement. From there, they will open an investigation, enforce corrective action, and issue any penalties to the provider for the violation.
Benefits of Retaining Copies of Your Medical Records
Since your medical records are scattered among your various providers and each provider maintains records about only their own services and notes related to their treatment with you, the best way for you to remain organized with your medical history is to request records and keep track of these on your own in a large file. Keeping organized in this way gives you an advantage. When a doctor asks: When was your last immunization for ___? Or do you recall why they chose to do this type of surgery over that other type for you? You will have more of the answers to these types of questions in your records.
Convenience for an Emergency or Future Caregiver
Imagine a medical event occurs down the line and you need to be taken from your home in an incapacitated state. Wouldn’t it give you peace of mind now to know your family could just grab a file of your medical records to hand to wherever you’re going to remove any guessing game they may have to do? Sure, they could request your records from your physician, but since that can take days or weeks, having your records all in one place gives your presiding physician the advantage you’ll want them to have regarding your care: knowledge.
To Prevent Unnecessary Testing or Treatments
Keeping records also keeps you up to date on what you still need and don’t need as far as procedures and tests go. Without this knowledge at your fingertips, would you easily be able to catch when a doctor is ordering an unnecessary test that you could simply provide the results of since you were already tested for it recently? Doctors often order tests when they are guessing, but armed with your full medical history, there is less guessing for them to do.
To Avoid Undue Medical Charges
Healthcare providers and insurance companies can and do make mistakes from time to time. They sometimes may even bill you for something that is standard yet for some reason you or your doctor opted you out of. Your medical records can reveal what they are truly authorized to charge you for as they should be an accurate record of what treatments and medications were administered and when.
To Find & Correct Any Mistakes in Your Records
Without seeing what the doctors view about your medical history, how would you ever know if they have mixed up your data with other patients by accident or have notated a wrong medication or dose in your file that other medical personnel may base future decisions off from? Obtaining your records soon after a service puts you on the best footing to double-check that everyone is on the same page. If you happen to notice a mistake, reach out to your healthcare provider administrator to let them know as soon as possible. Data integrity is super important when it comes to healthcare, and you can play a part in helping to ensure your records are well-maintained in this way.
To Document Facts for Medical Malpractice Investigations
An unfortunate reality is that just as people can make costly mistakes with records, medical professionals can also make mistakes that cost life or reduce a person’s quality of life. When they do, we call this medical malpractice.
Should a case or medical malpractice occur as part of your treatment, the first thing an attorney would want to know is if records related to the incident were retained by someone – a doctor, clinic, or hospital. If you already have these documents in hand, your legal advocate can act more quickly to build your case which is especially important considering medical malpractice cases must be filed before your state’s Statue of Limitations is up. For many states, the deadline is a quick 1-2 years from the date of incident!
Having your documents organized gets your case accepted by a legal advocate sooner and can help them file your case sooner. If you think there may have been some medical shenanigans going on in relation to your healthcare that may be considered unlawful, act quickly to document EVERYTHING and request your medical records to be sure everything you know about was properly documented, as well. (Medical Records Documents are relied upon as important evidence in these cases). Then, reach out to us here to let us know what happened to see if you have a case: Medical Malpractice – ALL STATES – Join Class Actions
Start Now and Move Forward
If you’ve had significant medical procedures in the last year or two, now is a good time to request those records for your personal files, if you haven’t already. Then consider making a habit of keeping records up to date as you move forward. Any recent provider who asked you about your health history on your intake forms should have this information in your current records, so it will likely still be captured for your file. You’ll feel so good knowing you’ve taken a huge step toward being your own best health advocate now and into your future.