MEDICAL RECORDS: Can I See Them or Not
I was to see the surgeon about the broken tendon in my hand and so was handed a large folder containing my medical records to take with me to the other side of the hospital. It was the first time I was pleased to have to wait to see the physician. I skimmed the records as quickly as I could, shocked at the large amount of information that I had shared with my doctor about my condition which was omitted from the records.
He had dismissed my most recently complaints of pain from active rheumatoid arthritis as "likely caused by stress of breaking up with boyfriend... "I now knew where I stood with this doctor, based on his scrawled inaccurate descriptions of our visits.
The nurse appeared and witnessed me reading my documents and in exasperation claimed, "You're not supposed to be reading that!" grabbing the folder out of my hand.
"They're my records," I said, "I don't understand why I can't."
"You just can't," she flustered. "It's not ethical."
She was wrong.
CAN I GET A COPY OF MY MEDICAL RECORDS?
Usually. Most states allow patients to review their medical information, but some states don't address the issue at all. Some may place restrictions on the information you can get, for example, psychiatric information is most difficult to receive.
IS THE INFORMATION MINE?
Technically, the documents belong to whoever made them, but in most cases the information about you belongs to you. Contact the you State Department of Health to find out your rights in your state. The number is in your local yellow pages or at the FDA web site at: www.fda.gov/oca/sthealth.htm.
Even in states where the law is restrictive or unclear, many medical providers will provide your records to you anyway, according to the American Health Information Management Association, the "keepers" of the nation's health records. If you received care in a federal medical facility, you have a right to access your record under the federal Privacy Act of 1974 (5USC Section 552a).
HOW DO I REQUEST A COPY OF MY RECORDS?
Ask your doctor's staff, hospital records clerk or other appropriate person for a patient authorization form that allows the release of information. You can also write a letter, just be sure to include the following information:
- Your full name and date of birth, date of treatment
- Name and address of the person or facility to which disclosure is to be made
- The specific kind and amount of information to be disclosed, such as laboratory results, X-rays or the doctor's notes on your chart.
- The purpose of the request, for example, "continuing care" or "insurance."
- Your signature and the date
IS THERE A CHARGE?
It's likely you will be charged $.25 to $.50 per page, however, you can request specific information to help keep the costs down. Your request cannot be denied even if you still owe your doctor money for appointments. If you are collecting them for a third-party, keep a copy for yourself so you don't have to pay for them in the future.
WHAT IF I DON'T AGREE WITH THE INFORMATION OR AM DENIED ACCESS?
The American Health Information Management Association has a sample for called "Request for Correction/Amendment of Health Information" that you can complete and file at http://www.ahima.org/consumer/index.html.