How Do I Get My Medical Records?

You may want to obtain copies of your medical records, but are uncertain about how to go about getting them. The doctor, or hospital, or other health care provider who has your records may be reluctant to provide them to you, knowing that you have become dissatisfied with your care and treatment. The health care provider will be concerned that you want the records simply to find out whether or not you have a “good case” in a potential lawsuit.

There is no denying that a common reason for a patient to request records is to get an opinion as to whether the health care provider may have committed medical malpractice. Often, the patient will already have consulted with another doctor, and/or a lawyer. Sometimes this will be because the patient suspects that malpractice was committed, or, as I often find, the patient simply wants to understand why the treated medical condition has not improved, or has even gotten worse.

In California, (and, I’m pretty sure in other States, as well) your medical records belong to YOU, the patient. They are not the “property” of the health care provider. They are yours. You do not need to give a reason or provide an explanation as to why you are seeking your medical records. In California, so long as an appropriate written request is provided, and you pay a reasonable fee, your records must be turned over to you or your designee.

The remainder of this article will discuss what you need to do in order to get your medical records from a health care provider in California.

Health care providers keep records to document your care and treatment. Medical records are an important component of the care and treatment provided to any patient. Even small medical offices will usually have a “Records” Department, or at least some part of the office’s operation will be devoted to the accumulation, organization, and copying of medical records. In major hospitals, Records Departments are vast operations, employing large numbers of individuals.

Generally, each medical provider will have its own printed “Release” or “Authorization” form which they will provide you for your signature. However, even if the health care provider does not have its own form, your handwritten request, specifying that you want “all of your medical records,” is acceptable. You may make your request for your medical records by sending the medical provider either a letter, e-mail, or a fax; or, you, or your designee can personally make the request at the provider’s facility. When providing your own request, you should provide your name and address, your telephone number, your e-mail address, your medical record number, if you know it, your date of birth, and the date(s) of service (such as the dates you were in a hospital). Finally, you should describe the information that you want to see or copy, which may include whether you want the entire record or just part of it. The medical provider is entitled to obtain certain other information from you, such as your social security number, and identification such as a driver’s license, since these are good ways to identify you. There is nothing in the State or Federal laws which prohibits this practice.

Your medical privacy is important, so health care providers are required to establish procedures to ensure your confidentiality under State and Federal Law. The specific Federal and California requirements which make the release or authorization lawful, will not be addressed in this article. Virtually all health care providers’ will have printed forms that meet the lawful confidentiality requirements. Periodically, the laws have been amended, so the requirements that are contained on the form will also change.

Under California law, Health care providers, including doctors, hospitals, HMOs, etc. must permit you to inspect your medical records during business hours within 5 working days from the time your written request has been received by the provider. It may be necessary for you to pay reasonable clerical costs in connection with locating and making your records available for inspection. Naturally, most people are not looking to read and inspect their records at the health care provider’s facility. They want a copy. You do have the right, however, to both inspect your records and get a copy.

The health care provider must provide copies of your records for not more than $.25 per page, or $.50 per page for records copied from microfilm. The health care provider does not have to give you copies of your diagnostic images (X-rays, MRIs, CT scans, etc.) if they provide them to another health care provider upon your written request within 15 days after receipt of the request. If you are seeking copies of X-rays or other diagnostic images, you can be charged all reasonable costs, not exceeding actual costs, incurred by your doctor, hospital, clinic, etc. in providing copies. It is usually a good idea to ask for an estimate of these costs before you request they be copied.

Generally, I find that it is reasonable to give the medical provider the full 15 days to locate and copy the records requested for later pick up. The law allows for up to 15 days, but it is generally not a good idea to be rigid about this requirement. You will likely be charged for this service, and you may also be required to pay this cost up front.

If you meet resistance in getting the records, politely but firmly inform the representative of the health care provider, that these records belong to the patient, not the doctor, hospital, clinic, etc. Not uncommonly, a health care provider will procrastinate and not provide the records within the mandated time.. What should you do then? Generally, through persistence you will eventually receive the items you requested. However, if you do not, it is probably not a bad idea to see an attorney for assistance (although even seasoned attorneys, who commonly request medical records on behalf of clients or prospective clients, will sometimes have difficulties in obtaining records).

California, Evid. Code Section 1158 provides that when an attorney or his or her representative presents a proper written authorization, the health care provider shall promptly provide the sought records. Failure to make the records available, during business hours, within 5 days after the presentation of the written authorization, may subject the person or entity having custody or control of the records to liability for all reasonable expenses, including attorney’s fees, incurred in any proceeding to enforce Evidence Code Section 1158. Sometimes, a court order is necessary to obtain records from the recalcitrant health care provider.