What to Request With Your Medical Records
Choose what information you want
Patients can request their medical records in whatever format they prefer, regardless of whether printed or digital. Usually, health care providers will be able to provide your records in your desired format, but some smaller medical practices may only be able to provide paper copies.
While doctors can’t charge access fees for providing your medical records, be informed that they can charge for “reasonable” costs of copying and printing your records. If you have a long or complex medical history, that can add up.
You can limit your request for medical records to certain time periods if you want to. You can also ask that you only get records that are for a certain condition or specialist, but you run the risk of missing key information.
Information that is included in your medical records include
- The initial history and physical examination from each doctor.
- Consultation reports from specialists, as well as any notes
- Operative reports
- Test results, especially those used to track chronic conditions or showing meaningful test results
- Current medication list
- Discharge summary if you were hospitalized
Information that may be excluded from medical records
- Psychotherapy notes
- Information that could endanger the physical safety of the patient or another person
- Information compiled for use in a lawsuit
- Information that is part of a research project while it is still in progress
- If your request for information would reveal the identity of a source that was promised confidentiality
Certain medical information such as HIV/STD records may require further authorization in addition to your initial request.
How to Request Your Medical Records
There are several ways you can request to see or get a copy of your health information. Health care providers that are affiliated with larger medical practices or hospitals may offer electronic access to your medical records. In many instances, these internet access systems offer summaries of care and medical tests, rather than full medical notes and detailed test results. If you have a relatively simple medical history and needs, these summary results may prove sufficient for you.
Typically these systems allow for internet download only after you have created an account. Before linking to these systems, make sure that your computer has the latest updates to its operating system, antivirus software, and web browser in order to ensure a secure connection and retrieval of your information. Check with your doctor’s office for instructions on access to the system or systems your doctor or hospital uses.
Under HIPAA, the federal law regarding medical information storage and access, you can request copies of your full medical records from all of your healthcare providers. This can be done in person or by written request; it may be possible to do so over the phone, depending on whether your healthcare provider feels that an appropriate level of proof of identity can be provided in this way.
- If you go in person (or are allowed to do so by phone), make sure to bring appropriate identification, typically either a state license with photo or a US passport, if you are requesting your own records. You will typically sign a written form confirming your request for your medical records at the office.
- If you make a written request, check with your healthcare providers’ office to see what information they need on your letter, and make sure to sign using your full, legal name, if you are requesting your own records.
- Regardless of how you request your medical records, make sure you have the following information readily available.
- your name, including your maiden name (if applicable)
- Social Security number
- date of birth
- address and phone number
- record(s) being requested
- date(s) of service (months and years under the doctor’s care)
- If you are requesting up another person’s records, you will require additional legal documents and information to demonstrate your right to access records on another’s behalf. Generally, a provider must allow a “personal representative” to receive a copy of protected health information.
Remember that each healthcare provider is only required to store and provide access to records documenting healthcare they provided. If you have used multiple physicians or have a complex medical history, you will have to contact all of these healthcare providers to make sure you have a complete medical records history.
What to do if you have trouble
While many healthcare providers are comfortable with the provisions of HIPAA, there are still a substantial number of people with dated or incorrect interpretations of patient access rights and believe that any release of medical records–even to the patient–is a violation of HIPAA medical information protection rules. You can refer problematic administrators to this federal document, which may help.
Other situations can be more complex or require further documentation. Generally, a provider must allow a legally designated “personal representative” to request and receive a copy of protected health information for another person (such as your child, your parent, or your spouse. You can read more about this in “Your Right to Request”
If you’ve made a written request and received no response, don’t assume the worst. Try calling your healthcare provider’s office and confirm that they’ve actually received your request. If they confirm receipt but haven’t done anything or object to the request, ask to see the provider’s “Notice of Privacy Practices,” which should include the contact information for a privacy official who can help. And remember, healthcare providers have 30 days to gather and provide copies of your medical records, so make sure you’ve allowed enough time. If you feel your rights to access your health information in a timely fashion have been violated, you can file a complaint with with the U.S. Department of Health & Human Services; just make sure to file the complaint within 180 days.
Special instructions for veterans’ medical and health records
Veteran and military medical records have been held by various military and government agencies at different times, and each service branch has had slightly different policies with regard to these records. Making things more complicated is that military medical records were treated differently depending on whether they related to outpatient medical services or were related to treatment requiring a hospital stay, so you will likely have to check in at least two places for complete military medical records history:
- Since 1960, hospital inpatient records only have been maintainedin the
Official Military Personnel File (OMPF) at the National Personnel Records Center (NPRC). NPRC has maintained these records in bulk accessions retired each year by the creating hospital, rather than with each individual personnel file. Therefore, most of these hospital inpatient records are filed by the name of the hospital in which the service member was treated. As such, the NPRC needs the name of the hospital, month (if known), and year of treatment, as well as the veteran’s name and Social Security or service number to locate these clinical records.
- Health records covering the outpatient, dental and mental health treatment that former members received while in military service are stored in a different location. Health records include induction and separation physical examinations, as well as routine medical care (doctor/dental visits, lab tests, etc.) when the patient was not admitted to a hospital. Military medical records and hospitalization records from the Department of Veterans Affairs (VA) are not included in these medical records. In general, those discharged from military service after 1979 will find their service medical records at the Department of Veterans Affairs.