Your medical records are a vital part of your health care and are also important to your finances. It is advisable that there is at least one place which has a complete, accurate and up-to-date copy of your medical records.  

• If you are in a health care system that uses electronic records, all your records will be in one place, accessible by each of your doctors. To be sure they are accurate, you can ask for access to the system. More and more health care facilities offer patients access to their records online. If you have such access, check your record periodically, say once a month.
• If you are not in such a health care system, and/or use medical care outside the system, like it or not, it is your job to make sure that your medical record is accurate and complete.  Alternatives to consider include:
  • Keep a copy of your records yourself. If you prefer, there are online sites that can help such as Microsoft's Health Vault  and/or
  • Ask each specialist and other doctor or health care professional you see to send copies of all medical entries, tests and test results to a doctor you pick - either a specialist  that you see regularly or your primary care doctor. This should include any doctors you see while traveling. Instead of relying on a doctor remembering to send the information:
    • Remind each doctor at each session to send the notes to your doctor of choice.
    • Ask how long it will take for the notes to be forwarded. 
    • Note the date on your calendar. 
    • Check with the office of your primary physician on that date to see if the records were received. 
    • If the records were not received, follow up with the office staff of the dotor who is supposed to send the information.

You can assure the accuracy of your medical record by taking the following steps:

• Obtain and review a copy at least once a year, say at tax time or other trigger date with your doctor or at least a member of his or her staff. 
• Ask about anything that you don't understand.
• Ask that anything that is wrong be corrected in the record. If the doctor or nurse balks at making a change, remind him or her that you have a right under the federal law known as HIPAA to make corrections to your medical record. If they refuse to make the change, you have the right to provide a written statement and ask that it be included with your medical records. To learn more about HIPAA, click here. 
• (If you have kept a Health Journal about your health, you can compare the dates, symptoms and procedures against the doctor's records. If you haven't been keeping a Health Journal, this is a good time to start. In addition to other advantages, a journal saves you time, particularly when getting ready to see a new doctor.)

If you work:

• Be sure that your medical records contain information about how your condition affects your daily living and ability to work. (Tell the doctor at every appointment, and ask that the information be included in your medical record). While this may not seem important now, it could become very important if you want to stop work at some point and apply for government or private disability benefits because of your medical condition. (For example, see applying for Social Security Disability Income or applying for a disability income benefit.)
• Your record should also include any emotional states you experience such as depression or anxiety. This information will also be important if you eventually apply for any government or private disability benefits.

Confidentiality of your medical records

• You have a right to privacy about your medical record. In addition to the state laws, the federal law known as HIPAA provides privacy except  in certain circumstances. The provisions of the law have been adopted by just about all doctors and medical facilities.
• The American Medical Association (AMA) confirms the existence of a basic right of patients to privacy of their medical information and records. The AMA also states that patients' privacy should be honored unless waived by the patient.
• General practice is for doctors and medical facilities to give you a copy of their confidentiality policy. Many ask that you sign a document agreeing to the policy. If you have questions, or disagree with what you read, speak with the doctor's office manager or with the doctor -- or a supervisor in the facility.
• For the steps you can take to protect the confidentiality of your medical record, click here. 

For additional information, see:

• Why It Is Important That Your Medical Records Be Complete And Accurate
• Federal and State Laws With Respect To Ownership, Access, And Copies Of Medical Records   
• How To Get A Copy Of Your Medical Record
  • Sample Letter Requesting A Copy Of Your Medical Record
• What To Do If You Are Denied Access To Your Medical Records
• What Should Be In My Medical Record?   
• How To Correct Inaccurate Information In Your Medical Record
• Assistance Available To Help Understand The Content Of Your Medical Record  
  
• Keeping Your Own Copy Of Your  Medical Record  (what should be in it, how to keep it)  
  
• How You Can Help Protect The Confidentiality Of Your Medical Record  
  

NOTE: 

• If you have an Advance Directive known as a Health Care Power of Attorney,your proxy stands in for you when it comes to making medical decisions and should be able to see your medical records. Rather than rely on "should," it is advisable to include a specific provision in your health care power of attorney saying you give your proxy authority to see and copy your medical record to the same extent you could, without limitation.  
• If you will be filing a claim to be considered to be disabled, it would be helpful to let your doctor know ahead of time you may be applying for something that will require disclosure of your medical records. For example, that you are thinking about applying for Social Security Disability. We're not suggesting the doctor change your records to make them misleading. Instead, if she knows what is important to you, your records can be written in such a way that they will bolster your case by making notes that would otherwise not be in your file or be said in a manner that is helpful. 
• If one of your doctors announces that he or she is retiring, or a facility in which you had x-rays or MRIs taken is about to close, ask for a copy of all your films in case they become relevant in the future.
• You can manage health care information with a mobile app such as AARP's AARP Rx.  For example, if you take a picture of your prescription bottles with your smart phone, the app will automatically record the drug name, dosage, pharmacy and refill schedule. You don't have to type anything.Next time you see a doctor, you have a handy list of your meds to show him or her.  You can also track informatoin such as blood pressure. You can download the free app at aarp.org/rxapp or by sending the text "aarprx" to 742864.

