Obtaining Your Medical Records
Medical records are vitally important to the quality of your healthcare. Your medical records consist of an exhaustive account of your medical history. Your physician and ancillary medical staff use your medical records to learn about your prior medical treatment, review your current health status and establish treatment plans for you.
Did you know that you have a legal right to review, obtain a copy of and even correct your medical records under federal and state law? The federal regulations that govern health information privacy and security commonly known as HIPAA (the Health Insurance Portability and Accountability Act) grant you, with few exceptions, the right to inspect, review and receive a copy of your medical records (and billing records) that are held by your healthcare providers. The Texas Medical Practice Act also grants you rights under state law to access your medical records. The Texas Medical Practice Act sets the standards for access to medical records held by doctors and hospitals in Texas. If a standard governing access to your medical records under Texas law conflicts with HIPAA, your healthcare provider must fulfill the obligation that is the most stringent.
What’s in my medical records?
Medical records typically contain your self-reported symptoms, injuries and personal habits and your physician’s findings, diagnoses, care, and treatments. In addition, lab results, sensitive biographical data such as your Social Security Number, physical exam results, identified allergies, prescribed medications (and any adverse reactions to medications), a recorded history of behaviors that affect your health such as substance abuse or smoking, family medical history, immunizations, and screenings are all examples of what can be found in your medical records.
Why would I want my medical records?
There are multiple reasons why you may need or want a copy of your medical records. You may need a copy of your medical records:
· To provide to a specialist or to a new doctor after your relocation to a new area, the retirement of your previous doctor or a decision to stop receiving care from your previous doctor;
· To manage your continuity of care across multiple healthcare providers, including your primary care physician and specialists;
· To build your case in a malpractice claim against a doctor; or
· To take a more active role in managing our healthcare (for example, tracking blood pressure or glucose levels over time to achieve your health goals).
How do I obtain my medical records?
You must submit a request to your healthcare provider in order to obtain a copy of your medical records. Under Texas law, your request for your medical records from a doctor or a hospital must:
· Be in writing;
· Be signed and dated;
· Describe the medical record (or part of the record) that you are requesting (the billing records, medical records, or other information to be covered by the release);
· State the reason you are requesting the medical record; and
· State that you want the information released to you.
Also, patients are encouraged to mail the written request to the health care provider by certified mail, return receipt requested so the patient has assurance the request was delivery.
Before submitting your own written request, contact your healthcare provider to inquire about their own procedures for responding to requests for medical records. Your healthcare provider may have a form available for you to fill out to request your medical records. If available, use the healthcare provider’s form, which should conform to the requirements for the written request under Texas law and HIPAA. If your healthcare provider does not have a form, prepare a written request consistent with the requirements and recommendations for requesting a medical record set forth above. Also consider adding the following to your written request:
· Your address, telephone number or e-mail address;
· Your date of birth or medical record number;
· Whether you want to review your medical record, want a copy or both;
· Whether you want a paper copy or digital copy; and
· If you want a paper copy, whether you want the copy mailed to you, and if so, include your preferred mailing address; or
· If you want a digital copy, whether you want the copy downloaded to a USB drive, CD-ROM or e-mailed to your provided e-mail address.
Your healthcare provider must give you your medical record copy in the format that you request if it is not burdensome to do so. Doctors and hospitals once primarily kept physical medical records in their office spaces, but now, in most cases, medical records are maintained in digital form. This means the healthcare provider can make your medical records available to you in a variety of ways.
What is the cost to obtain a medical record?
A Texas doctor responding to a request for medical records in paper format or electronic format may charge a reasonable, cost-based fee for providing the requested medical records. If you request a copy of your medical records in paper form, Texas doctors may charge you no more than $25 for the first twenty pages and $.50 per page for every copy thereafter. Your doctor may also charge you postage if you have the copies mailed to you. If you request a copy of your medical records in digital format, Texas doctors may charge you no more than: $25 for 500 pages or less; $50 for more than 500 pages. The doctor may also charge you a reasonable fee for copying the electronic copy to the requested medium (i.e., USB Drive) and postage if the item upon which the electronic copy is stored is mailed to you.
A Texas hospital responding to a request for medical records in paper format or electronic format may charge a reasonable fee for providing the requested medical records.
If you request a copy of your medical records in paper format, Texas hospitals may charge you no more than $45.74 for the first ten pages, $1.54 for the 11th through the 60th page of provided copies; $.76 for the 61st through the 400th page of provided copies; $.41 for any remaining pages of the provided copies; and (B) the actual cost of mailing, shipping, or otherwise delivering the provided copies;. The hospital may also charge you postage if you have the copies mailed to you. If you request a copy of your medical records in electronic format, Texas hospitals may charge you no more than a retrieval or processing fee, which may not exceed $82.87 and the actual cost of delivering the provided copies.
How long will a health care provider keep my medical record?
Texas doctors are obligated by state law to keep your medical record for at least 7 years after the date they last treated you. If you were a minor when you were last treated, your doctor must keep your medical record until you are 21 years old or at least 7 years after the date of the last treatment, whichever is longer.
Texas hospitals are obligated by state law to keep your medical records for at least 10 years after the date you were last treated in the hospital. If you were a minor when you were last hospitalized, the hospital must keep your medical record until you are 20 years old or at least 10 years after the date you were last hospitalized, whichever is longer.
How long will it take to obtain my medical records?
A Texas doctor must provide a summary or narrative of the medical records within 15 business days after the date of receipt of the request and reasonable fees for furnishing the information. Please note that your medical records cannot be withheld based on a past due account for medical care or treatment previously rendered to you.
Written by Cliff Robertson, Strasburger & Price, www.strasburger.com