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 let you see your record within 10 days after they receive your written 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.

Can my provider require me to put my request for my medical record in writing?

Yes. Your provider can require that you put your request in writing (such as by sending a letter, an e-mail, or a fax). Your provider must let you know that it has such a requirement.

 

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

If your provider does not have a form for requesting your medical record, you should check to see what information your provider requires.

Generally, when you ask for your medical record, your request should include:

• Your name.
• Your address.
• Your telephone number.
• Your e-mail address.
• Your medical record number (if you know it) or your date of birth.

• A description of the information that you want to see or copy. This might include:

• Dates of treatment.
• 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.

 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 include my Social Security number on 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.

Will I have to show some proof of who I am in order to see or get a copy of my medical record?

Maybe. If your health care provider does not know you well, they are supposed to make sure you are the person who has the right of access to the medical record before they give it to you.

If you request someone else’s medical record as their personal representative, you generally have to prove that you have the right to get their medical record. For example, if you ask for someone’s medical record as their “health care proxy,” you must give the provider a copy of the “health care proxy” form along with your request.

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?

Your provider must let you inspect or see your medical record within ten (10) days of your request. If you request a copy of your medical record, your provider must give you the copy within a reasonable time, usually within 30 days after they receive your request.

Can I Control Where the Copy of My Medical Record Is Sent?

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 another 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.

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 health care provider generally must give you the summary within 30 days from when you request the summary. If they are unable to produce the summary in this time they can get a 30 day extension.

Your provider can charge you a reasonable fee for the actual time they spend preparing the summary or explanation.

Leon requests 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 at 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. However, your provider is not required to give you an explanation. Section 6 lists some resources that explain medical terms.

Will I Have To Pay for My Medical Record?        

Maybe. Your health care provider can charge you up to 75¢ per page for paper copies of your medical record. You also can be charged for postage if you have the copy mailed to you.

Can I be charged if I just want to look at or read my medical record?

No. Although New York law permits a provider to charge you an “inspection fee” if you just want to look at your record, the HIPAA Privacy Rule does not. Because the HIPAA Privacy Rule is more protective of your rights in this area, your provider must follow the HIPAA Privacy Rule. Your provider cannot charge you an inspection fee.

 Can I be charged for someone searching for my record or for processing my request?

No. You cannot be charged a fee for someone searching for and getting your record. Neither can you be charged for someone processing your request for your record. These fees are often called “retrieval” or “clerical” fees. They are not permitted.

Can I be charged for copies of X- rays and similar records?

Yes. Your health care provider may 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.

What happens if I am unable to pay the copying fee?

Under New York law, you cannot be denied access to your medical record solely because you are unable to pay the copying fee.

Can I be charged if I want a copy of my medical record sent to another health care provider?

The procedures and fees for having a copy of your medical record sent to another health care provider may be different. Because these procedures and fees are not covered by the HIPAA Privacy Rule, they are not discussed in 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 in a few cases. For example, if your provider believes that letting you see your record might physically endanger you, they can deny your request for your record.

How will I know if my request for my medical record has been denied?

Your health care provider must tell you in writing (by letter, fax, or e-mail) 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.

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 someone else.

Can my health care provider deny my request for records related to my mental health treatment?

Records about mental health treatment may be treated differently from other types of medical records. This guide does not discuss mental health records. Section 6 lists some resources for information about mental health records.

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 happens if my provider doesn’t have the medical record that I requested?

If your health care provider doesn’t have the record that you requested, they don’t have to locate it for you. But your provider must tell you where your medical record is kept if they know.

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 physically endanger you or someone else, you have the right to have another health care provider 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 obtain a review. Both New York law and the HIPAA Privacy Rule have procedures for obtaining a review when your request is denied due to potential harm.

New York Law

Under New York law, you may request a review by a medical record access review committee. Medical record access review committees are made up of three to five licensed health care professionals. For example, a committee of doctors reviews the decisions of doctors. The members of the committee are appointed by the Commissioner of Health.

The committee will review your provider’s decision. The committee decides whether you should get access to your medical record. If the committee decides you should be given access to your record, your provider must let you see or get a copy of your medical record.

If the committee decides that you should not get access to your medical record, they must tell you that your request has been denied. They must also give you notice that you have the right to seek judicial review of their decision. To obtain judicial review, you must start a proceeding in New York Supreme Court within 30 days of receiving the committee’s notice. The judge will decide whether you get access to your medical record.

HIPAA Privacy Rule

You may request a review by another health care provider under the HIPAA Privacy Rule. If you request such a review, your provider must choose another licensed health care professional who was not involved in the original decision to review the denial of your request for your record. The reviewer will decide whether you can see or get a copy of your medical record. Your health care provider must follow the reviewer’s decision. Your provider must tell you in writing (such as by a letter, fax or e-mail) the reviewer’s decision.