Most people know that doctors keep patient
records. The records include notes about signs and symptoms of illness,
examination and test results, and treatment plans, as well as the doctor's
assessment of medical problems.
At some point during your life, you may need
to obtain your records from your doctor or hospital because you:
- may be changing doctors and need the old
records to bring your new doctor up-to-date on your care;
- may be moving away from the area and need your
records to be readily available to your new doctor or hospital;
- may need the records to receive full
reimbursement from your health insurance company; or,
- may need records for a legal action against a
doctor or hospital.
Obtaining medical records can be confusing,
time-consuming, and even a costly process. However, Maryland law and the Health
Insurance Portability and Accountability Act of 1996 (HIPAA) provide guidelines
for both patients and health care providers to follow.
Gaining
Access to Your Records
Health care providers may maintain their
records on paper or by computer. In either case, you have a right under Maryland
law to obtain a copy of the record. To do so, you must make a written request.
This signed and dated request must state your name, the name of your health care
provider and the party who should receive your records. Your authorization to
release your records is good for one year. A provider must disclose a medical
record within a reasonable period of time after receiving your written
request.
Under state law, you may be charged no more than 76
cents per page for having your records copied, plus actual postage and handling
costs. (These limitations do not apply to x-rays.) If a medical practice is
using an electronic medical records system, they must provide a patient
requesting their medical record with a copy in electronic format, if the patient
so requests. The charge for the copy provided can be no more than the actual
labor costs incurred by the practice in responding to that request. These fees
may be adjusted annually for inflation. Federal law forbids a provider from
charging preparation fees, including fees for retrieving or handling the
information or for processing the request, if the records are being provided to
the consumer. If the records are being sent to someone other than the consumer,
the law allows for an administrative fee of no more than $22.88 in 2014, which
may also be adjusted annually. To avoid a surprise bill, ask about fees before
requesting records. In most cases, the provider may withhold your records unless
you pay the fee. However, the provider may not withhold the records because you
have not paid an outstanding bill for treatment.
Most healthcare
providers must maintain a patient's medical bills, laboratory reports and X-ray
reports for five years after the record or report is made. In most cases, the
medical record of a minor may not be destroyed until the patient turns 21 or for
five years after the record or report is made, whichever is later, unless the
patient or guardian is notified. Many providers will send notice to consumers
regarding the destruction of records to allow the consumers time to request a
copy.
Mental Health Records
If your medical records relate to a psychiatric
or a psychological problem, your doctor or the facility's doctor in charge of
the case has the discretion to decide whether or not to release them with you.
However, you are entitled to receive a written summary of the records if you
make a written request. Even if you cannot obtain the records, the health care
provider from whom you are requesting the records may allow another health care
provider treating you for the same condition to see and copy
them.
Correcting Mistakes
If you find errors in your medical records, you
can ask to have additions or corrections made. All health care providers must
have a procedure for correcting information in their medical records; ask about
the procedure. Make sure you request changes and correction in writing, keeping
a photocopy for your files. You may not, however, have information deleted from
your medical record.
After you request a change in your medical record,
the health care provider must make the change or explain the refusal to make the
requested change in writing. This explanation must also describe any appeals
process, if the health care provider offers one. If your provider refuses to
make the requested change, you have the right to insert in your record a written
statement explaining why you disagree with the information in the
record.
Getting Records from a Federal Medical
Facility
A federal medical facility (such as a Veterans
Administration hospital, Public Health Service Facility or military hospital) is
not covered by Maryland law. However, you are entitled to obtain your records
under the Federal Privacy Act. This Act guarantees your right to inspect and
copy records maintained by federal agencies and to contest inaccuracies. If the
records contain psychological or psychiatric information, the doctor in charge
of the case has the discretion to decide whether the material can be
released.
Each federal agency has its own procedure for patient access to
medical records. Some agencies allow you to make a Privacy Act request over the
phone, while others require that the request be made in writing or in person.
You must complete a special consent form to have information released when the
diagnosis is drug or alcohol abuse, sickle cell anemia, or HIV infection. It's
best to contact the facility's medical records department to find out its
procedure.
Get Some Help
If you would like to
review your medical records, it is best to do so with your doctor or other
health care provider. The information in medical records is often in technical
language that is not easily understood by most people. Getting assistance from a
medical professional will reduce confusion and help relieve fears and
misunderstandings about your records' contents.
Having Trouble
Getting Your Medical Records?
If you tried without success to
get your medical records, do not give up. Help is available. For records from
facilities (hospitals, nursing homes, etc.) and doctors, or other health care
providers, contact the Office of the Attorney General's Health Education and
Advocacy Unit toll-free at 877-261-8807, or online at www.marylandattorneygeneral.gov/Pages/CPD/HEAU/default.aspx.
For records from doctors, you may also contact:
The
Maryland Board of Physicians
Department of Health and Mental
Hygiene
4201 Patterson Ave.
Baltimore, MD 21215
The
numbers for the Board of Physicians are 410-764-4777 or toll-free at
800-492-6836. The Board of Physicians is also available online at www.mbp.state.md.us.