I was to see the surgeon about the broken tendon in
my hand and so was handed a large folder containing my
medical records to take with me to the other side of
the hospital. It was the first time I was pleased to
have to wait to see the physician. I skimmed the
records as quickly as I could,
shocked at the large
amount of information that I had shared with my doctor
about my condition which was omitted from the records.
He had dismissed my most recently complaints of pain
from active rheumatoid arthritis as “likely caused by
stress of breaking up with boyfriend.” I now knew
where I stood with this doctor, based on his scrawled
inaccurate descriptions of our visits.
The nurse appeared and witnessed me reading my
documents and in exasperation claimed, “You’re not
supposed to be reading that!” grabbing the folder out
of my hand.
“They’re my records,” I said, “I don’t understand why
I can’t.”
“You just can’t,” she flustered. “It’s not ethical.”
She was wrong.
CAN I GET A COPY OF MY MEDICAL RECORDS?
Usually. Most states allow patients to review their
medical information, but some states don’t address the
issue at all. Some may place restrictions on the
information you can get, for example, psychiatric
information is most difficult to receive.
IS THE INFORMATION MINE?
Technically, the documents belong to whoever made
them, but in most cases the information about you
belongs to you. Contact the you State Department of
Health to find out your rights in your state. The
number is in your local yellow pages or at the FDA web
site at: www.fda.gov/oca/sthealth.htm.
Even in states where the law is restrictive or
unclear, many medical providers will provide your
records to you anyway, according to the American
Health Information Management Association, the
“keepers” of the nation’s health records. If you
received care in a federal medical facility, you have
a right to access your record under the federal
Privacy Act of 1974 (5USC Section 552a).
HOW DO I REQUEST A COPY OF MY RECORDS?
Ask your doctor’s staff, hospital records clerk or
other appropriate person for a patient authorization
form that allows the release of information. You can
also write a letter, just be sure to include the
following information:
+ Your full name and date of birth, date of treatment
+ Name and address of the person or facility to which
disclosure is to be made
+ The specific kind and amount of information to be
disclosed, such as laboratory results, X-rays or the
doctor’s notes on your chart.
+ The purpose of the request, for example, “continuing
care” or “insurance.”
+ Your signature and the date
IS THERE A CHARGE?
It’s likely you will be charged $.25 to $.50 per page,
however, you can request specific information to help
keep the costs down. Your request cannot be denied
even if you still owe your doctor money for
appointments. If you are collecting them for a
third-party, keep a copy for yourself so you don’t
have to pay for them in the future.
WHAT IF I DON’T AGREE WITH THE
INFORMATION OR AM DENIED ACCESS?
The American Health Information Management Association
has a sample for called “Request for Correction/
Amendment of Health Information” that you
can complete and file at
http://www.ahima.org/consumer/index.html .
You can also locate your local state disclosure laws
at the Health Privacy Project at
http://www.healthprivacy.org .
