Accessing Your Hospital Records: A Step-By-Step Guide

Accessing your hospital records is a powerful tool in staying healthy. In the US, the Health Insurance Portability and Accountability Act (HIPAA) gives you the right to access your health information, make better decisions with your doctor, better track your progress, and do more to be healthy. You can request your records through your provider's patient portal or by filling out a health or medical record release form, sending an email, or mailing or faxing a letter to your provider. Some hospitals, doctors' offices, and clinics may also provide access to a website that stores patients' medical records. If you are seeking a specific hospital record, it is best to request it from the facility rather than your primary care provider.

Your rights to access hospital records

Patients have certain rights to access their hospital records. These rights are provided by the Health Insurance Portability and Accountability Act (HIPAA) and the Health Information Technology for Economic and Clinical Health (HITECH) Act. Under the HIPAA Privacy Rule, patients have the right to access Protected Health Information (PHI) maintained about them by a covered entity in a designated record set. This may include electronic or non-electronic PHI. A designated record set refers to information maintained by or for a covered entity (e.g. a hospital) that is used to make decisions about a patient. This covers medical, billing, and claims records, as well as lab test results, X-rays, and doctors' notes.

However, there are some exceptions to the right of access. Patients do not have the right to access a provider's psychotherapy notes, which are the personal notes of a mental health care provider and are kept separate from the patient's medical and billing records. Additionally, hospitals are not responsible for how patients' mobile apps use or secure their information.

To access their hospital records, patients can submit a written request to the hospital or make a request over the phone. They may be asked to provide identifying information such as their name, address, date of birth, and account or guarantor number. Patients can specify the method and format in which they would like to receive their records, such as email, fax, postal mail, or a specific electronic file format. Hospitals are legally required to provide access to records within 30 days of receiving the request, although this timeframe may vary in practice. Patients may be charged a reasonable fee to cover the costs of copying and mailing the records, but providers cannot charge a fee for searching for or retrieving the records.

It is important to note that patients' rights to access their hospital records empower them to take control of their health and well-being. With access to their health information, individuals can monitor chronic conditions, adhere to treatment plans, identify and correct errors in their records, and directly contribute their data to research.

How to request hospital records

In New York, patients have the right to access their medical records, with a few exceptions. These exceptions include personal notes and observations, information disclosed under the condition of confidentiality, and information that may cause harm to the patient or others. If access is denied, the healthcare provider must provide a written explanation.

To request hospital records, individuals can contact the hospital or healthcare facility directly. Requests must be made in writing and should be as precise as possible. Most healthcare facilities offer forms in multiple languages that can be completed, printed, and mailed to the appropriate facility. It is important to have personal information ready when making inquiries, including full name, date of birth, and approximate dates of treatment.

For records held by facilities licensed or operated by the New York State Office of Mental Health, written requests should be directed to the director of the individual facility. Substance abuse records inquiries should be directed to the individual facility.

If individuals cannot get in touch with their previous healthcare provider, they may seek assistance from the New York State Department of Health (NYSDOH), which oversees healthcare facilities and may have information about closed practices. County medical societies may also assist in managing record transitions when practices close and can provide information on record transfers or designated record custodians. Professional medical record retrieval services are another option, although they may charge a fee for their services.

Online services, such as OMR, also assist individuals in requesting their medical records. They provide convenient online request forms and can help facilitate the transfer of records from the doctor. Individuals can then choose to receive their records on paper or as a digital download.

Accessing records online

In the digital age, accessing your medical records online is a convenient option. Many medical practices maintain an online patient portal to allow patients to access their records. These portals may be referred to as "personal health record" or "PHR" or "patient portal."

To access your records online, you can check with your healthcare provider or doctor to see if they offer such access. If they do, you may be required to fill out a form, send an email, or mail/fax a letter to request access. This is known as a health or medical record release form, or a request for access. You may also need to present identification to prevent unauthorized access to your records.

Once you have access, you can log in to the patient portal to view your records. Depending on the website's features, you may be able to do more than just view your records. Some common functionalities include viewing test results and medication lists, scheduling appointments, obtaining follow-up instructions, paying bills, and refilling prescriptions.

In addition to patient portals, there are other electronic ways to access your health records. For instance, the Blue Button icon on your government health plan or provider's portal allows active-duty service members, veterans, and Medicare beneficiaries to access and download their health information. The Joint Health Information Exchange (jHIE) and eHealth Exchange are other electronic methods to securely share and access your health records.

Fees for obtaining hospital records

In California, state law allows healthcare providers to charge a maximum of $0.25 per page or $0.50 per page for records copied from microfilm, with a reasonable clerical fee also permitted. On the other hand, federal law prohibits charging a clerical fee for locating medical records, even if they are off-site. Additionally, patients are entitled to one free copy of the relevant portion of their record when appealing a denial of eligibility for a public benefit program.

In Pennsylvania, the Department of Health has published guidelines and fees that healthcare providers can charge for medical records requests. These fees are adjusted annually based on changes in the Consumer Price Index. While the fees can vary, they generally include the cost of postage, shipping, and delivery of the requested records.

It is important to note that patients have the right to review their medical records and obtain a copy, but the fees associated with this process can sometimes be a financial burden, especially for those with chronic conditions who may have lengthy records.

Reasons for denied access to hospital records

In most cases, it is illegal for healthcare providers to deny patients access to their medical records, according to the Health Insurance Portability and Accountability Act of 1996 (HIPAA) laws. However, there are some instances where access to hospital records may be denied. These include:

• Mental health records: Disclosing certain mental health records may be denied if they are considered "impressions" rather than diagnoses, as this may harm the provider-patient relationship if the information is misconstrued or taken out of context. However, denial must be provided in writing and can only be justified if the information might cause harm to the patient or others.
• Information compiled for a lawsuit: Under federal law, access to medical information compiled for use in a lawsuit may be denied.
• Psychotherapy notes: HIPAA does not give patients the right to access a provider's psychotherapy notes. These are notes that a mental health professional takes during conversations with a patient, kept separate from medical and billing records.
• Information obtained under confidentiality: If the requested information was obtained by someone other than a healthcare provider, such as a family member, under a promise of confidentiality, access can be denied if providing it would reveal the source.
• Endangerment: If a licensed healthcare professional determines that disclosing the information is reasonably likely to endanger the life or physical safety of the patient or another person, access can be denied. However, this does not extend to concerns about psychological or emotional harm.

If you believe you have been unfairly denied access to your medical records, you can file a complaint with the Office of Civil Rights (OCR) at the Department of Health and Human Services. It is important to note that there are medical records storage time requirements, and the length of time records are stored varies depending on state laws, the type of record, and where the records are kept.

Frequently asked questions