In healthcare, documentation is key. The Code of Federal Regulations (CFR) mandates that medical providers keep detailed records of patient care, known as medical records. These records contain crucial information about your health history, diagnoses, treatments, and more. Although you have the legal right to access your records, you must submit a request to obtain a copy. This article will guide you through the process and explain the benefits of keeping your medical records.
What’s Included in Your Medical Records?
Your medical records typically include a comprehensive history of your health, such as:
- Personal health history and current diagnoses
- Congenital conditions
- Treatments and surgeries
- Medications and allergies
- Immunizations
- Lab results, X-rays, and other imaging
- Medical assessments and recommendations
Even if your doctor retires or a hospital closes, your records are required to be transferred to another facility to ensure they are safely stored. Medical records can be both digital (electronic data) and paper-based.
How to Request Your Medical Records
There are several ways to request a copy of your medical records:
- Hospital Patient Portal: If your healthcare provider offers an online portal, you can often request records directly.
- Provider’s Website: Many healthcare providers allow record requests via online forms.
- Written Request: You can submit a letter requesting your records.
- Apps: Some apps (like Apple’s HealthKit) allow limited access to records, depending on your provider.
- In Person or By Email: Requesting records in person or through email may be possible, though email isn’t the most secure method.
Some healthcare providers may charge a small fee for the cost of copying records, particularly if you need paper copies or a digital storage device (like a CD or USB drive).
Information Needed for Your Request
To process your request, your provider will generally need the following:
- Full name, social security number, date of birth
- Contact information (address, phone number, email)
- List of records requested and dates of service
- Preferred delivery method (mail, in-person, digital file)
- Your signature (for written requests) or ID (for in-person requests)
If you’re requesting records for a loved one, you may need to provide legal documentation proving your authority, such as a Medical Power of Attorney. For a deceased loved one, you’ll likely need the death certificate, proof of your relationship to the deceased, and the reason for the request.
How Long It Takes to Receive Medical Records
According to HIPAA regulations, your healthcare provider has 30 days to fulfill your request. If your records are stored offsite, they have an extended 60-day grace period. If the provider fails to meet these deadlines, you can file a complaint with the U.S. Department of Health and Human Services.
Benefits of Retaining Copies of Your Medical Records
There are several advantages to keeping your own medical records organized:
Staying Organized
Since your records are spread across various providers, keeping a personal file helps you stay on top of your medical history. It allows you to answer questions more easily when a doctor asks about past treatments or surgeries.
Convenience for Emergency Situations or Caregivers
In case of an emergency, having your records on hand means your family or caregiver can provide crucial information to healthcare providers immediately, ensuring quicker and more accurate care.
Avoiding Unnecessary Tests or Treatments
By maintaining your medical records, you can prevent unnecessary tests or procedures. If a doctor orders a test you’ve already had, having your records allows you to remind them of previous results, saving time and money.
Protecting Yourself from Overbilling
Your medical records help ensure that you’re only billed for treatments and medications you’ve actually received. They also help you identify any discrepancies or errors made by healthcare providers or insurance companies.
Correcting Mistakes
Occasionally, errors can be made in your medical records, such as incorrect dosages or wrong medications. Keeping your records allows you to quickly spot any mistakes and correct them with your provider.
Supporting Medical Malpractice Investigations
If you suspect medical malpractice or negligence, having a complete record of your treatments is essential. If you decide to pursue a legal case, these records will be crucial evidence, helping your attorney build a stronger case. Medical malpractice cases often require records to be filed within the statute of limitations, typically 1–2 years after the incident.
Start Now and Move Forward
If you’ve had significant medical procedures in the past year or two, it’s a good idea to request those records for your personal file. Make it a habit to stay organized, ensuring your medical history is up to date. This will empower you to be your own health advocate and provide peace of mind in the event of any future healthcare needs.
If you have questions about medical malpractice, fill out the form here to schedule a time to speak with a qualified medical malpractice attorney. It has never been more important to have a knowledgeable and compassionate advocate on your side.
