What is a medical record?
A medical record is the file created by a healthcare provider for a clinical episode of care. A separate record of each episode of care is combined into your personal medical record. If you see providers in different groups (or hospitals or clinics), each provider group (or hospital or clinic) will have a medical record containing files for each episode of care. Examples of things that can be found in your medical record include:
- Office visit/hospital notes
- List of problems or diagnoses
- Procedure notes
- Laboratory test results
- Medication list
- Imaging study results and images
- Immunization records
- Pathology reports
- Other relevant items depending on the specialty.
Can I see my medical record?
Yes. Under federal and state law you have a right to review your medical records, and you have a right to obtain a copy of your medical records (with certain exceptions) as long as they are maintained by the healthcare entity in which you received your services.
How do I obtain a copy of my medical record?
To obtain a copy of your medical record you have several choices.
- If your provider has a patient portal and your electronic medical record is available on it, you should be able to download a copy of those items that are stored electronically.
- If your medical record is not available online, you may request a copy in writing from your provider. The simplest way to do this is to call and ask how to request a copy of your records. You may also be able check their website online and see if they have a release of records form available for you to fill out.
- You will need to determine what information you want. Do you need specific dates of service? Do you need the office visit notes? Do you need laboratory results? Do you need a medication list? Decide before you submit your request what you actually need.
- If you are requesting a paper copy of your medical record, it may be less expensive for you to receive it electronically rather than paper. Check with your provider to see what your options are and the cost associated with those options.
- Choose your method to receive your records. If you want them mailed to you, then you may be charged a per-page cost for paper records and the price of materials and mailing. If you want your records sent to another provider have the name, address, phone, and fax numbers available to ensure delivery is correct and timely.
Is there a cost to get a copy of my medical record?
- If you are having a copy of your record sent to another provider then there should not be any charge to you.
- If you are requesting a copy for your own use then the provider or entity has the right to charge you a reasonable fee for providing you the information. Check with your provider for the cost.
There are a lot of questions on the form. Do I really have to fill it all in?
The following information is required in order for the records to be released to protect your privacy:
- It needs to be written, dated, and signed.
- Specify exactly what medical records you want.
- The release needs to have the name of the provider, institution, or individual from whom you are requesting the records.
- Your name, date of birth, and other demographic information need to be supplied.
- You may be asked to provide a copy of a government issued ID.
We recommend that you include a date for which the request expires.
What should I do if I find a mistake in my medical record?
If you find something in your record that you feel is incorrect, contact your provider. You have a right to request that your record be amended. Ask them how to go about making this request. They may have a form available to help the process. The request must be in writing. The provider will review the request. If they agree it is incorrect, they will make an amendment to the record. If they do not agree, you have the right to have a statement placed in the record noting your disagreement.
Is there someplace I can go to request a copy of all of my medical records from different doctors?
Not at this time in most states. You will need to place a separate request at each provider/organization whom you have seen and from whom you want a copy of your records.
How long does my doctor keep my medical record?
Check with your provider regarding the length of record retention. Washington State Law requires hospitals to retain medical records which are related to the care and treatment of the patient for a period of not less than 10 years following the most recent discharge. For minors, the time frame is not less than 3 years after they have reached 18 years of age or 10 years following discharge.
How do I get a copy of my child’s medical record?
If you have a minor child for whom you need to have medical records sent to another provider, you may request in writing to have those records sent for you. Check with the office of your child’s provider for instructions.
If you need a copy of your child’s medical records released to you directly, you will need to follow the procedure outlined above in: How do I obtain a copy of my medical record? This applies to children from birth to the age of 13 years.
There are special circumstances that protect adolescents in the state of Washington. For minors age 14 to 17, there are special rules in place to protect their right to privacy. Contact your provider’s office for their policy. See RCW 70.2 for more information: http://app.leg.wa.gov/RCW/default.aspx?cite=70.02
Where can I learn more about medical records?
Need more information on medical records and the rights of consumers? The U.S. Department of Health & Human Services has a webpage set up for consumers to learn about their rights. This information may be found here: http://www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
To learn more about health information technology and its benefits, visit https://www.healthit.gov/patients-families/electronic-health-records-infographic.
To learn more about protecting the privacy and security of your health information, visit https://www.healthit.gov/patients-families/protecting-your-privacy-security.