Martin had seen a gastroenterologist several times. He was about to see a new primary care doctor, and wanted to have his records so that he could explain his medical history clearly. He called the number he had for the GI doctor and asked how to get a copy of his records. The woman who answered the phone said, “Oh, this is his hospital office. He keeps his records at his other office. I’ll let his secretary know that you want them and she’ll send them to you.”
A month went by, and the records didn’t arrive. Over the next couple of months, Martin sent two certified mail letters to the address he had for the doctor, saying essentially, “I asked for my records and I still haven’t gotten them.”
It was years later, after Martin finally learned how to properly request his records, that he actually received them.
Previous columns have discussed why having your own medical records can make a big difference to your health, and what medical records it’s important for you to get. This column discusses how to go about getting those records.
The requirements for requesting your records differ a little depending on which state you were treated in -- see http://hpi.georgetown.edu/privacy/records.html for the specifics for each state -- but the following steps will cover the requirements in most states.
Get the correct phone number and mailing address for the doctor, hospital, or other service provider from whom you need records. (For the sake of simplicity, the rest of this article will talk about getting records from a doctor, but the same steps apply to getting records from other people or institutions.)
In Martin’s case, he would have been better served by asking the woman in the doctor’s office in the hospital to give him the phone number for the doctor’s other office -- the one where the medical records were kept -- and calling there instead of expecting that she would relay a message.
If you are asking for one test result related to a recent office visit, a phone call may be enough. However, if you want records from, say, two years of treatment, you will probably need to put your request in writing.
Call the doctor’s office and ask if there is a form to fill out to request your medical records. If they have a form, your chances of getting your records -- and getting them quickly -- are greater if you use their form than if you write your own letter.
If the doctor does not have a form, then ask what information they need to have in a letter from you in order to give you your medical records. Generally, the items they will ask for include:
- The date
- Your name
- Your mailing address
- As many ways to contact you as you can offer -- e.g., cell phone, email address, etc.
- The doctor’s name and mailing address
- Your social security number, or your medical record number if they use their own numbering system to identify patients
- Your date of birth
- A request to release your medical records to you, and in what format: Do you want to go and simply look at your records without getting a copy? Do you want a paper copy of the records mailed to you? Do you want an electronic copy of the records, if it is available? If it isn’t, then do you want a paper copy?
- The medical condition for which you were seen, if the doctor is a specialist; not needed if you are asking your primary care doctor for your records
- The range of dates during which you were seen, e.g., June 2008 - September 2011
- What records you want: all records? Specific test results? Actual x-rays or other diagnostic imaging?
- How you will pay the costs for a copy of the records (if you simply go look at your records, they typically cannot charge you a fee); such as, “Please call me to tell me what the charge will be and I will give you my credit card information” or “… and I will bring in a check”
- Your signature
Occasionally, a doctor might ask you to specify the reason for asking for your medical records. Sometimes, they use the answer to this question to understand better exactly what records you are looking for. For example, if you are going to get a second opinion from another knee surgeon, you will probably need to take copies of your actual x-rays.
Sometimes, though, asking you why you want the records is a throwback to days when people generally could not get their records, and if someone asked for them, it probably meant that they were going to sue or were going to stop seeing the doctor and go to another doctor. It is perfectly acceptable to say simply, “I am getting copies of all of my medical records for my personal files.”
Figure out when your doctor is likely to receive your written request, add 30 days, and make a note on your calendar to follow up -- call your doctor’s office -- if you haven’t received your records by then. In most cases, your records should be forthcoming shortly. If you are requesting records from a number of doctors, you may find it helpful to make a list and check their names off once you have received the documents.
Future columns will discuss what to do once you’ve gotten your records, and what to do about errors you find.