Medical records serve a variety of purposes, each of which can be important to your health and financial well-being.

Your records provide:

• A history for the doctor to review before each visit to recall your medical history and other factors in your life that can affect your health.
• A basis for the planning of your future care and treatment.
• A means of communication for the many health professionals who contribute to your care, including people who are seeing you for the first time and who may be unaware of an error.
• Documentation for legal purposes of the care you have received.
• Verification of services and treatment with regard to medical billing and payment for your care. Medical notes that are inaccurate or incomplete can allow an insurer to avoid responsibility.
• An important factor in determining whether you obtain life and/or disability income insurance, whether you qualify for government benefits such as Social Security Disability, or qualify for selling your life insurance policy in a Viatical Settlement and how much you will obtain for it on a sale.
• Better continuity of care when a copy of your records is provided to a new doctor, when traveling, moving, or in the event of an emergency.
• Once you allow their release, medical records also disclose your health condition and treatment to employers and insurance companies.

Thanks to federal law, you are entitled to a copy of your complete record - including the doctor's notes. Health care providers are permitted to charge for copying and mailing records. Some states have a statutory maximum charge that ranges from ten cents per page to one dollar per page. A facility or doctor may not make it financially impossible for a patient to exercise the right to medical records by charging an exorbitant charge for copying. To save money:

• If your records are in electronic format:
  • Find out if patients are given access to the database. If so, a pat ient I.D. and password is generally required.
  • If not,  you can ask that a copy of your medical record be e mailed to you, or that it be downloaded onto a disk. There is generally no copying charge if a record is sent electronically. The cost of a disk is minimal. 
• If your records are still on paper: you can request specific documents or summaries within your record rather than a copy of the entire record. For example, you can ask for the problem list, medication list, list of allergies, immunization record, most recent history, physical, consultations, operative reports, pathology reports, and/or hospital discharge summaries.
• If you have to ask for a copy of your record, make certain your request is to the right person or department. While you're identifying the person, obtain their extension number or direct phone number so you can follow-up easily.

Request/Authorization Forms

Most medical facilities have their own patient authorization form that allows for the release of information. If they have such a form, it is generally preferable to use it. In fact, some facilities will not provide you records unless you complete their form.

You may also simply write a letter asking for a copy of your records or requesting / authorizing the release of your records. The letter should contain the following information: (A sample letter follows)

• Your full name at time of treatment
• Dates of treatment for information being requested to the best of your recollection
• Date of birth
• Name and address of the person or facility to which disclosure is to be made
• The specific kind and amount of information to be disclosed, including laboratory results, other diagnostic tests including X-rays, and the doctor's notes
• You may wish to include the purpose of the request, for example, "continuing care" or "insurance" or "my own records"
• Your signature and the date of request
• There is no need to have your signature notarized

For a sample letter, click here. 

For details about regulations about charges in your state, see Georgetown University's Center for Medical Record Rights and Privacy at http://hpi.georgetown.edu/privacy/ .

• If you need to get a file from a medical institution and have difficulty gettng through to the right person or getting the file, ask for the patient advocate or president's office. They can likely get through on different phones or can send an internal message so help speed up the process.
• If a doctor refuses to give you or your representative a copy of your records, ask another doctor to get them for you. As a last resort, consider going to your state's regulatory authority. As a last resort, you can sue.

While the information contained in your record is technically yours, the medical institution or doctor owns the medical record. Still, a variety of overlapping laws provide patients a right of access to, and to copy, their medical records. 

• Federal laws and regulations
  • Regulations under the federal law known as HIPAA require that patients must be allowed access to their own medical records, and be given the ability to correct mistakes in the records. For an excellent analysis of the HIPAA rules, and how to enforce them, see Rights to Access Medical Records Under the HIPAA Privacy Regulation by Sonya Schwartz at www.hapnetwork.org/assets/pdfs/Rights_to_Access_to_Medical_Records_PI2003-01_APR20033f0a.pdf .
    
