• Whether you want the entire record or just part of the record.
• Dates of treatment.
• Medical condition for which you are asking information.
• Specific test results.
• Whether you want X-rays or records made by heart monitors or similar medical devices.
  
  
• Whether you want to see your medical record, want a copy of your record, or would like both.

Can my provider require that I include my Social Security number in my request for my medical record?

Yes. Because some health care providers use Social Security numbers as a way to identify medical records, they may need your Social Security number to locate your medical record. There is nothing in the HIPAA Privacy Rule or the Social Security Act that prohibits a private provider from engaging in this practice. 

Do I have to choose between seeing my medical record and getting a copy of it?

No. You have the right to do both. 

Will I have to show some proof of who I am in order to see or get a copy of my medical record?

Maybe. If your health care provider does not know you well, they are supposed to make sure you are the person who has the right to get the medical record before they give it to you. Your provider is allowed to choose the method for verifying your identity. For example, your provider might ask for an identification card (such as a driver’s license).

If you are acting under a health care power of attorney your provider may require you to show them a copy of the power of attorney form. You also may be required to show that the power of attorney is in effect. For example, you may need a letter from the doctor treating the patient to show that the patient is unable to make health care decisions.

What Will Happen If My Request for My Medical Record is Accepted?

Your health care provider will inform you if they agree to give you your medical record. If you asked to see your records, your health care provider must arrange a convenient time and place for you to review the record. If you have requested a copy of your record, your health care provider must either send it to you or arrange for you to pick up a copy.

How Long Should It Take to Get My Medical Record?

Generally, within 30 days after receiving your request, your health care provider must either

• Let you see or give you a copy of your medical record or
• Tell you that they are denying your request for your record.

My health care provider says that in certain cases they can take up to 90 days to give me a copy of my medical record. Is that true?

No. Although there are times when the HIPAA Privacy Rule would let a health care provider take up to 90 days to respond to a request for a medical record, New Jersey law requires a provider to give you a copy of your record no later than 30 days after receiving your request. Your health care provider must follow the shorter deadline set by New Jersey law.

Can I Control Where My Medical Record Is Sent?

Yes. You can ask your health care provider to send the copy of your medical record to your regular address (such as your home) or to another address (such as to your office or to a friend’s house). As long as your request is reasonable, your provider must send your record to the place that you identify.

Can I Get a Paper, E-mail, or Fax Copy?               

It depends. Generally, your health care provider must give you your medical record in the format that you request if it is not difficult to do so. For example, if you request a paper copy of your record, your provider generally must give you a paper copy.

Providers also must make sure that they send your records to you in a secure manner. Due to security concerns, many health care providers are reluctant to send copies of medical records by e-mail or fax.

Can I get a Summary or Explanation of My Medical Record?

It depends. You may want just a summary of your record. You may want your provider to explain some of the information in your record. Under the HIPAA Privacy Rule, your health care provider can give a summary or explanation of your medical record if you both agree in advance

• That it is all right for them to give you a summary or explanation, and
• To the fee, if any, they want to charge for writing the summary or explanation.

Your provider can’t give you a summary in place of your medical record unless you agree. Your health care provider generally must give you the summary within 30 days from when you request the summary.

Your provider can charge you a reasonable fee for the actual time they spend preparing the summary or explanation. Health care professionals (such as doctors) cannot charge more for a summary than they could have charged you for copying the original record. In any case, the maximum your health care professional can charge you for preparing a summary is $100. This fee limit does not apply to hospital records.

Leon asks for a copy of his medical record. Leon’s doctor would prefer to give Leon just a summary of the record. Leon does not agree to accept a summary. The doctor must give Leon a full copy of the record.

I received a copy of my medical record, but I can’t read my doctor’s handwriting. Does my doctor have to give me a copy that I can read?

Yes. Under New Jersey law, if a doctor or other health care professional gives you a copy of a medical record that you can’t read because it is illegible or was written in a language other than English, they must provide a typed copy in English. The health care professional cannot charge you for this transcription. This rule does not apply to hospital records.

I can’t understand the medical terms used in my record. Does my health care provider have to translate this information into plain language?

No. Health care providers often use technical words or a type of medical shorthand. Providers are not required to translate technical medical language into plain language for you. If you cannot understand what is written in your medical record because it is in technical language you can request an explanation of your record. However, your provider is not required to agree to your request. Section 6 lists some resources that explain medical terms.

