Summary

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 record no later than 30 days after receiving your request.

Generally, your health care provider must give you a copy in the format that you request if they are able to do so.

In many cases, your provider may charge you a fee to copy your medical 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.

Can my provider require that I put my request for my medical record in writing?

Yes. Your health care provider can require that you put your request in writing. Your provider must let you know that they have such a requirement.

What information should I include in my request for my medical record?

If your health care provider does not have a form for requesting your medical record, you should check to see what information they require. Generally, when you ask for your medical record, your request should include:

• The date of your request.
• Your name, address, telephone number or other contact information.
• Any previous name you may have used (such as your maiden name).
• Your date of birth or medical record number.
• Date(s) of treatment or service (such as dates you were in the hospital).
• A description of the information that you want to see or copy. This might include:
  • 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.
• If you are requesting the medical record of someone else as their personal representative, your relationship to the patient.

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 under a medical power of attorney, your provider may require you to show them a copy of the form. If you are requesting medical records as the personal representative of a deceased patient, you should expect to show documentation 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 to Get My Medical Record?

Generally, no later than 30 days after your health care provider receives your request, they must either

• Let you see or give you a copy of your medical record or
• Tell you that they are denying your request for your record.

Can it ever take longer?

Yes. If your medical records are kept off site, your health care provider can take up to 60 days to respond to your request.

If your provider cannot respond in 30 days (or 60 days if your records are kept off site), they can get one 30-day extension. Your provider must give you a written explanation for the delay and tell you the date they expect to respond. It should not take more than 90 days total to get a response to your request for your record.

When does the 30-day time period begin?

The 30 days does not start until your provider receives your request for your medical record. If you mail your request, you should include some time for mail delivery when you compute the date you should receive your record.

Can My Provider Charge Me for Copying My Medical Record?

Generally, health care providers may charge for copying your medical record. In West Virginia, your provider is allowed to charge you no more than $0.75 per page.

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. Your health care provider may not charge you a fee for searching for your record. Although West Virginia law permits providers to charge a search fees, the HIPAA Privacy Rule prohibits them. Because the HIPAA Privacy Rule gives you greater rights in this area, your provider must follow HIPAA. Your provider may not charge these fees.

Can I be charged for a copy of my medical record that I need to support a Social Security claim or appeal?

It depends. If you are indigent (poor), your health care provider must give you one free copy of your medical record if the record is necessary to support a Social Security claim or appeal. You are eligible for a free copy of your medical record if you are represented by an organization or free law program that provides legal assistance to indigent people. You can also show that you qualify for a free copy of your medical record by stating on your request for your medical record that you need the record to support a Social Security claim or appeal. Along with your request you must submit reasonable proof that you are not financially able to pay full copying charges due to:

• Unemployment;
• Disability;
• Income level below the federal poverty level; or
• Receipt of state or federal income assistance.

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. In West Virginia, you may also obtain the original x-ray upon request and payment for the exam.

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.

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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?

In West Virginia, providers generally may not deny you access to your medical record.

The rules for mental health records (records related to psychiatric or psychological problems) and records related to substance abuse may be different. Section 6 lists some resources that have more information about getting mental health records.

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 30 days after receiving your request for your record.

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.

What if I send my request to a provider who doesn't have the record I need?

If your provider does not maintain the record that you requested, they must tell you who has the record if they know.

Tony sends a request for his chest x-ray film to his primary care physician. Although his physician has a report of the x-ray results, he does not have the original x-ray film that Tony requested. However, the primary care physician knows that ABC Radiology took the x-ray and has the original film. When the primary care physician responds to Tony's request, the physician must inform Tony to send his request for his x-ray film to ABC Radiology.

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