Medical records make up an array of vital documentation in a person’s health or medical care and history to help patients, as well as doctors, keep track of the patient’s official medical details throughout their life. Whereas a Medical Records Release Form is used to submit a request to the health department to get copies of a person’s health records.
Medical records are inclusive of but not limited to doctor’s notes, medical test results, billing information, lab reports, clinical trial data, insurance forms, death certificates, etc. Medical records can be as simple as handwritten notes to audio-visual records such as pictures, videos, and recordings.
Medical records are commonly requested for different reasons such as:
- Patients moving to a different town, city, state, or locality.
- When patients must change their primary physicians due to unavoidable circumstances.
- For litigation purposes-when, patients want to sue third parties for medical consequences inflicted, for example, accidents during official duties.
- As proof of rightful absence from work to employers
- When applying for settlement of health fees from insurance providers.
Medical records are used for different purposes depending on the need(s) at hand.
Why you Should Have your Medical Records
The following are some of the significances of ensuring one has access to their medical records; access to medical records allows you to update information relevant to your health care. Also, it allows one to identify inconsistencies such as missing or incorrect information so that appropriate corrections can be made.
Apart from that, it grants patients an opportunity to enquire about prescriptions or test results in the records for clarification.
Patients and/or their chosen representatives have the right (by law) to access their medical records. Regardless of whether the records are on paper or electronically stored (electronic medical records). Electronic medical records, commonly known as EMR, are medical documentation stored in digital or electronic health care systems.
With EMRs, patients will normally have patient portals where they can access their medical records online without having to physically visit their medical providers to pick copies of their medical records.
Health Insurance Portability and Accounting Act also referred to as HIPPA, is a 1996 act that allows patients to access certain medical records from their health care providers. HIPPA protects patients by prohibiting medical practitioners (by setting limits and conditions) from disclosing their patient’s information in the absence of a valid authorization under any circumstance unless otherwise stated by the law. Alternatively, it is also referred to as the HIPAA Privacy Rule.
Laws Associated with Getting Medical Records
Issuing and ways to get your medical records are governed by certain laws to protect medical practitioners as well as patients.
Some of these laws include;
- 45 C.F.R. Part 160 and 45 C.F.R. Part 164 are federal laws that provide comprehensive protection of a patient’s medical information. They are part of the HIPAA administrative regulations
- 45 CFR 164.524 is a law that governs the timeline within which medical records should be released once requested.
- 45 CFR 164.524(b)(1) is a law that permits the holder of medical records to demand a written request before releasing the records, even from the patient.
Who Can Request Medical Records
Based on law, there are different ways to get your medical records or issue a copy of a patient’s medical records depending on the circumstances. Parties allowed to access a person’s medical records are listed on a HIPPA form which is included in the patient’s medical file.
The following categories of people can be listed in the HIPPA medical records release form;
A personal representative is defined under HIPPA as any person who is legally permitted to make and implement medical decisions on behalf of another person. Other than the patient themselves, the medical release authorization form can allow the patient’s parent, spouse, family, friends, or primary care physician to access one’s medical records.
For example, in a situation where a married individual gets into an accident and requires emergency interventions, the attending doctor can request the spouse to obtain his/her spouse’s medical records to facilitate treatment. Depending on the gravity of the injuries, the patient’s consent is needed. If they are in a position to give permission, they should, and if not, consent might not be necessary if the patient’s life is on the line.
Adult or legal guardian
Legal or adult guardians of minors below the legal age which is ordinarily 18 years of age are permitted to access the minor’s medical records. Consent is given through documents that transfer legal custody to the adult. Also, caregivers and advocates, can access their client’s medical records provided they have written consent from their client, for example, a caregiver attending to a senior citizen at home. Sometimes a medical power of attorney can be used as consent – it should be attached to the patient’s HIPPA release form.
