- your name, including your maiden name (if applicable)
- make sure that you date the letter for the date of delivery if possible
- your social security number
- your full date of birth
- your complete address
- your phone number or cell phone number
- the list of record(s) being requested
- the date(s) of service when you were under this doctor's care
- delivery method preferred – pick-up, fax, email, or other method
- your signature
August 28, 2012
The Trip to Obtaining Your Medical Records
Now that you are ready to obtain copies of your medical records, make a list of each doctor, period that you were a patient of this doctor, and whether the doctor is still alive or still in practice. Then make a list of medical labs you have used or that your doctors has used, whether they are still in business or not, and locate their address. The purpose is if your doctor is deceased, you may need to contact the labs for test results. Not the best solution, but this may be all that is available to you.
To obtain copies of medical records, you have to be the patient, or the parent of a minor child or the legal guardian of the patient for whom you seek medical records. If you are a caregiver, you may be able to obtain medical records if the patient has provided a legal medical power of attorney to the provider. Verbal authorization generally is not sufficient, but may work for some providers for a limited time. Forget about inquiring or obtaining medical records for your spouse, children of legal age, or parents without legal authorization.
The US Department of Health and Human Services provides background information to help you understand who may, or may not, be able to access your medical records. Providers are required to follow the state rules in which the records are kept. Generally, this means for an adult medical records are kept six or more years. Most children's records are kept three to 10 years beyond the age of 18 or 21. It is always wise to contact the provider to see if the records are still available.
Your doctor or provider is required to share any notes or records they have created or any test results which they have copies. Any information provided to them by another doctor is accessible if that information was used for the diagnosis or treatment being discussed with you. Diagnostic lab tests are a little more complicated, as blood tests, CT scan, x-rays, mammograms, or other tests should be requested from the doctor who ordered them, or from your primary care physician. In most states, the lab will refuse to provide them directly to you. For other records such as hospital records, clinics, or any other medical facility, be sure to request the copies directly from them.
When it involves mental health and related records, this is an area where many doctors will refuse you access. If they do, they must make the reason for denial clear in writing.
Many patients unfortunately believe they or their legal representatives are the only ones that can get copies of their medical records. This is false; there are people that can legally gain access to your medical records without your permission.
When you request copies, most practices, offices, or hospitals will have a form to complete to receive a copies of the requested medical records. They normally will send it to you by fax, email, postal mail, or you may pick it up from the doctor's office. If the facility does not have a specific form, you may write a letter, but be sure to include the following information:
Deliver the letter or mail the letter to the doctor's office. If you deliver, record in your own records the date the date of delivery and it might be beneficial to have a second copy that the person receiving the letter can sign, date, and show their title.
Now we come to the problem of gettingrecords from a doctor that has sold out, merged into another practice, or had simply left the practice (whether died, quit, retired, or another reason).
If your doctor has left the practice or sold the practice or it was combined with another practice, then the new practice should still have your records. If this is the case, follow the same procedure above as if the doctor was still working in that practice.
If your doctor is no longer in practice, or for some reason you cannot locate the doctor or office where you think your records should be, there are some steps you can take to locate your medical records. These steps include:
1. Contact your local medical society. You may be able to look up the phone number online or in the phone book, or you may find the contact information you need through this list of medical societies in each state. You will need to drill down by state to your local society.
Someone at the medical society should be able to let you know what became of your doctor's practice, and will possibly know where the doctor's records are being housed. They may also be able to tell you how to get copies if the procedure will vary from the basic procedure described here.
2. If your local medical society does not have the information you need, then contact your state medical society association, as per the list linked in #1 above.
3. Finally, if the medical societies cannot help you, then begin contacting other practices of the same specialty in your area. Some doctors will ask other practices of the same specialty to house their records when they close their practices. The idea is, that if your doctor is not in business any longer, then the other specialist might want to pick you up as a patient.
Simply call the office of each of the other same-specialty doctors and tell them, "I was a patient of Dr. ____'s. I am hoping to find my medical records. Can you tell me if Dr. _____ gave them to your practice?" If they say yes, then ask their protocol for getting your copies. If they say no, then ask if they know where those records are being kept. If they do not know, then call the next same-specialty practice and ask them the same question.
4. Finally, if none of these possibilities work out, contact the hospitals in your area. Unless you can determine a better department, then try Human Resources. They may know where your records are being kept.
Keep in mind that when your records have been housed elsewhere, they will be difficult to retrieve unless they are among the minority of records that have already been transferred to an electronic health record. For that reason, you will very likely be charged for the copies you want. Learn more about how much you may have to pay for copies of your medical records.