How to access your medical records

Patients have a right to access their medical records.

Most of us take the privacy of our patient-doctor relationship for granted. That includes the belief that our medical files, which generally provide a complete overview of our visits, our diagnosis, our test results and any notation the doctor might make on our care, are kept confidential.

But sometimes patients need access to those records, whether to share with another doctor or to get information to make decisions about care.

Fortunately, the law that governs the privacy of our medical records also provides guidelines for how to obtain them.

HIPAA, the federal Health Insurance Portability and Accountability Act, signed into law by President Clinton in 1996, provides all individuals with protection against unauthorized review or disclosure of their written, electronic or oral health records.

Release of those records is only permissible when an individual patient, age 18 or older, provides written consent.

But in reality, most patients don’t understand HIPAA regulations. To help readers understand how to properly secure their medical records from physicians, hospitals or pharmacies, Carol Brayshaw Longwell, an attorney shareholder in Buchanan Ingersoll Rooney PC and member of PinnacleHealth’s Patient Safety Committee; Ami Zumkhawala-Cook, Holy Spirit Hospital’s chief compliance officer; and Ashley Flower, Rite Aid public relations senior manager, lend their expertise.

IT’S UP TO YOU

HIPAA regulations are there to protect you, the consumer. If you want your medical records, you must be the one asking for them, or in the case of a child (under age 18), the parent or legal guardian is the one to request records (The exception being if the minor is married, has a baby, graduated from high school, has an emancipation court order, or is being treated for a condition where parental permission is not needed.) Don’t send your spouse or friend. The permission must come from you and generally be in written form.

WHAT’S NEXT?

Your physician owns your medical records, but you have the right to inspect and copy them. If your doctor doesn’t have a specific medical records release form, send your request in writing to the office and include: name (maiden name as well), Social Security number, date of birth, address and phone number, email address, what records you are requesting, and date(s) of service. Sign your request, provide the format you’d like to receive the records (hard copy, electronic) as well as delivery options (mail, pick up, fax, etc.). There may be a copying fee. If you want your hospital records, make your request directly to that facility.

PATIENT RIGHTS

After reviewing your record, you have the right to amend any doctor’s notes in your file by writing your own note if you feel the information needs to be more accurate or complete. Your note will become a permanent part of the file. You also have the right to file a complaint with the State Board of Medicine or U.S. Department of Health and Human Services’ Office for Civil Rights if you cannot get your files.

WHAT IF YOUR DOCTOR RETIRES OR DIES?

A physician must provide notice to patients if he or she is retiring or otherwise withdrawing services and must provide copies of records at a reasonable cost. If the doctor was part of a practice and retires or dies, the patient may obtain his/her medical records from others in the practice. If your doctor was a sole practitioner and dies, it’s more complicated. You could contact the doctor’s lawyer or check public notice on his death.

ARE ALL RECORDS AVAILABLE?

There are some exceptions. If the provider or facility is concerned that the record’s content may be harmful to the patient, your request may be denied. These are often mental health records. Providers cannot simply refuse because they believe it might upset the patient, unless it’s believed that upset will lead to the patients’ attempt to physically harm him or herself or others because of the content.

WHAT ABOUT HOSPITAL RECORDS?

Hospitals in central Pennsylvania have a network of compliance officers and trained staff to help patients who want their records. Authorization forms for release of your information are readily accessible at hospitals and easy to understand. Some can be downloaded from hospital websites.

According to Zumkhawala-Cook, records are retained for six years, in accordance with HIPAA regulations, and cover all services a patient has had within a health system. These services could include care from the hospital, a physician practice, ambulance server or any other system provider.

“If a patient meets any barrier, our privacy officer is always available,” she said. “Some issues that may arise in release of records are interfamily dynamics (divorce, shared custody), mental health issues or patient’s state of consciousness. We protect the patient in all cases.”

ARE PHARMACY RECORDS COVERED?

Yes. According to Rite Aid’s policy, great lengths are taken to protect a patient’s privacy and personal information. Store associates are trained on store privacy policies and procedures. Patients can receive their records by asking any pharmacy associate, who will first validate their identity (with either a photo ID or by correctly answering a series of questions). Patients can also contact the corporate office and request their records upon validation of identity.

DO HIPAA REGULATIONS WORK?

“All the doctors and hospitals I know have worked very hard to establish processes to preserve the confidentially of patient records and to insure that patients have access to their records,” Longwell said. “I have great faith in health care providers as they have taken all these requirements very seriously.”

-By SUSAN SILVER COHEN For The Patriot-News