Those blood tests you had last year at your annual checkup, the tetanus booster you got two years ago, the X-ray you had for chest pain in 2019—what becomes of all this information? And how can you ensure that you and your current healthcare provider have access to your whole health history?
Under federal law in the U.S., you have a right to see and get a copy of your medical records. Yet, many people are unaware of this and hardly give their health records a second thought—until, that is, they need to seek a second opinion, change doctors, or receive continued care from various providers for a chronic condition.
For many patients, getting their medical records is a mystery, and doctor’s offices don’t necessarily make it any easier. In a study published in the medical journal JAMA Network Open, researchers analyzed 83 U.S. hospitals and found noncompliance with federal and state regulations regarding medical record requests. More than half of the hospitals’ authorization forms did not even provide patients with the option to obtain their complete medical record.
Below, we’re going to demystify medical records, explaining what they are, why they matter, and how you can get a copy of yours.
What Are Medical Records and Why Do They Matter?
Every time you visit a healthcare provider, they take notes and sometimes conduct lab tests and order imaging, which are added to your health chart that is kept on file with that specific provider. This is for continuity of care; each time you schedule a follow-up, it’s crucial that the provider is able to check your medical records to see your health history and be able to continue to treat you and help you get better.
Challenges arise if you decide to change doctors, seek a second opinion, or move to a different state. Unfortunately, your health records with that one provider do not automatically transfer over. Unless your new provider uses the same Electronic Health Record (EHR) software as your old provider, your new provider has no way of knowing what was in your previous provider’s health records for you.
So let’s say you have a thyroid condition and have received lab work and a CT scan to diagnose and treat it. If you change doctors, your new doctor will not be able to view the CT scan and provide the necessary treatment options. If the new doctor is not able to obtain that CT scan, they’ll have to order another one, and you’ll have to undergo this imaging procedure again.
Medical records matter because they ensure continuity of care and that you and your whole health care team are up-to-date on the entirety of your health. Additionally, they’re a crucial part of patient autonomy, granting you access to essential information you need to make the right decision about seeking care.
What Is an Electronic Health Record?
Medical records are often referred to as electronic health records or EHRs. They may also be referred to as electronic medical records (EMRs), but there is a difference: An EMR is meant to stay with a specific provider. An EHR is meant for sharing with the patient and other healthcare providers.
EHR software, such as MyChart and Athenahealth, create online portals that patients and providers can access. Providers can upload visit summaries and lab results and send secure messages. Patients can often download their health records or request to have them transferred to another provider—all within the online portal.
There is an exception, though: Imaging, such as CT scans or MRIs, are often not available on online health portals because they can be quite large files or require special software to view.
Here are some example situations in which an EHR proves extremely helpful:
- Sally has a chronic condition that requires frequent visits to a specialist for her to keep it in check. She’s established a great care team in her hometown of San Diego, but she’s planning a move to Houston soon. Thanks to an EHR, she’s able to transfer her health records to her new doctor in Houston, so he can see her full history of the condition and ensure to continue to provide her with the best care possible.
- John steps on a rusty nail, and his doctor tells him that he needs a tetanus booster if he hasn’t had one in the past five years. But, John can’t remember when he last got his tetanus shot. He checks his health records online and realizes that he had one three years ago, so he avoids having to get an unnecessary tetanus booster.
- Megan is admitted to the ER for a severe allergic reaction and is unable to communicate well with the healthcare staff. Doctors are able to quickly check her EHR to find out her health history and the probable source of the allergic reaction.
Essentially, an EHR is the digital version of those paper records that all doctors used to keep—and many still do! In a 2020 Software Advice survey of 1,000 medical providers, 44% reported still using paper charts.
From here on out, this article will use the terms “health record,” “medical record,” and “EHR” interchangeably.
Is There a Central Database That Contains All My Health Records?
Wouldn’t that be nice? But, no, unfortunately, in the United States at least, there is no central database that contains all your health records. While some countries with universal healthcare have achieved a universal EHR (central database for medical records)—Singapore, Australia, and Spain are a few—in the U.S., it’s very complicated due to the separate private health systems.
Therefore, if you receive care in the U.S., your records are scattered among the many providers you’ve seen over the course of your life. That’s why it’s essential for you to keep track of your own health records and transfer them, as needed, to each new provider you see.
Your Rights to Your Medical Records
In the U.S., your right to see and get a copy of your medical records, as well as have them sent to someone you choose, is protected by a federal law known as the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
According to the U.S. Department of Health & Human Services:
“With limited exceptions, the HIPAA Privacy Rule (the Privacy Rule) provides individuals with a legal, enforceable right to see and receive copies upon request of the information in their medical and other health records maintained by their health care providers and health plans.”
In addition to the federal law, there are state laws that govern your access to medical records as well, so be sure to check with the state your records are in (and are being sent to). For example, Kentucky law requires that healthcare providers provide the first copy of medical records to the patient free of charge, even though HIPAA allows providers to charge fees for copying and mailing records.
