Medical Record Release: Fill & Download for Free

Facsimile.Yes, you read that correctly. In the 21st century, when the power of the internet can provide instant secure connectivity to transfer enormous quantities of data, U.S. hospitals pour millions and millions of dollars into EMRs that aren't compatible with each other, necessitating reliance on an ancient technology from the '60s unknown to the majority of human beings born in this country past 1995.In case you're curious, this is the process I usually go through:Step 1a: Make sure patient is conscious, can communicate, and has capacity to consent. If any of the above do not apply, hope that patient has legally recognized party that can consent for them present/reachable.Step 1b: Hope that patient or other related party remembers where they were treated, or at least enough information to successfully Google the treatment facility, like a street name, an intersection, anything. Hope that previous treatment facility still exists (they're obviously not getting care there right now for a reason, maybe the reason is because it's shut down).Step 2: Fill out, by hand, an extensive form to be signed by the patient explicitly consenting to the release of their medical information by the other healthcare entity.Step 3: Before asking the patient to sign the form, spend time explaining to the patient why access to prior records is necessary. Deal with patient reaction.Best scenario: Patient just nods, smiles, and signs form.Ok scenario: "Doc, I don't get it. I'm obviously here because I want treatment. If my past records are needed for treatment, why can't you just get them without having to go through me? Just do whatever it takes to get me better already." Patient signs form, shaking head.Stressful scenario: "Why the %$#& are you wasting my time with this @$#%&*!# instead of treating me?! If you need the *&@# records just get the $#@%ing records so we can get this &^*% done!" Patient throws pen in my face.Step 4: Find a working fax machine. This can be harder than an act of Congress.Step 5: Fax the form to the other facility. Hope their fax machine is working. Hope they have someone working at that time (at 3AM, this is not guaranteed). Call them to (hopefully) confirm receipt of the fax and explain that I need this information ASAP. If this step fails, try not to feel too much frustration that I spent over 2 decades studying to become a doctor only to be stalled by a piece of hardware that even my parents didn't own.Step 6: Wait for the other facility to find the requested records. This is, of course, assuming that they have someone working in medical records at that time. Even if they do, it could still be hours.Step 7: Receive, by fax, a bundle of grainy scanned papers from other facility. Hope desperately that the information I need is in there. Groan in realization that Control-F isn't going to help me and I need to search through the entire stack (sometimes hundreds of sheets, depending on patient's history) by hand to find what I need. Enlist medical student assistance if possible....and people wonder why I'm so obsessed with EMRs and how they need to be improved.

When I was 20 weeks pregnant with my second child in 1982 I had a sonogram during an emergency room visit after a heavy vaginal bleeding event. The test took forever, but having never had a sonogram before, I didn't know that wasn't normal. When the doctor returned after the test, he said the placenta had attached very close to the birth canal, which had contributed to the bleeding event . . . . but, it also appeared the baby had no kidneys. The baby's preliminary diagnosis was Potter Syndrome (aka renal agenesis) in which kidneys are either rudimentary or absent.We were literally in process of moving from one city to another and had a moving truck already half loaded waiting in front of our house when I went to the hospital. I was placed on bed rest and spent the next week at my grandmother's house. My husband, his best friend, and my father finished loading that truck and moved us into our new place sixty miles away. My OBGYN had told me I needed another sonogram ASAP to confirm this diagnosis and gave me the name of a doctor he knew in the new city.I made an appointment via telephone, and after a tearful week, my husband and father came to get me. My appointment was the following week. We had no insurance at the beginning of the pregnancy, so we were making regular cash payments to my original doctor. I had spoken to my new doctor's staff in the intervening week, and was told I would have to pay for my visit and the routine bloodwork, pap smear and other labs on the day of the visit. We were cash strapped after the moving expenses we'd had and I was worried about money.I explained my issue, and told them I didn't want to repeat all those tests. I wanted to just be seen and to schedule a sonogram. I also told them I was expecting a refund of excess monies already paid to my first doctor, and I wanted to transfer my records so I wouldn't have to pay for these tests twice. Once received, I would immediately pay those excess funds over to them. They were unmoved. I asked to speak to the doctor, and was ultimately contacted by his partner, who assured me they would wait for payment and not repeat the tests.On the day of the appointment the reception staff found no record of my conversation with the partner. The woman at the desk insisted I pay for that day's visit and the labs I would have. The partner was not in the building, so I couldn't talk to him. I was an emotional wreck, as you can imagine and I couldn't help but sob in the waiting room. I called my husband from their desk phone (we had no cell phones in 1982) and tearfully told him what was going on. I should tell you that he is legally blind and cannot drive, or he'd have rushed to my side at that moment. We agreed to just write them a damn check, to allow all the labs except the pap smear, and to tell the doctor what had happened when I saw him so I could get my sonogram scheduled.I sat through unnecessary blood work and then pointlessly peed in a cup for them. I also signed paperwork authorizing the transfer of my medical records. When I saw the doctor and explained my whole situation, he was a completely callous, heartless ass. He did a pelvic exam and, even though I had made it clear I did