Medical Record Questions

  1. How do I obtain a copy of medical records?

    Medical records maintained by a physician and/or hospital are confidential and legally cannot be disclosed to anyone without the consent of the patient. There are certain exceptions to this rule, such as required reporting of certain information to state and federal agencies, etc.


    State law [Medical Practice Act, Section 5.08(K)] allows a patient to obtain a copy of his records, or ask that a copy be sent to a new doctor or someone else, such as an insurance company. This law requires a physician to release copies of a patient's medical records (or a narrative summary) if the physician receives written consent from the patient or the minor patient's parent or legal guardian. The written consent must specify the following:

    • The information or medical records covered by the release
    • The reasons or purposes for the release
    • The person to whom the information is to be released.
    • The physician shall furnish copies of medical records requested, or a summary or narrative of the records, unless the physician determines that access to the information would be harmful to the physical, mental, or emotional health of the patient, and the physician may delete confidential information about another person who has not consented to the release. The physician shall furnish the information within 15 business days after the date of receipt of the request, and reasonable fees for furnishing the information shall be paid by the patient or someone on his behalf.

  2. What are reasonable fees for medical records?

    Board rule 165.1 defines a reasonable fee to be a charge of no more than $25 for the first twenty pages and $.50 per page for every copy thereafter. For x-rays, $8.00 per film. In addition, a reasonable fee may include actual costs for mailing, shipping, or delivery. The physician shall be entitled to payment of a reasonable fee prior to release of the information unless the information is requested by a licensed Texas health care provider or physician, if requested for purposes of emergency or acute medical care. In the event payment is not included with the request, within ten calendar days from receiving a request for the release of records for reasons other than emergency or acute medical care, the physician shall notify the requesting party in writing of the need for payment and may withhold the information until payment of a reasonable fee is received.


  3. Billing Records?

    Unless the billing records are specifically requested, the physician is not required to provide copies of billing records as part of the medical records.

  4. How should I mail my request for records?

    It is best to mail the written request for records to the physician by certified mail, return receipt requested. This method provides assurance that the request was delivered. The physician is not obligated to honor oral or telephone requests for records.

    Although physicians are required to provide copies of records that they maintain, they are not required to create a new report in a special format to satisfy the specifications of the patient. The physician also is not required to fill out special forms (including business records affidavits) or insurance papers. These are extra services, which must be requested and fees negotiated with the physician.

  5. What about hospital records?

    Requests for records created and kept by a hospital should be directed to the hospital rather than to the physician. Fees by hospitals differ from those records provided by physicians.

  6. Samples of Record Requests
    The following are samples of record requests which contain the required three elements mentioned above:

    • Sample #1
      Dear Dr.___. Please send a complete copy of my medical records to my new physician, Dr.___, (provide complete address, including zip code), so that he/she can review my medical history. (Patient signature, followed by complete name, legibly printed or typed).

    • Sample #2
      Dear Dr.___. Please send a copy of the immunization records of my child, (child's full name), to the following school, (give complete name and address of school, and name of person at school who is to receive the report), for their records. (Signature of parent or legal guardian, followed by complete name, legibly printed or typed).

    • Sample #3
      Dear Dr. ___. Please send a complete copy of my medical records to me for my personal files. (Patient signature, followed by complete name, legibly printed or typed).

    • Sample #4
      Dear Dr. ___. Please send a complete copy of my medical records, excluding any reference to HIV testing, to my employer, (give complete name and address of employer), for their files. (Patient signature, followed by complete name, legibly printed or typed.

    • Sample #5.
      Dear Dr. ___. Please send copies of the EKG and the results of the lab studies performed in your office last month to Dr. ___ (complete address). I need this information for ongoing medical care. (Patient signature, followed by complete name, legibly printed or typed).

  7. How long do physicians have to keep medical records?

    Generally, seven years from last treatment.

    Additional tips for obtaining records:


    • Don't forget to provide a complete address and zip code for the location where you wish to have the records sent.
    • If you have changed your name, don't forget to provide the name as it appeared in your medical records.
    • If your name is not uncommon (e.g., Mary Johnson) provide your date of birth or social security number to ensure proper identification.
    • If it has been a long time since you have been to the doctor's office, call before mailing the request, to be sure the doctor is still located at the same address.

     

    DISCLAIMER:
    Any and all statements herein should not be construed as official policy or positions of the Texas Medical Board and are merely provided by Board staff for general guidance. No individual staff member is authorized to provide a binding opinion or statement for the full Board. Nothing herein should be construed as legal advice for any particular situation.


 

 

Updated: Wednesday, February 16, 2005