A Guide to Create, Manage and Use Your Personal Health Record

The Guide to Getting & Using Your Health Records is for patients, parents, and caregivers who want to get their health records. A health record (also known as a medical record) is a written account of a person’s health history, including appointment notes, prescriptions, treatments, tests, and vaccines. It’s also for people who need the record of someone they represent or care for, like a child, elderly parent, or an adult with a disability.

You have a right to your health record

A federal law called the Health Insurance Portability and Accountability Act (HIPAA) gives you the right to see and get a copy of your health record. Most health insurance plans and health care providers — including clinics, hospitals, pharmacies, labs, and nursing homes — must follow this law.

Yet it can be a real challenge to get your health record if you’ve been cared for by multiple doctors in multiple places. Each one may have a different process for asking for and getting your record.

Why Do You Need a Personal Health Record?

Having your health record makes it easier to:

• Share important health information with family members, a new doctor, or a medical emergency team
• Coordinate health care with different doctors, clinics, and hospitals
• Make sure your information is up-to-date and accurate
• Avoid repeating tests and procedures you’ve already had
• Share health information, like vaccination records, with schools, camps, and others

What am I asking for?

Health records can sometimes be hundreds of pages long, so knowing which part of the record you want can be important. If you’re not sure, ask at your provider’s office for help.

• Full record: If you have a new primary care doctor or health insurance plan, you’ll want to get a copy of your full record to give to them. You may also want a copy for your own use.
• Partial record: If you want to share specific health information with new doctors or others, you may only need a partial record. For example:
  • Allergies
  • Medications
  • Immunization record
  • Clinical notes from a single visit
  • Test results or x-rays

  How many copies do I need?

  If your health record is not available electronically, or you or your doctor prefer a paper copy, you’ll need to determine how many copies you need.

  • Personal use: If you want a copy for your personal use, you may need only 1 copy.
  • Care providers: If you are sharing with your care team, family, or personal representative you may need a copy for each person or office.

  How do I want it delivered?

  Depending on the format of your health record, you have some choices about how it will be delivered to you and your care team. For example:

  • Secure email through your patient portal (for your own use)
  • Directly into your electronic health record (for your provider’s use)
  • Non-secure email (your personal email)
  • CD or thumb drive
  • Fax
  • Mail (standard postal service)

  What format do I need?

  For yourself: Choose the format that works best for you. Electronic formats are the most convenient because they’re easier to update and to share. In most cases, they take up less space. But several formats are available, for example:

  • Structured data (data your computer or smart phone app can read)
  • Text file (like a Word document)
  • PDF
  • Paper

  Getting Your Health Record

  If you need to get your health record, it helps to understand how the process works. That way, you’ll know what to do if you hit a road block.

  How do I get started?

  The first step is to check your health care provider’s online patient portal. A patient portal is a secure website, where patients can often do things like make appointments, contact their doctor, and look at lab results. Some of your health information, like your immunizations, may also be available through the patient portal.

  Have you tried your provider’s online patient portal?

  About 8 in 10 individuals who used their online patient portal found it helpful and easy to understand.

  If the health information you need is not available through the patient portal, you may be able to contact your provider directly through the portal to ask for it. You may even be able to request your complete health record through the patient portal.

  If your provider does not have an online patient portal, try other ways to contact them:

  • Check their website: Information about how to get your health record can often be found under the Contact Us section of a provider’s website. It may direct you to an online portal, a phone number, an email address, or a form.
  • Phone or visit: You can also call or visit your provider or doctor and ask them how to get your health record. Ask for the health information services department or the administrative staff in charge of releasing health records.

  How do I ask for it?

  How you make your request will depend on your provider’s processes. You may be able to request it through your provider’s patient portal. You may have to fill out a health or medical record release form, send an email, or mail or fax a letter.

  How to fill out a health or medical record release form

  Your provider’s medical request release form may be organized differently — there is not a standard form — but these are the questions you’re likely to see.

  Do I have to pay a fee to get my health record?

  You may have to pay a fee. However, according to your federal rights, your provider may only charge a reasonable fee for:

  1. Making a paper copy or electronic media copy (e.g. CDs or USB drive) of your health record
  2. Mailing you a paper or electronic media copy of your health record

  When you send in the request for your health records, ask your provider how much it will cost to get your record.

  How long will I have to wait?