not want a pap smear, HE DID ONE ANYWAY without my knowledge or consent, and without payment. He told me I didn't need a sonogram and that I should go home and wait to deliver my baby. He was “sure” it would be healthy.After I got home, I called my original doctor to ask his advice. He immediately gave me another doctor's name and apologized for my horrible experience. He promised to expedite my refund and encouraged me to call him if I had any other issues. This third doctor was an absolute saint, and given my issue, his staff got me in right away. I suspect my first doctor called him with a heads up because it was a nurturing experience and not the torture I had gone through with doctor number two.I mentioned earlier that I had signed an authorization to transfer my medical records from doctor one to doctor two. That transfer did happen. When doctor three asked for my records from the medical monster's office, they held my records for ransom because I hadn't paid for that redundant pap smear. I had to pay for it in order get them to release my records. I was so fragile emotionally that I just did it.Before he would allow his staff to release my records, doctor two called me personally to discuss why I didn't want to continue to see him. I am not a confrontational person, but I told him what his staff did to me, and what he had done. I told him I would never, ever set foot in his office again, and that I wanted my records transferred immediately. Stunningly, he agreed, and he said he would refund everything I'd paid him, EXCEPT THE FEE FOR THE PAP SMEAR, because that specific test was done outside his office. I just wanted to stop talking to this awful man and I hung up.On October 16, 1982, my 3 lb., 13 oz. daughter was delivered 8 weeks early by doctor three. She lived for about 30 minutes. My doctor asked for permission to request an autopsy, which we agreed to. We wanted other children and needed to understand the risk of recurrence. It wasn't until we discussed the autopsy results with my doctor, that we learned that the person who did her autopsy was the very doctor who had told me to go home and wait for my healthy baby to be born. I was disgusted to think he had even touched her. Indeed, this was the man who confirmed her cause of death as Potter Syndrome. Now, forty years later, I think there was an element of karma in all of that. I sincerely hope he learned to treat people with compassion.

How to Get Copies of Your Medical RecordsReviewing your medical records is not only the smart thing to do, it's your right. It allows you to update any information that may be vital to your care or to query your doctor about prescriptions or test results that are missing or incorrect.Historically, medical records were kept and maintained by the primary care provider. In recent years, a trend has emerged that has seen patients taking responsibility for the storage and maintenance of their own medical records.Unless you are in a health care system which provides you access to your electronic medical records (EMR), you will need to take steps a request for copies for yourself.According to the Health insurance Portability and Accounting Act (HIPAA) of 1996, you have the right to obtain copies of most of your medical records, whether they are maintained electronically or on paper. These include doctor's notes, medical test results, lab reports, and billing information.Who May Request Medical RecordsWhile designed to protect your privacy, HIPAA regulations are so extensive that many providers are still confused about how to enforce them. This can sometimes make it difficult to obtain your records, even if you are fully entitled to them.According to HIPAA, you have the right to request medical records if:You are the patient or the parent or guardian of the patient whose records are being requested.If you are a caregiver or advocate who has obtained written permission from the patient. In some cases, the health care provider will provide you a form that the patient must complete.Many people assume that only they or their designees can obtain copies of their medical records. Under the law, there are other individuals or organizations who may also have the right.This not only includes your primary care physician but third-party covered entities to whom you may have knowingly or unknowingly granted the right when signing a patient intake or registration form. These not only include medical practitioners but organizations like insurance companies, hospitals, labs, nursing homes, rehabilitation centers, and billing providers.Today, some people are even requesting their medical information be shared with mobile apps (such as those that monitor your heart health or diabetes). Under HIPAA, you have the right to request this with the understanding that the doctor who releases the information is not responsible for how the mobile app provider uses or secures your information.To this end, it is in your interest to read any medical registration or intake document to fully understand the rights you are granting and with whom your information may be shared.Which Records Can Be Provided and Which DeniedAlthough you have a right to most of your medical records, there are some that healthcare providers can withhold. Note that the age of a particular set of records also can affect the ability to obtain them: Most providers, including doctors, hospitals, and labs, are required to keep adult medical records for at least six years, although this can vary by state. Depending on the state, a child's records must be kept for three to 10 years beyond the age 18 or 21.Among the various records you have the right to obtain:Any notes or records that a provider has created themselvesAny diagnostic results for which a provider has copies including blood tests, X-rays, mammograms, genetic tests, biopsies, etc.Any information provided by another doctor that was used to establish a diagnosis and/or direct treatmentIf you're seeking specific lab tests or hospital admission records, often it's best to request them from the lab or hospital rather than your primary care provider. They are likely to be more complete and may even be kept for a longer period of time than a private medical practice.Records Your Provider May DenyThere are records to which you may be denied access. These primarily involve mental health