A patient is entitled to a copy of his/her entire medical chart, except in very limited circumstances. The health care provider does not have the authority to decide unilaterally which portions of your chart you can receive. If you ask for a copy of your entire file, the provider must give you a copy of your entire file. The same is true for someone holding a power of attorney for the patient or other authority for a deceased patient.
While we fully appreciate the need to maintain the confidentiality of personal information in medical records, the providers often cite HIPAA concerns as an excuse not to furnish copies of records to persons who are entitled to receive them. Do not be fooled. If you are entitled to receive the records, be persistent. Making it difficult for you to obtain the records can be a ploy to discourage you. Many people will give up and walk away. We find that the more obvious the negligence is, the more hoops the facility will try to make you jump through. The facility may be aware of its potential liability, and common sense tells you they will be more resistant to giving you copies of the records that may prove it.
In some circumstances, an oral request may be sufficient, but we encourage you to make a written request for records, and even if you request the records orally, you should follow up with a written confirmation of your prior oral request. We also suggest you send it priority or certified, so there is a tracking number for proof that your request was delivered. Once the provider has received your written request, be sure to call after a few days to ask what the cost of the records will be and when they will be available. Keep notes of all of your contacts with the provider – the date/time of your call, who you speak to, and what you are told. A complaint can be lodged against providers who do not respond to an appropriate request for records. There is a board or agency to whom complaints can be made for all providers (for instance, the Medical Board for a physician, the state survey agency for a nursing home or assisted living facility, or the Joint Commission for a hospital). Your notes of your contacts with the provider about the record requests will make it very simple for you to give a timeline of events when you make your complaint.
Be sure to ask if they have records available in electronic format, especially if you are asking for a lengthy record. The EHR (Electronic Health Record) may be available at a flat rate cost, rather than paying per page. The facility does not have to offer this format unless they are asked to do so.
The bottom line is do not be intimidated. If you know you are entitled to the records, then urge your position. Don’t walk away. If your efforts are not successful, then contact us for advice on how to proceed.