to Get and Use Your Medical Records
Most people know that doctors keep patient records. The records include notes about signs and symptoms of illness, examination and test results, and treatment plans, as well as the doctor's assessment of medical problems.
At some point during your life, you may need to obtain your records from your doctor or hospital because you:
- may be changing doctors and need the old records to bring your new doctor up-to-date on your care;
- may be moving away from the area and need your records to be readily available to your new doctor or hospital;
- may need the records to receive full reimbursement from your health insurance company; or,
- may need records for a legal action against a doctor or hospital.
Obtaining medical records can be confusing, time-consuming, and even a costly process. However, Maryland law and the Health Insurance Portability and Accountability Act of 1996 (HIPAA) provide guidelines for both patients and health care providers to follow.
Gaining Access to Your Records
Health care providers may maintain their records on paper or by computer. In either case, you have a right under Maryland law to obtain a copy of the record. To do so, you must make a written request. This signed and dated request must state your name, the name of your health care provider and the party who should receive your records. Your authorization to release your records is good for one year. A provider must disclose a medical record within a reasonable period of time after receiving your written request.
Under state law, in 2012, you may be charged no more than 76 cents per page for having your records copied, plus actual postage and handling costs. (These limitations do not apply to x-rays.) These fees may be adjusted annually for inflation. Federal law forbids a provider from charging preparation fees, including fees for retrieving or handling the information or for processing the request, if the records are being provided to the consumer. If the records are being sent to someone other than the consumer, the law allows for an administrative fee of no more than $22.88 in 2012, which may also be adjusted annually. To avoid a surprise bill, ask about fees before requesting records. In most cases, the provider may withhold your records unless you pay the fee. However, the provider may not withhold the records because you have not paid an outstanding bill for treatment.
Most healthcare providers must maintain a patient's medical bills, laboratory reports and X-ray reports for five years after the record or report is made. In most cases, the medical record of a minor may not be destroyed until the patient turns 21 or for five years after the record or report is made, whichever is later, unless the patient or guardian is notified. Many providers will send notice to consumers regarding the destruction of records to allow the consumers time to request a copy.
Mental Health Records
If your medical records relate to a psychiatric or a psychological problem, your doctor or the facility's doctor in charge of the case has the discretion to decide whether or not to release them with you. However, you are entitled to receive a written summary of the records if you make a written request. Even if you cannot obtain the records, the health care provider from whom you are requesting the records may allow another health care provider treating you for the same condition to see and copy them.
If you find errors in your medical records, you can ask to have additions or corrections made. All health care providers must have a procedure for correcting information in their medical records; ask about the procedure. Make sure you request changes and correction in writing, keeping a photocopy for your files. You may not, however, have information deleted from your medical record.
After you request a change in your medical record, the health care provider must make the change or explain the refusal to make the requested change in writing. This explanation must also describe any appeals process, if the health care provider offers one. If your provider refuses to make the requested change, you have the right to insert in your record a written statement explaining why you disagree with the information in the record.
Getting Records from a Federal Medical Facility
A federal medical facility (such as a Veterans Administration hospital, Public Health Service Facility or military hospital) is not covered by Maryland law. However, you are entitled to obtain your records under the Federal Privacy Act. This Act guarantees your right to inspect and copy records maintained by federal agencies and to contest inaccuracies. If the records contain psychological or psychiatric information, the doctor in charge of the case has the discretion to decide whether the material can be released.
Each federal agency has its own procedure for patient access to medical records. Some agencies allow you to make a Privacy Act request over the phone, while others require that the request be made in writing or in person. You must complete a special consent form to have information released when the diagnosis is drug or alcohol abuse, sickle cell anemia, or HIV infection. It's best to contact the facility's medical records department to find out its procedure.
Get Some Help
If you would like to review your medical records, it is best to do so with your doctor or other health care provider. The information in medical records is often in technical language that is not easily understood by most people. Getting assistance from a medical professional will reduce confusion and help relieve fears and misunderstandings about your records' contents.
Having Trouble Getting Your Medical Records?
If you tried without success to get your medical records, do not give up. Help is available. For records from facilities (hospitals, nursing homes, etc.) and doctors, contact the Office of the Attorney General's Health Education and Advocacy Unit toll-free at 877-261-8807, or online at www.oag.state.md.us/consumer/heau.htm.
For records from doctors, you may also contact:
The Maryland Board of Physicians
Department of Health and Mental Hygiene
4201 Patterson Ave.
Baltimore, MD 21215
The numbers for the Board of Physicians are 410-764-4777 or toll-free at 800-492-6836. The Board of Physicians is also available online at www.mbp.state.md.us.