The administrator of the estate
Some people entrust their estate to a legally appointed administrator that assumes the responsibility of managing the estate either short-term or long-term if the person becomes incapacitated and unable to make and communicate decisions. Through a HIPPA form, estate administrators can be listed to gain access to one’s medical records. However, a signed medical authorization release form would still have to be presented. If the patient is deceased, the administrator can obtain the records regardless if they were appointed through a Last Will and Testament or court.
Note: Parties who have not been listed in the medical records release authorization form should not obtain any of the patient’s medical information by law. Additionally, patients are awarded the right to revoke and/or reassign access to his or her medical records at any time at their discretion.
Which Records Can be Requested
Physicians are not permitted to give every patient medical record in their possession. In legal terms, the patient only has the right to his or her “medical information,” which is obtained from their medical records.
Some of the patient’s medical records that can be requested are as follows:
Records of adults
Most healthcare providers are usually required to keep medical records for the previous six years for adult patients. Adults are entitled to this information and can therefore ask for it as need arises.
Records of children
Physicians are required to keep children’s medical records for at least three to ten years after the age of 18 or 21. Therefore, records of children below the age of 18 can be requested by their legal guardians.
Lab tests and Admission Records are included in a patient’s medical records and can be requested. These include blood tests—biopsies, X-rays, etc.
Records from retired doctors
If the doctor is no longer in practice, they are requested by law to transfer the patient’s records to another health care provider.
Records that Might be Denied
In a bid to protect doctors and patients there are certain medical records your physician is legally permitted to deny you access to.
These records include;
Mental health records
Mental records are common exclusions from medical records requests. This is because the doctor’s notes can be deemed to be more of “impressions” or personal or subjective opinions rather than diagnoses. If disclosed and the patient misinterprets the information, the doctor-patient relationship could be harmed and may hinder continuing treatment interventions.
Consent form to obtain records
Doctors can deny patients release authorization forms if the patient intends to seek access to any medical records that a doctor is legally allowed to deny. This denial must be put into writing.
Psychotherapy notes are notes taken by doctors during the treatment of mental or emotional disorders and include details obtained from dialogue and other psychological techniques. As a patient, you can be rightfully be denied access to such medical records.
Lawsuits will often require the collection and compilation of information. If this information is to be presented in court, doctors can deny patients from accessing this information until the lawsuit is settled.
ER (Emergency Room) records that can disclose procedures specific to the hospital or company and not patient care may also be denied to you.
Medical records that include information about other people or a third party and can potentially be used to cause harm if released may also be denied on the basis of confidentiality of a patient’s personal matters.
On-going research records
On-going medical research records that have not yet reached conclusion/completion could also be denied to you on the basis of their ongoing nature
Tip: Breach of medical confidentiality or unfair denial of access to medical records can be protested by filing a complaint against the health care provider with the Department of Health – The Office of Civil Rights (OCR).
Getting your Medical Records
Commonly, ways to get your medical records will depend on your health care provider’s process. Some providers make it possible for their patients to access their medical records through a portal, and others issue a free release authorization template to be completed and sent via email, mail, or fax.
Below is a guide on the different ways to get your medical records, depending on the situation;
Step 1: Choose the form
The first step in obtaining your medical records is choosing a release form that meets your needs. One can take two approaches depending on who is to access the medical records – the patient themselves or a third party.
Types of forms to request your records
Different HIPAA forms can be used to request different types of medical records from a medical practitioner. Ensure that you choose the correct form.
These forms include;
Chiropractic HIPAA Consent Form
Chiropractors practicing hands-on or hand-held instrumental movement of a patient’s bone structure of the body to improve the patient’s function of the joints and/or nervous system have to be HIPAA-compliant. A chiropractic HIPAA form allows the chiropractor to release medical notes of their session with the patient.
Download: Microsoft Word (.docx)
Dental HIPAA Release Form
Dental health records are vital; dental firms or dentists should issue a dental (ADA) HIPAA form for parties requesting dental records to ascertain that access to the dental records is within legal boundaries under HIPAA.
