You have the right to see your medical record. You also have the right to get a copy of your medical record. These rights are often called the right to access your medical record.
Usually, your health care provider must respond to your request for your medical record within 15 days of receiving your written request.
Generally, your health care provider must give you a copy in the format that you request if they are able to do so.
You may have to pay a fee to get a copy of your record.
How Do I Ask for My Medical Record?
You should ask your health care provider about their specific procedures for getting your medical record. Often, your provider has a form for requesting your medical record. You should use this form if one is available. You should be able to find some information about getting your medical record in your health care provider’s notice of privacy practices.
What information should I include in my request for my medical record?
Generally, your request must be in writing. You must sign and date your request. You must also identify the information that you are requesting. For example, you might want to include:
- Any prior name you may have used (such as your maiden name).
- Date(s) of treatment or service (such as dates you were in the hospital).
- Whether you want the entire record or just part of the record.
- Medical condition for which you are asking information.
- Specific test results.
- Whether you want X-rays or records made by heart monitors or similar medical devices.
- Whether you want to see your medical record, want a copy of your record, or would like both.
Can my health care provider require that I include my Social Security number in my request for my medical record?
Yes. Because some health care providers use Social Security numbers as a way to identify medical records, they may need your Social Security number to locate your medical record. There is nothing in the HIPAA Privacy Rule or the Social Security Act that prohibits a private provider from engaging in this practice.
Do I have to choose between seeing my medical record and getting a copy of it?
No. You have the right to do both.
Can my health care provider require me to show some proof of who I am in order to see or get a copy of my medical record?
Yes. Your health care provider must make sure you are the person who has the right to get the medical record before they give it to you. Your provider is allowed to choose the method for verifying your identity. For example, your provider might ask for an identification card (such as a driver’s license).
If you are acting as an agent under a health care power of attorney, you should include a copy of the power of attorney form with your request. If you are requesting medical records of a deceased patient, you should include documentation that you are authorized to have access to the deceased’s medical records, such as proof that you are the administrator or executor of the deceased's estate.
What Will Happen If My Request for My Medical Record Is Accepted?
Your health care provider will inform you if they agree to give you your medical record. If you asked to see your records, your health care provider must arrange a convenient time and place for you to review the record. If you have requested a copy of your record, your health care provider must either send it to you or arrange for you to pick up a copy.
How Long Should It Take My Provider to Act on My Request for My Medical Record?
Within 15 days of receiving your written request for your medical record, your health care provider must take one of the following actions:
- Let you see or give you a copy of your medical record
- Inform you if the information does not exist or cannot be found
- If the health care provider does not maintain the record you requested, inform you and provide the name and address of the health care provider who maintains the record or
- Tell you that they are denying your request for your record.
Can My Provider Charge Me for Copying My Medical Record?
Yes. Generally, health care providers may charge you a reasonable, cost-based fee for copying your medical record. The fee can include the cost of supplies and the labor for making copies. Your provider can also charge you the actual cost of postage if you have the copies sent to you.
Can I be charged if I just want to look at or read my medical record?
No. Your health care provider cannot charge you a fee if you just look at or read your medical record.
Can I be charged a fee for someone searching for and retrieving my medical record?
No. The HIPAA Privacy Rule does not allow health care providers to charge search or retrieval fees.
Can I be charged for copies of X-rays and similar records?
Yes. Your provider may charge you a reasonable cost-based fee for copying x-rays, fetal monitoring strips and other records not in standard paper form.
Can I be charged if I want a copy of my medical record sent to another health care provider or to a lawyer?
The procedures and fees for having a copy of your medical record sent to someone else (such as to another doctor or to a lawyer) are not covered by the HIPAA Privacy Rule. They are not discussed in this guide.
Can I Have My Medical Record Sent Somewhere Other Than My Home Address?
Yes. You can ask your health care provider to send the copy of your medical record to your regular address (such as your home) or to a different, preferred address (such as to your office or to a friend’s house). As long as your request is reasonable, your provider must send your record to the place that you identify.
