Living with Chronic Pain
How to Obtain Medical Records in the United States
Obtaining personal medical records can be a complicated process, but it is worth the aggravation for many individuals with chronic pain conditions. Having up-to-date records allows individuals to recall what diagnoses have been made, what treatments they have tried and what tests have been completed. This helps prevent unnecessary repeated tests and treatments.
Requesting medical records
The process of requesting medical records is similar across states and provider types. Whether an individual is obtaining personal medical records from a doctor's office, a hospital or a clinic, the same federal law known as HIPAA applies. HIPAA entitles every individual the right to access their medical records. It also allows them to receive copies of medical records and request that amendments be made to the records. Individual state laws have some variations in the process of requesting records, such as charging a cost for copying or sending the records.
The first step in obtaining medical records involves contacting or visiting the individual’s primary care provider’s health care management department. Small medical offices may not have a separate department, so talking with the administrative staff in charge of releasing patient records is sufficient.
After contacting the correct department, the next step involves completing a "patient access request" form. A completed and signed authorization form is mandatory for all record releases, and unsigned or incomplete form requests will not be fulfilled. In cases of especially sensitive records, such as behavioral health, substance abuse and HIV/STD records, state law may require additional authorization forms. Also, in some mental health records, the doctor's notes may be omitted. It is also important to note that individuals only have the right to copies of their records, not the original record which belongs to the health care facility.
How long does it take?
If requesting the records in person, an individual will be required to show a valid government-issued photo identification. The fulfillment of a records request does not usually happen on the same day. HIPAA allows providers 30 days to complete a record request and a 30-day extension if deemed necessary. Most facilities do not require that much time, and the request can be filled in as little as 10 days. The time it takes to fulfill a request often depends on the type of facility that is holding the records. For example, if it is a small primary care provider’s office, the request could be fulfilled the same day. However, when requesting medical records from a large hospital, it could take the full 30 days simply due to the large volume of requests. The bottom line is that any individual in the U.S. over the age of 18 has the right to obtain a copy of their medical records with as much ease as possible.