  According to federal law, your provider can take up to 30 days to deliver your health records. However, if you requested a specific delivery date, you may get your records sooner. If your provider needs more than 30 days, they must give you a reason for the delay and a new delivery date. They can take up to 30 extra days.

  Check Out Your Health record for Accuracy

  Once you’ve got your health record (also known as a medical record), review it to make sure that all of your health information is complete, correct, and up-to-date. This is important because you may have forgotten to tell your doctor something or they may have forgotten to write it down. The folks in your provider’s office are busy people, who make mistakes just like everyone else. Some examples of common errors:

  • You may have forgotten to tell your doctor about something — like a new medication or allergy
  • Your doctor might have misunderstood, incorrectly noted, or left out something — like information about your health history or your symptoms or the date of your appointment
  • Your doctor might have ordered a test you’ve already had — or charged you for a test you didn’t have

  If you don’t review your record, you won’t know these mistakes have been made, and they could impact your future health and treatment. Explore these tips on what kind of mistakes to look for — and what to do if you find one!

  It’s important to check it!

  Nearly 1 in 10 people who check their online health record ask to have a mistake corrected.

  What kind of mistakes am I looking for?

  You’re looking for mistakes or out-of-date information that will have an effect on how your provider diagnoses and treats you, whether your provider can contact you, and how you’ll be billed. You can let typos go, but if a mistake can affect your health, it should be fixed.

  Check your personal information:

  • Name, address, and phone number
  • Health insurance plan provider
  • Identification numbers, like your patient identification number or social security number
  • Emergency contact names, addresses, and phone numbers

  Check your health information, including:

  • Doctor’s appointment notes
  • Health or medical history
  • Symptoms
  • Immunizations
  • Diagnoses
  • Allergies
  • Medicines
  • Tests
  • Procedures

  Check your medical bills:

  Make sure you’re only being billed for services you’ve received. You can do this by comparing the information in your health record with:

  • The reports your health insurance plan sends you
  • The bills from your doctor or other health care providers

  What do I do if something is incorrect or missing?

  Under HIPAA, if you think there’s a mistake in your health record, you have a right to ask your provider to fix it.

  If you want to have a mistake fixed, here are the steps to follow:

  Step 1: Contact your provider

  Contact your provider’s office and find out what their process is for making a change to your health record. They may ask you to write a letter or fill out a form. If they have a form, ask them to email, fax, or mail a copy to you.

  Step 2: Write down what you want fixed

  If your provider has a form, and you want to fix a simple mistake: Fill out the form and attach a copy of the record page where you found the mistake to help them find it.

  If your provider doesn’t have a form or it’s a more complex mistake, you may want to write a letter describing the correction. Make sure you include:

  • Your full name, address, phone number
  • Your doctor, nurse, or provider’s full name and address
  • Date of service
  • A short, specific, and clear explanation of what needs to be fixed and why
  • A copy of the record page where you found the mistake
  • Your signature

  Step 3: Make a copy of your request

  Make a complete copy of everything you’re sending to your provider for your own records.

  Step 4: Send your request

  Depending on your provider’s processes, you can deliver your request by:

  • Secure email through your patient portal
  • Non-secure email (your personal email)
  • Fax
  • Mail (standard postal service)
  • In person

  Note: If you want to send your request by email (secure or non-secure) you’ll need to attach digital copies (PDF files) of the record page where you found the mistake and the request form. Remember, using secure email or a patient portal helps protect your privacy and personal information.

  What happens after I request a correction?

  Your provider has 60 days to respond to your request, unless they ask for an extension (extra time). Here’s what you can expect:

  If your provider agrees there’s a mistake in your health record, they’ll update your record and send you a notice — either in your patient portal or via email or mail — that they’ve taken care of it.

  If your provider does not agree with you, they’ll send you a denial notice that should include:

  • The reason they’re not going to fix the mistake. For example, they might say they believe your health record is correct and complete.
  • Information about how to reply to their decision

  What do I do if my provider doesn’t agree with my request?

  If your provider does not agree that there is a mistake in your health record, you can:

  • Send them a formal letter in reply to their decision, stating clearly why you disagree. Their denial notice should include instructions on how to do that. If not, call their office. This response will be attached to your health record.
  • If you don’t want to reply to the denial notice, you can ask your provider to attach a copy of your original request and the denial notice to the affected page(s) of your health record.
  • File a complaint with the Department of Health and Human Services. Get more information on filing a complaint at HHS.gov.
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