  • Under Federal regulations, if you have been treated in a long-term care facility that accepts payment from Medicare or Medicaid, you are entitled to the records that facility has about you. 
  • If you are a Federal employee or a person treated in a Federal medical facility, you have a right to obtain medical records maintained by the government.
  • Residents of Nursing Homes: Any resident of a nursing home that participates in Medicare or Medicaid has a right to access their own medical records upon request, or upon request of the person's legal representative.
  • If you are enrolled in Medicaid Managed Care: You have a right to request and receive a copy of your medical records, and to ask that they be corrected.
    
• State laws: Many states provide patients a right of access to medical records. Even in states where there is no statute, common law may give you a right to a copy of your records. The website www.healthprivacy.org provides free of charge, a summary of the laws for all fifty states. (Click on "State Law" then on "View The Summary of A Specific State.") Also see Georgetown University's Center on Medical Records Rights and Privacy which offers state-specific guides on accessing your medical records, http://hpi.georgetown.edu/privacy/records.html .
• The American Medical Association has a policy stating that doctors are obliged to provide a copy or record summary to a patient.

NOTE: Pychiatric Information: In some cases psychiatric information may be difficult to obtain. Generally, the law gives psychiatrists wide discretion to withhold information that may alarm or agitate a patient and cause his or her condition to deteriorate.

If you are not allowed access to your medical records, or given a copy, see What If I Am Denied Access To My Records?

It may be useful to find out from the doctor or a staff member why there is a reluctance to provide the requested information. If you know the "why," it becomes easier to figure out how to get what you want -- especially when you keep in mind that you have a legal right to the records.

For instance, there are times when a doctor or institution deny a patient access to his or her own medical record on the basis that seeing the records could be harmful to the patient. If this happens to you, ask that a copy be given to another doctor who doesn't have a problem giving them to you, or to a representative of yours. The doctor or institution is then off the hook. You can then get the copy from the cooperative doctor or from your representative.

In the event that your request is ignored or denied, the following are useful tools with which to fix the situation. 

• Confirm that your request has been submitted to the correct person. If so, you can ask for a supervisor or the office manager. If that doesn't help, you can write a letter to the doctor or medical institution which:
  • S tates that you requested your records on the specific date you made the request. Include the name of the person to whom you made the request if you know it.
  • Ask why the records are not being made available.
  • Request the response in writing.
  • Set a deadline to receive a response, such as a week from the date of your letter.
  • If you have an attorney, note on your letter that you are sending a copy to the attorney. An effective way to do this without being obnoxious is to type below your signature: cc: Michael Novin, Esq.
  • Make a copy of the letter for yourself before sending.
  • Send the letter in a manner that provides a receipt (for example, Overnight mail, or US Mail, Certified Mail, Return Receipt Requested) or have it hand delivered.
• If your records are held by a doctor: Consider asking another doctor to request the medical records who will then give you a copy. Doctors are sometimes more willing to share information with another medical professional. The rules of the American Medical Association obligate a doctor to transfer records to another doctor at the patient's request.
• If your records are held by a hospital:
  • If you are in the hospital:
    • You can refuse to consent to further treatment until you see your records. And/or
    • Complain to the hospital's patient representative or head administrator.
    • The hospital ethics committee may also be able to help.
  • If you are discharged from the hospital: Complain to the highest level administrator you can access -- including the head of the hospital. The higher you go, the more likely you will be to get your records.
• If the above suggestions fail:
  • Contact your state's attorney general, Office of Consumer Affairs or Department of Health.
  • Also complain to the state medical board which licenses doctors.
  • Complain to the Centers for Medicare and Medicaid Services (CMS). CMS conducts investigations and attempts to resolve problems like this. A penalty of $100 - $25,000 penalty per year for each standard violated can be imposed. You'll find the complaint form at http://www.cms.hhs.gov/Enforcement/Downloads/HIPAANon-PrivacyComplaintForm.pdf or call 800.368.1019

As a last result you may wish to consult an attorney to enforce your rights.

We cannot overemphasize the importance of having all your medical records in one place. The more information about you and your health history a doctor has, the better he or she is able to treat you.

The medical records of a person with a serious health condition should at least include the following:

Assistance Available To Help Understand The Content Of Your Medical Record

How To Correct Inaccurate Information In Your Medical Record

If You Want A Copy Of Your Medical Records

Keeping Your Own Copy Of Your Medical Record (contents/how to)

How You Can Help Protect The Confidentiality Of Your Medical Record

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