Your Guide to Medical Records

You’ll likely be asked to obtain patient medical records from one doctor and provide them to another for you or someone you care for. This allows the new medical provider to review the diagnostic and treatment history, preventing duplicate or unnecessary tests and showing the new provider relevant medical information. Furnishing a copy of your medical records will also be necessary when seeking a second opinion.

Obtaining medical records

In the U.S., your legal right to view and request your records is governed by the Health Insurance Portability and Accountability Act (HIPAA). HIPAA’s Privacy Rule outlines the appropriate sharing of your protected health information (PHI), such as between medical professionals and insurers or with other medical staff or contractors with insurance companies or hospitals. This means that you’ll be required to authorize that a copy of your records is sent to the new doctor who requested them. A good resource for information about medical records and HIPAA is the U.S. Department of Health and Human Services (HHS) website.

The process for obtaining your records can vary slightly depending on the medical provider. Still, you can generally follow these steps to have your records sent to a treating medical professional. These basic steps apply to the sharing of both paper and electronic health records (EHRs). Please note that HIPAA doesn’t give you the right to access notes from treatment by a psychotherapist, and the rules for sending those notes to other providers differ.

To obtain your medical records:

1. Contact the doctor’s office or hospital where you were treated to find out the process for requesting your medical records. In some cases, you will be asked to submit a signed letter. Ask the office about any requirements for the format of the letter. In other cases, the medical center will have a form for you to fill out. These forms can sometimes be downloaded from the provider’s website and printed.
2. Be sure to indicate on the form or in the letter whether your records should be sent to another provider’s office or if they should be sent to you. Provide detailed, accurate address information for the recipient of the medical records. If you’re sending the records to another provider, contact that provider’s office to find the exact address and who should be listed as the recipient. In addition, you should follow up with the recipient provider to ensure that all pertinent information has been properly sent.
3. Ask the provider from whom you’re requesting the medical records about any fees that you’ll need to pay. By law, providers are allowed to charge you a reasonable fee for copying and sending medical records (though not for retrieving the records).
4. Photocopy the records and keep a copy in your home files for future reference. If you have the medical records delivered to your home or office and before giving them to your new provider, be sure to make a copy of them for your own personal records.

Keeping a personal health record (PHR) at home

One step to feeling more in control of your healthcare or your child is to maintain a PHR. This is simply a term for a record that you maintain on your own versus a medical record that is maintained at your medical provider’s office. A PHR allows quick access to your medical information, such as notes, provider contact information, and test results, in case of an emergency or if you need to supply past health information to a new provider.

You can keep your PHR in whatever format is easiest for you: as a paper file, using software on your computer, or by using a web-based platform. If you use a web-based platform, read the privacy practices carefully and feel comfortable with the privacy statement and the website's security.

Each format has advantages and disadvantages:

• Paper file – Request a copy of your medical records from your doctor (see the guidelines above) and put these records in a binder, file folder, or other containers. You may wish to keep this file in a firebox alongside other vital papers. Keep notes of any medications you have taken or are taking and when and any allergies to medications. Also, note tests you’ve had performed, any immunizations and allergies, and a list of surgical procedures that includes the diagnosis, date of surgery, and the surgeon’s name and contact information. A paper file gives you complete control over your health information, but you can only access that information if you have the file with you.
• Software – Choose a computer program that has the features that appeal most to you. Keep notes about your doctor’s visits, diagnostic tests, surgeries and procedures, family history, immunizations, and allergies. Software may make it easier for you to organize your information. Be sure to create backup copies of the electronic file or periodically print out your health information and store it in a secure location if your computer crashes and the information is lost.
• Web-based platform – This is the most portable form of a PHR. You can access your information wherever there is an internet connection. You can also allow your doctor to access the information directly. This is still an evolving format. Shop around for the product that works best for you. Some web-based PHRs specialize in certain diseases or conditions, while others are more general. This is the least secure of the three options, as you’re transmitting your health information electronically and storing it with a third party. Be sure you feel comfortable with the platform’s privacy policy and security practices.
• Electronic patient portal – Many physician practices and hospital systems offer patient portals that allow you to review your medical records, test results, progress notes, procedure and operative notes, and discharge summaries in real-time through a secure website or application on your mobile device. These portals have the advantage of offering a safe platform and automatic medical record updates. In some cases, when different providers in different hospital systems share the same electronic health record system, records can be shared between providers instantly. In other cases, the electronic records will still have to be printed and sent by mail or fax.

Questions to ask your doctor about medical records

The questions below can help you start a conversation with your doctor about your medical records. You can print them out and take them with you to your appointment and share them with friends and loved ones when you are encouraging them to see their doctors.

1. Which medical records do you need from me?
2. Who (hospital social worker, etc.) can help me with requesting my medical records or those of my child?
3. What is the process for having medical records from another provider sent to you?
4. How do I have medical records from treatment with you sent to another provider?