Requesting Your Medical Records
Your health records are important documents that can impact the quality of your health care. They contain information and observations about your health and the treatment that you receive. The federal privacy regulations (HIPAA) gives all patients the right to inspect or copy their medical records and to request an amendment if they believe the records are in error.*
Why Are Medical Records Maintained?
- Legally documents the care you receive.
- Helps health care professionals communicate about your care.
- Verifies services covered by your health insurance.
- Provides data for health research and planning.
Who Has Access to Patient Medical Records?
- Adult patients, patient guardians, or conservators.
- Minor patients who have the right to consent to medical treatment.
- Parents of minor patients (with exceptions).
- Heirs or personal representatives of patients who have died.
Reasons You Need Your Medical Records:
- You can be more informed and involved in decisions about your health care.
- Gives you continuity when you change doctors.
- Allows you to ensure the accuracy of information that will be released to others.
- Provides supporting documentation when filing health insurance appeals or grievances.
Hospital Medical Records:
- Identification sheet and Problem List (your significant illnesses and surgeries).
- History and Physical, physician's orders, and nursing care sheets.
- Progress Notes (provider notes on treatment plans and your response).
- Consultation (opinion provided by a physician specialist).
- Laboratory, X-ray, Imaging and Electrocardiogram (EKG) Reports.
- Other Reports (operative, anesthesia, pathology, recovery room).
- Authorization Forms and Discharge Summary.
- Records and reports from ambulatory services, e.g. emergency/urgent care, lab, x-ray.
- Records from visits to your doctor's office.
Obtaining the Records:
- Contact your doctor or hospital to find out procedures you follow to obtain access; keep a record of dates, names and phone numbers from your calls and office visits.
- If required, submit your request in writing and/or sign a release of information form.
- Pay reasonable copying costs, if requested.
- If your request for records is denied, ask that the provider put the reasons for the denial in writing.
- In most cases, you should not encounter any difficulty when you request copies of your medical records. If you are unable to obtain a copy of your medical record, lodge a complaint with the Office of Civil Rights.
* Updated in May, 2003.
All about CareCounsel for employers and prospective clientsRead more »
All about CareCounsel for brokers & benefits consultantsRead more »
Overview of health advocate services for employees, retirees and their familiesRead more »
Health advocacy reports to manage your health benefits investmentRead more »
CareCounsel members love our health advocacy programRead more »
About CareCounsel VideoRead more »
Already a CareCounsel Member?Read more »