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 of access to your medical record.
Usually, your health care provider must respond to your request for your record no later than 21 working days after receiving your request.
Generally, your 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 provider about their specific procedures for getting your medical record. Often, your health care 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 provider’s notice of privacy practices.
Generally, your request for your medical record must:
- Be in writing
- Be signed and dated
- Include the name of the health care provider
- State that you want the information released to you
- State the time period for which it is valid
- Specify if you want the part of the medical record that was developed by another health care provider
You should also include:
- Any other name you may have used, such as your maiden name.
- Your contact information such as your phone number.
- Your date of birth or your medical record number.
- 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.
- Dates of treatment or service.
- 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 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 provider require that I 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 a designated health care agent your provider may require you to show them a copy of the advance directive. If you are a personal representative of an estate, you should expect to show documentation proving that you are the executor or administrator of the 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 21 working days after receiving your written request, your health care provider 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.
My health care provider says that in certain cases they can take up to 90 days to give me a copy of my medical record. Is that true?
No. Although there are times when the HIPAA Privacy Rule would let a health care provider take up to 90 days to respond to a request for a medical record, Maryland law requires a provider to give you a copy of your record no later than 21 working days after receiving your written request. Your health care provider must follow the shorter deadline set by Maryland law.
Can My Provider Charge Me for Copying My Medical Record?
Yes. As of August 2005, Maryland, your health care provider may charge you 65¢ per page for copies of your medical record. This fee is adjusted for inflation every year. Your provider may also charge you for postage if you request that your record be mailed to you.
Can I be charged if I just want to look at or read my medical record?
No. Under the HIPAA Privacy Rule, your health care provider cannot charge you a fee if you just look at or read your medical record.
Can I be charged a preparation fee for my record?
No. You cannot be charged a preparation fee for your record. Although Maryland law permits providers to charge preparation fees, such fees are not permitted under the HIPAA Privacy Rule. Because the HIPAA Privacy Rule is more protective of your rights, your provider must follow the HIPAA Privacy Rule. They may not charge you a preparation fee for copying your medical record.
Can I be charged for copies of X- rays and similar records?
Yes. Your health care provider can charge you a reasonable fee for copying x-rays and similar records. This fee must be based on the actual cost of making the copies. You can also be charged postage if you ask that the records be mailed to you.
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.
Your provider can’t give you a summary in place of your medical record unless you agree. If you agree to receive a summary, your health care provider generally must give you the summary no later than 30 days after receiving your request.
Example
Leon asks for a copy of his medical record. Because the medical record is long and complicated, Leon’s doctor would prefer to give him just a summary of the record. Leon does not agree to accept a summary. The doctor must give Leon a full copy of the record.
Your provider can charge you a reasonable fee for the actual time they spend preparing the summary or explanation.
I can’t understand the medical terms used in my record. Does my health care provider have to translate this information into plain language?
No. Health care providers often use technical words or a type of medical shorthand. Providers are not required to translate technical medical language into plain language for you. If you cannot understand what is written in your medical record because it is in technical language you can request an explanation of your record. However, your provider is not required to agree to your request. Section 6 lists some resources that explain medical terms.
Can My Provider Deny my Request for My Medical Record?
In Maryland, a provider generally may not deny you access to most of your medical records. However, the rules for records related to mental health or substance abuse conditions and treatment may be different. Section 6 lists some resources that have more information about your rights to get records related to mental health and substance abuse.
Can my health care provider refuse to give me 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 my provider doesn’t have the medical record that I requested, but knows who has it?
Your provider must tell you who has your medical record if they know. Your provider is not, however, required to obtain your record for you if someone else has it.
Example
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.
