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 within 30 days of 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.
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 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 (such as by sending a letter, an e-mail, or a fax). 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:
- Your name, address, telephone number or other contact information.
- Your date of birth or medical record number.
- Date(s) of 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.
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.
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 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 health care power of attorney, your provider may require you to show them a copy of the power of attorney form. You also may be required to show that the power of attorney is in effect. For example, you may need a letter from the doctor treating the patient to show that the patient is unable to make health care decisions.
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 should 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, within 30 days after they receive your 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.
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 I Control Where 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. 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.
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.
Will I Have To Pay for My Medical Record?
Maybe. Your health care provider is allowed to charge you for copying your medical record. In Pennsylvania, the cost per page depends on how many pages your provider copies. As of January 2007, your health care provider generally may charge you $1.25 per page to copy the first 20 pages of your record; 93¢ per page to copy pages 26 through 60; and 31¢ per page for pages 61 and up. If your records are made from microfilm, your provider can charge you $1.83 per page. Copying fees are adjusted every year based on the consumer price index. You also can be charged the actual cost of postage, shipping, or delivery if you have the copy sent to you.
Can I be charged for a copy of my medical record that I need to support a claim for Social Security benefits?
When you request your record to support a claim for Social Security or other public benefits, your provider may charge you no more than $23.19 to copy your medical record. This fee is adjusted every year. You also can be charged the actual cost of postage, shipping or delivery if you have the copy sent 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 fee for someone searching for and retrieving my medical record?
No. Although Pennsylvania law permits a charge for searching for and retrieving medical records, the Health Privacy Rule does not. Because the Health Privacy Rule is more protective of your rights in this area, your provider must follow the Health Privacy Rule. Your provider may not charge you a search or retrieval fee.
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 copy. You can also be charged postage if you ask that the records be mailed to you.
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 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 or someone else, 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.
Generally, your health care provider must give you this information within 30 days after receiving your request for your record. You can read a more about this time limit in the section of this guide titled “How Long Should It Take to Get My Medical Record.”
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 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.
My medical record contains some information that my provider is allowed to deny me access to. Does this mean that I can’t get any of my medical record?
No. Under the HIPAA Privacy Rule, your health care provider must give you as much of your medical record as possible. Your provider may remove only the information that they are allowed to refuse to give you access to.
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 endanger you or another person, you have the right to have a different health care professional 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 a review. They also must tell you how to ask for a review.
If you request a review, your provider must choose another licensed health care professional to review their decision. They cannot choose someone who was involved in the original decision. The reviewer makes the final decision whether you are allowed to get your medical record. Your provider must notify you in writing (such as by a letter, fax or e-mail) what the reviewer decides.
Can I choose the reviewer?
No. Your health care provider gets to choose the reviewer.
