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Medical
Record Questions
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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:
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The information or medical records covered by the release
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The
reasons or purposes for the release
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The
person to whom the information is to be released.
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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.
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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.
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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.
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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.
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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.
Samples
of Record Requests
The following are samples of record requests which contain
the required three elements mentioned above:
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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).
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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).
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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).
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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.
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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).
- 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.
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Updated: Wednesday, February 16, 2005 |
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