Will I Have To Pay for My Medical Record?

Maybe. Your health care provider is allowed to charge you for copying your medical record. They may also charge you for postage if you request that your record be mailed to you. The maximum rates are different for health care professionals (such as doctors) and hospitals.

Health care professionals (such as doctors) may charge no more than $1.00 per page or $100 for the entire medical record, whichever is less.

Hospitals may charge up to $1.00 per page for the first 100 pages and 25¢ per page after that. Hospitals may not charge more than $200 for the entire medical record. Every hospital must have a policy in place to ensure that patients who are unable to pay can get access to copies of their medical records.

Can I be charged if I just want to look at or read my medical record?

No. Under the HIPAA Privacy Rule, your health care provider cannot charge you a fee if you just look at or read your medical record. 

Can I be charged for someone searching for my record?

No. You cannot be charged a fee for someone searching for your record. Although search fees are permitted under New Jersey law, they are not permitted under the HIPAA Privacy Rule. Because the HIPAA Privacy Rule is more protective of your rights, your provider must follow the HIPAA Privacy Rule. They may not charge you a search fee.

Can I be charged for copies of X- rays and similar records?

Yes. Your health care provider can charge you a reasonable fee for copying x-rays and similar records. This fee must be based on the actual cost of making the copies. You can also be charged postage if you ask that the records be mailed to you.

Can My Provider Deny my Request for My Medical Record?

Yes. In very limited cases, your health care provider can deny your request for your medical record. For example, in New Jersey, a health care professional (such as a doctor) can deny you access to subjective information in your medical record (such as their opinion of your condition) if they believe that seeing it would endanger your life or physical safety. A health care professional cannot deny you access to any objective information in your medical record, such as test results and x-ray results.

A New Jersey hospital can deny you access to your medical record where they believe that seeing the information would endanger your life or physical safety.

How will I know if my request for my medical record has been denied?

Your health care provider must tell you in writing (by letter, fax, or e-mail) if they deny your request for your medical record. They must tell you why your request was denied. They also must tell you if you have a right to have their decision reviewed and how you can file a complaint. Generally, your health care provider must give you this information within 30 days after receiving your request for your record.

Can my health care provider deny my request for my medical record just because they think I might get upset if I read it?

No. Your health care provide cannot deny you access to your record because they think the information in the record might upset you or that it might cause you mental harm. However, they can deny your request if they believe you will become upset enough to physically harm yourself.

Can my health care provider deny my request for records related to my mental health treatment?

Records about mental health treatment may be treated differently from other types of medical records. This guide does not discuss mental health records. Section 6 lists some resources for information about mental health records. 

Can my health care provider refuse to give me my medical record because I have not paid my medical bill?

No. Your provider cannot deny your request for your medical record because you have not paid your medical bill.

What happens if my provider doesn’t have the medical record that I requested?

If your health care provider doesn’t have the record that you requested, they don’t have to locate it for you. But your provider must tell you where your medical record is kept if they know. 

What Can I Do if My Health Care Provider Denies My Request for My Medical Record?

If your health care provider denies your request for your medical record, you have rights under both New Jersey law and the HIPAA Privacy Rule.

New Jersey Law

In New Jersey, if a health care professional (such as a doctor) denies you access to your medical record, you have the right to require them to give a copy of your record directly to: your attorney, another health care professional, your health insurance carrier, or a governmental reimbursement program (such as Medicaid).

If a hospital denies you access to your medical record, you have the right to require them to give a copy to your legally authorized representative (such as your attorney) or to your physician.

HIPAA Privacy Rule

You also have rights under the HIPAA Privacy Rule if your health care provider denies you access to your medical record because they believe that seeing it will endanger your life or physical safety. When you are denied access for this reason, you have the right to have someone else review your provider’s decision. This right is called the right to review.

If you request a review under HIPAA, the health care provider must select another licensed health care professional to review their decision. They cannot choose someone who was involved in the original decision to deny your request. The reviewer will make the final decision whether you can see or get a copy of your medical record. Your health care provider must follow the reviewer’s decision.

How will I know what the reviewer has decided?

Your health care provider must tell you in writing (such as by a letter, fax or e-mail) the reviewer’s decision.

Can I choose the reviewer under the HIPAA Privacy Rule?

No. Your health care provider gets to choose the reviewer.