Can I Get a Paper, E-mail, or Fax Copy?
It depends. Generally, your health care provider must give you your medical record in the format that you request if it is not difficult to do so. For example, if you request a paper copy of your record, your provider generally must give you a paper copy.
Providers also must make sure that they send your records to you in a secure manner. Due to security concerns, many health care providers are reluctant to send copies of medical records by e-mail or fax. You should check with your provider to see whether they are willing to send you a copy by e-mail or fax and to find out their specific procedures.
Can I get a Summary or Explanation of My Medical Record?
It depends. You may want just a summary of your record. You may want your provider to explain some of the information in your record. Under the HIPAA Privacy Rule, your health care provider can give a summary or explanation of your medical record if you both agree in advance
- That it is all right for them to give you a summary or explanation, and
- To the fee, if any, they want to charge for writing the summary or explanation.
If your health care provider agrees to give you a summary, they generally must give it to you no later than 30 days after they received your request. If they are unable to produce the summary in this time, they can get a 30-day extension. Sometimes it can take longer.
Your provider can charge you a reasonable fee for the actual time they spend preparing the summary or explanation.
Leon asks for a summary of his medical record. The record does not currently contain a summary and the doctor does not have the time or staff to prepare one. Leon’s doctor is not required to prepare a summary in response to Leon’s request. But the doctor must let Leon see or get a copy of his medical record.
I received a copy of my medical record, but I can’t understand it. Doesn’t my provider have to give me a copy that is in plain language that I can understand?
No. Health care providers often use technical words or a type of medical shorthand. Providers are not required to translate this information for you or give you your medical record in a form that you can understand. If you cannot understand what is written in your medical record, you can request an explanation of your record. But your provider is not required to give you an explanation. You can find some resources that explain medical terms in Section 6 of this guide.
Can My Provider Deny My Request for My Medical Record?
Yes. Your health care provider can deny your request to see or get a copy of your medical record, but only for a few reasons. For example, if your treating physician determines that letting you see your record might physically endanger you or another person, they can deny your request.
The rules that control whether a provider can deny your request to see or get a copy of records related to mental health or substance abuse conditions or treatment may be different and are not discussed in this guide.
How will I know if my request for my medical record has been denied?
Your health care provider must tell you in writing if they deny your request for your medical record. They must tell you why your request was denied. They also must tell you if you have a right to have their decision reviewed and how you can file a complaint.
Generally, your health care provider must give you this information within 15 days of receiving your request for your record.
Can my health care provider deny my request for my medical record just because they think I might get upset if I read it?
No. Your health care provider cannot deny you access to your record because they think the information in the record might upset you or that it might cause you mental harm. However, they can deny your request if they believe you will become upset enough to physically harm yourself or another person.
Can my health care provider deny my request for my medical record because I have not paid my medical bill?
No. Your provider cannot deny your request for your medical record because you have not paid your medical bill.
My medical record contains some information that my provider is allowed to deny me access to. Does this mean that I can’t get any of my medical record?
No. Your health care provider must give you as much of your medical record as possible. Your provider may remove only the information that they are allowed to refuse to give you access to.
What Can I Do if My Health Care Provider Denies My Request for My Medical Record?
If your health care provider denies your request for your medical record because they believe that seeing it might endanger you or another person, you have the right to have a different health care professional review their decision.
At the time your provider denies your request for your record, they must tell you in writing if you have a right to a review. They also must tell you how to ask for a review.
In Virginia, there are two ways that you can obtain a review. First, you can select the reviewer. If you want to select the reviewer, you must designate the physician that you select in writing. You also must pay for the review. Alternatively, you can allow your health care provider to choose the reviewer. If your health care provider selects the reviewer, you do not have to pay for the review. The reviewer selected (by you or your health care provider) must have a license, training, and experience related to your condition that are at least equal to those of the physician who denied your request.
The reviewer makes the final decision whether you are allowed to get your medical record.
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