By Trisha Torrey. Patient Empowerment Expert
Updated December 18, 2014.
Written or reviewed by a board-certified physician. See About.com's Medical Review Board.
One of the most responsible and useful steps a smart patient can take is to review her medical records whenever she visits a doctor for any type of medical problem, even for well visits and check-ups. To do that, she needs to get copies of her medical records to review.
Doctors' notes, medical test results. lab reports and billing information must be supplied to us if we ask properly.
The federal law that addresses access to our medical records is called HIPAA (pronounced HIP-a), the Health Insurance Portability Accountability Act. These rules mostly address privacy issues, but are so extensive that many healthcare providers are still confused about how to enforce them. That confusion sometimes makes it difficult for us to get our records, even when we are entitled to them.
Who May Request Medical Records and Who Must Share Them
- You must be the patient, or the parent or guardian of the patient for whom you seek records.
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Providers, including doctors, hospitals, labs and other medical practitioners are required to keep most adult medical records
for six years or more, although this varies by the state where the records are stored. In most states, children's records must be kept for three to 10 years beyond age 18 or 21. If you seek older records, contact the provider to see if they are available.
Providers are required to share any notes or records they have created themselves, or any test results for which they have copies. They are also required to share any information provided to them about you by another doctor if that information was used for the diagnosis and/or treatment being discussed with you.
Diagnostic lab test records, for such tests as blood tests, CT scans. x-rays, mammograms or others, should be requested from the doctor who ordered them, or your primary care physician. In most states, the lab will not provide them to you directly.
If you seek hospital records or records from any other medical facility, you'll want to request them directly from that facility.
Be aware that you may be denied access to some records. usually related to mental health records. If a provider believes that letting you look at your medical records can endanger your physical health, your request may be refused. They cannot deny you access just because they think you will be upset, unless they believe that upset will lead to an attempt to physically harm yourself. If you are refused, the provider must make that clear, in writing.
A note about privacy: Many patients believe they or their designees are the only people who can obtain copies of their records. In fact, there are many others who can gain access to your medical records without your permission.
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