records for which the provider's notes may be considered "impressions" rather than diagnoses. It has been argued that disclosure of these record may harm the doctor-patient relationship or be misconstrued when taken out of context.With that being said, a provider cannot deny your request because it might hurt your feelings. It can only be denied if the release of the information may compel you to harm yourself or others. If denied, the denial must be provided to you in writing.Under the law, the following may be reasonably withheld:Psychotherapy notesEMR records that are not in a "designated record set" (meaning those that do not pertain to your health but are used for quality assurance to improve patient care)Records that might endanger your life and safetyInformation compiled for use in a lawsuitRecords that includes mention of another person who may be harmed by the release of the informationRecords that breach the confidentiality of a third-party who was promised confidentialityRecords that may compromise your health, safety, custody, or rehabilitation if you are in prison (or those of other inmates or persons in the correctional facility)Records that are part of ongoing research that has not been completedMany of these limitations are subject to broad interpretation.If you feel you are being unfairly denied access to specific medical records, you can file a complaint with the Office of Civil Rights (OCR) at the DHHS. You can do the same if your medical confidentiality has been breached.If the OCR agrees that your complaint is justified, it will instruct the doctor or facility to take corrective action or enforce a settlement if actual harm was done. The complaint must be filed within 180 days of the violation.The law also prohibits retaliation on the part of the covered entity if a complaint is lodged, such as the termination of services or an increase in the cost of services.What to Do if You are Denied Access to Your Medical RecordsHow to Request Your Medical RecordsMost practices or facilities will ask you to fill out a form to request your medical records. The forms can be usually be collected at the office or delivered by fax, postal service, or email,If the office doesn't have a form, you can write a letter to make your request. Be sure to include:Your nameSocial Security numberDate of birthAddress and phone numberEmail addressThe list of records being requestedThe dates of serviceDelivery option (fax, post, email, in person)SignatureOnce the request has been made, you may have to wait a while before the records are actually received. State laws vary but typically require delivery within 30 to 60 days. Be sure to keep a copy of the original request, and contact your state's Department of Health if you fail to receive the documents after repeated attempts.Cost of ServiceBe aware that you may have to pay for the cost of your medical records if you want them delivered on paper, by fax, or via electronic media. While the price can vary, it must be reasonable.Moreover, you are entitled to the records even if you haven't paid the doctor or facility for the procedure involved. The records cannot be withheld for non-payment, and you cannot be charged an exorbitant fee to compensate for the non-payment of services. If monies are owing, the doctor or facility can pursue avenues for collection, such as legal action or a debt collection service.For a Doctor No Longer in PracticeIf your doctor retires or is no longer in practice, all medical records must still be maintained under the law. This pertains even if a doctor has died or dissolves the practice without a sale.Under the law, the medical records should be transferred to another health care provider that agrees to accept the responsibility. If a provider cannot be found, the records may be archived with a reputable commercial storage firm.Similarly, if your doctor has left the practice but the practice is still operating, your records must be maintained by the remaining members. If the practice was sold, the new practice will be responsible for the maintenance of the records and be liable if the records are lost or mishandled.Tracking down your records can sometimes be a challenge, particularly if a doctor's office was closed with no forwarding details. In this instance, there are several things you can do:Contact your state or local medical society. Because many of these organizations require annual registration, they will most likely have the latest contact information.Speak with your health insurance company. If the doctor is still an approved provider, your insurer will have contact details.Contact any hospital where you doctor made rounds. Hospitals require doctors to undergo a formal process to obtain hospital privileges. Human resource departments will usually have details on file.If all else fails, you may need to reconstruct your file by contacting the various labs, hospital, or specialists you used. Your health insurers, both past, and present can provide you with the details of any claims made on your behalf.Correcting ErrorsOnce you've obtained a copy of your medical records, review them carefully. If you find errors or omissions, you will want to have them corrected immediately to ensure that they don't compromise your future care.Most providers will agree to correct factual errors or track down reports that should have been maintained in your file.However, this does not extend to differences of opinions for which your doctor has the right to express a medical opinion. This includes notes regarding contributing factors to an illness (such as alcoholism or HIV) that you would rather not have in your medical records. Altering or omitting the records would not only be ethically problematic, it could subject the doctor to legal action.With that being said, if you believe that that the refusal of a correction is unjust or places you in harm's way, submit a complaint to the OCR detailing the dispute. They can review the evidence and decide if the correction is warranted.A Word From VerywellKnowing what is in your medical records can be every bit as important as seeing a doctor in the first place. If you have access to your EMR, be sure to review it after every appointment or well-care visit. It allows you to make corrections when needed and participate more actively if and when medical treatment is needed.