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Medical Records: Can I See Them or Not?
By Lisa Copen
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
www.ahima.org/consumer/index.html.
You can also locate your local state disclosure laws at the Health Privacy Project at
www.healthprivacy.org.
YOUR HEALTH IS IMPORTANT! Get it organized in just minutes! Lisa is the editor of
A Woman's Health Resource
Journal and the founder of Rest Ministries, an organization for people who
live with chronic illness or pain at
www.mychronicillness.com. She lives with rheumatoid arthritis and fibromyalgia.
Copyright 2002. [Adapted from "A Woman's Health Resource Journal," p. 14]
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