Download: Microsoft Word (.docx)
Most health care providers will have standard free release authorization templates patients can fill out to access their medical records.
Download: Microsoft Word (.docx)
Medicare HIPAA (CMS10106)
CMS10106 form is used when you want to permit someone else (other than the patient) to access one’s medical records. It outlines the specific information that will be disclosed to the third party and declares if there is no limitation to the information to be disclosed.
Download: Microsoft Word (.docx)
Step 2: Choose your approach
Either you as a patient can request your medical record release or you can authorize someone else to access your medical records. Both approaches have different steps to proceed.
Approach 1: Sign an authorization form for someone else to access your medical records.
Under 45 CFR § 164.502(g), third parties can access a patient’s medical records using Medical Records Release Authorization Form. Third parties include personal representatives, adult or legal guardians, and administrators of estates, etc. By signing the medical authorization release form, the patient gives consent and specifies what information they want to be shared. This way, there is no confusion of what should be shared, and the doctor’s liability is transferred to the patient. The signed authorization form will usually be accompanied by powers of attorney to be executable.
Approach 2: how to request records with a standard written form for yourself under the law 45 CFR 164.524(b)(1)
Patients can obtain medical records using a standard written form which is often obtained from the health care provider. This may need a physical trip to the medical office to be made. However, some health care facilities issue authorization forms online. If the request is via email or mail, fundamental components should appear in the medical release form. When requesting your medical records, your standard request letter should include the following details; patient’s name, social security number, contact information (address, phone number, and email), date of birth, list of records asked for, delivery option (mail, email, in person or fax) and signature. A standard release form will have the following sections;
- Releasor and Recipient – The form should identify who has the medical records and who will be receiving the records once released.
- Time Period – The form must outline the time period whose records will be released.
- Record Types – There should be a description of the specific information that will be disclosed.
- Expiration Date – A deadline after which the authorization will be void should be included in the release form.
- Others – The form can also include the purpose, risk of disclosure, date, and signature.
Step 3: Sending the letter and receiving the medical records
Often, medical facilities within the same state will normally adopt a uniform process for requesting records. The letter can be sent either in person or mailed/emailed. If the letter is to be sent digitally, one should check the medical facility’s format requirements. The requestor normally determines and states how they wish to receive their medical records. Electronic Medical Records (EMR) are usually faster to access.
The medical facility will typically charge a fee for sending the records. HIPAA awards health care providers 30 days to send the records and a one-off extension of another 30 days with an explanation for the delay. However, due to the urgency of these records, it is recommended that they be sent the earliest possible, and most do so within 5-7 days.
Free Medical Records Release Form
Here is a free medical records release form you can download.
Forms by State
Cost of Releasing Your Medical Records
The fee charged by medical facilities to send medical records will vary from state to state, and physicians should ensure it does not exceed the state-specific limit.
Mediums of getting the records
The most common means amongst the different ways to get your medical records are:
- Patient portals where patients can access certain information as permitted by law
- Collecting medical records in person – Patients will often be required to present a valid government-issued photo ID or driving license.
Through legal action
Medical records cannot be withheld due to non-payment; patients are legally entitled to their medical records. Health care providers should not exploit their patients by charging an exorbitant fee. If the patient fails to pay the asked fee, other means of collecting, such as the use of legal action and debt collection service providers, can be sought after. A release fee is usually applicable regardless of the means of receiving the records. However, the fee billed will vary depending on the method used to send the records. For example, in New York, the maximum fee is 75 cents per page, whereas, in California, facilities can only charge up to 25 cents per page.
Better Safe Than Sorry
Once the medical record is obtained, patients are always advised to cross-check their documents and ensure that everything was sent. Likewise, physicians should also refer to a patient’s medical records for clarity before the next appointment. This way, medical care offered to the patient can be a seamless process serving the patient’s best interests.