How to Request Your Medical Records if You Don’t Have Access to Them via an EHR Online Portal
At any time, you may request a copy of your medical records or request that a copy be sent to someone of your choosing. For instance, if you were to seek a second opinion from a rheumatologist, it would be helpful for your former doctor to send your records to the new one.
Below are some steps to help you request and transfer your records.
Ask the doctor’s office or hospital for their specific request procedure
Each healthcare provider will have their own records request process. Usually, you’ll need to fill out and sign a medical release form. Then, if both healthcare practices are using the same EHR, they can easily share records digitally with each other. If they are not on the same EHR or one of them uses paper records, they can fax (yep, fax! Around 70% of healthcare organizations still use them) or mail the records over.
Getting imaging done? Ask for a physical copy on the spot
Because the files are so large and therefore difficult to email or upload to an EHR, it’s wise to always request a copy of these images at the time of your appointment. For example, if you go in for a CT scan, be sure to ask the front desk for a physical copy of the images. That way, they can put the files onto a USB flash drive or CD (for those born after the turn of the last century, this is a disc that you can physically bring to another provider, who can then insert it into the computer and view using special software).
It’s often faster to ask the doctor’s office to make the medical records request on your behalf
When transferring medical records, you have two options: You can make the medical records request yourself (and the records get sent to you), or you can have the doctor’s office make the medical records request on your behalf (and the records get sent to the doctor’s office). The latter is often faster. Plus, it’ll help you avoid paying any fees that doctors are legally allowed to charge patients to cover the costs of copying and mailing.
Remember, though, you can receive a copy of your medical records directly
You have a right to directly receive your medical records instead of merely having them transferred to another provider. If you want the copies for your own records, tell the provider so. They can mail or email your records to you or upload them to a secure online portal.
Sign up for services that gather your medical records into one place
Companies such as PicnicHealth and OneRecord will gather all your disparate medical records into one online portal, so you don’t have to fill out request forms, make phone calls, or waste time hunting down records.
Store your records in a secure location
You don’t have to use a paid service to gather your records. If you want to track down and keep copies of your own medical records yourself, store them in a secure location. One idea is to sign up for a secure cloud storage service, such as Sync, where you can upload digital copies of your health records.
Medical Record FAQs
Who is authorized to access my medical records?
You may notice that every time you visit a new doctor’s office, they have you sign a HIPAA form that explains your rights to your medical records and allows you to give permission for specific people to see all or some of your medical records. You may choose to authorize a family member or a friend to access your health record.
But beyond the people you designate in your medical release forms, healthcare providers may request or receive your health records without your written authorization. For example, if your primary care physician refers you to a gastroenterologist about frequent heartburn, your PCP might send the GI doctor your health records to ensure proper diagnosis and continuity of care.
According to the U.S. Department of Health & Human Services: “The HIPAA Privacy Rule permits a health care provider to disclose protected health information about an individual, without the individual’s authorization, to another health care provider for that provider’s treatment of the individual.”
How long does it take to get medical records transferred?
This depends on each hospital or doctor’s office. Under HIPAA, healthcare providers have up to 30 days after your request to provide the medical records. But state laws may give an even shorter timeframe. For example, in Washington, providers have up to 15 working days. Be sure to look up the law in your state to see the maximum amount of time it may take your provider to transfer your records to a new provider.
Can a doctor charge you for your medical records?
Yes, under HIPAA, a doctor’s office is permitted to charge a fee to cover the costs of copying and mailing the records. These medical records fees vary by state.
However, HIPAA prohibits doctors from charging you a fee simply for “searching for or retrieving your records.”
Can a health provider deny me access to my health records because I haven’t paid my bill?
No. According to The Office of the National Coordinator for Health Information Technology (the government entity that leads health IT efforts): “A provider cannot deny you a copy of your records because you have not paid for the health services you have received.”
Can a doctor refuse to release medical records?
Yes, in very limited circumstances, a healthcare provider may legally refuse to reveal information to you from your own health records. Below are two examples of categories that HIPAA excludes from a patient’s right of access:
- Psychotherapy notes
- “Information compiled in reasonable anticipation of, or for use in, a legal proceeding”
What if there’s a mistake on my health record?
Under HIPAA, you have a right to correct mistakes in your health records. To do this, contact your healthcare provider’s office and ask how to correct your health record.
What can I do if my doctor won’t release my medical records?
If you think your rights under HIPAA have been violated, you can file a complaint with the U.S. Department of Health & Human Services’ Office for Civil Rights, which has the ability to investigate this for you.
You Have a Right to Your Medical Records
If there’s one thing you need to take from this article, it’s that access to your medical records is a federally protected right.
We hope this article provides you with the tools to practice self-advocacy in your healthcare, as you now know the steps to take to request and transfer your medical records anytime. They’re essential to your health, especially if you have a chronic condition.
