How To Get Your Medical Records

There are many reasons an individual would wish to request and review their own medical record from a doctor’s office, hospital, or other medical care providers. They may want a record to provide a new doctor, want to understand more about a certain medical condition, or may even be considering a lawsuit and want to have a third party review the records. For any reason, all patients have the right to a copy of their record (the original belongs to the healthcare facility). However, this task is daunting to many. We’ve created a guide to help you navigate the language and “hoops” to jump through.

How Do I Get My Medical Records?

HIPAA is the acronym for the Health Insurance Portability and Accountability Act, which in part regulates Protected Health Information (PHI) to ensure the privacy and security of your private information. While there may be slight differences between states and provider types for requesting your records, HIPAA entitles every person the right to access their medical records, receive copies of them, and request amendments to them. Some types of records, such as psychiatric records and HIV information may require additional authorization from you.

The Process

The American Health Information Management Association (AHIMA) recommends that you follow these steps:

1. Contact your provider’s medical records or health information services department. Tell them you want to complete an “authorization for disclosure of protected health information.” Some facilities have this online or by email, and some you will have to visit. You must complete and sign the request and return it to the medical records office.
2. On the authorization form, you will need to specify which information you would like to have copied. There is a varied fee per page in most facilities, not to exceed a maximum set by state law, and some facilities may not charge a fee for copies at all unless they exceed a set page limit. The provider’s medical records office will notify you when they are ready for pick up.
3. Many patients wonder how long it will take to receive medical records. HIPAA allows providers 30 days to complete a records request but also allows for a single 30-day extension if the facility can explain the delay. However, most facilities can fulfill a request in 5-10 days.
4. Bring a photo ID to pick up your records. If you are picking up another person’s records, you will need additional legal documents and information to show that you can access the records on their behalf.

Medical Records Requests in Anticipation of a Lawsuit

In a medically related lawsuit, one or both sides of the litigation will request the Plaintiff’s records. Since medical records are not public documents, the records are required to be “certified”. What is a certified medical record? This means that a notary (in most states) must witness that the copy is the same as the original.

If the Defense in a potential lawsuit wants to request a Plaintiff’s records, they will usually need to be “subpoenaed.” In many instances, the Plaintiff’s attorney will not give the Defense a signed authorization that complies with HIPAA, so there is a process in place during the discovery phase of the trial to obtain valuable information. The Defense must first prove proper jurisdiction, and then fill out a subpoena form in the correct jurisdiction.

Then, the Defense must identify if the records are physiological or psychological, and name the provider and address. In some states, psychological records are not discoverable. The subpoena must be “served” or given to the provider whose records are requested. The adequate time needed to comply varies by state. Many firms on both sides of litigation will use a “medical records retrieval service” which can be a cost-effective way to obtain, either by authorization or subpoena of the records, organized and securely delivered records.

Obtaining Medical Records

Regardless of the motive, all patients have the right to a copy of their medical records. Knowing the required steps and documents will help you obtain these records as quickly as possible. In preparation for a lawsuit, extra steps may be required to use medical records in a defense claim.

While obtaining medical records can be complicated, ensuring that they are complete is essential to any case. With our extensive legal nurse consulting expertise, ALN Consulting advises attorneys by reviewing medical records and identifying gaps in documents needed to efficiently resolve a case. After you’ve received the medical records, you may need some guidance on how to review medical records.

How Med Law Advisory Partners Can Help

Obtaining and analyzing medical records for litigation can be complex. Legal and risk management teams don’t always have the time, resources, and expertise to review clinical information. With extensive knowledge of the health care industry and claims management expertise, Med Law Advisory Partners’ Legal Nurse Consultants helps our partners evaluate the merits of a medical case. Through thorough medical records review, we can identify the issues that truly matter and guide strategy towards a favorable outcome.

Would you like to hear more about how our legal nurse consultants can assist you? We’d love to chat – reach out to schedule a conversation.

Founded by Alicia Davis, RN, LNCC, Med Law Advisory Partners (and former ALN Consulting) provides resources and expertise in the areas of safe opioid prescribing, medical malpractice, and post-acute care litigation, including COVID-19 claims. Alicia and her team have worked with government entities, healthcare systems, insurers, and senior-living operators for nearly 20 years, helping mitigate risk and manage medical-legal and healthcare fraud claims.

Originally published November 5, 2015. Last reviewed Feb. 28, 2021.

References

1. Conetta, R. (2005). Subpoenas – How to Make Them Stick. Retrieved October 9, 2015 from American Bar Association Newsletter website.
2. American Society of Notaries. (2010). Making Certified/Attested Photocopies. Retrieved from American Society of Notaries website.
3. Journal of AHIMA. (2012). How to Request Your Medical Records. Retrieved from the Journal of AHIMA website.