Your Medical Records

The Privacy Rule gives you, with few exceptions, the right to inspect, review, and receive a copy of your medical records and billing records that are held by health plans and health care providers covered by the Privacy Rule.

Health care professional and medical files

Access
Only you or your personal representative has the right to access your records. A health care provider or health plan may send copies of your records to another provider or health plan as needed for treatment or payment or as authorized by you. However, the Privacy Rule does not require the health care provider or health plan to share information with other providers or plans.

Charges
A provider cannot deny you a copy of your records because you have not paid for the services you have received. Even so, a provider may charge for the reasonable costs for copying and mailing the records. The provider cannot charge you a fee for searching for or retrieving your records.

Provider’s Psychotherapy Notes
You do not have the right to access a provider’s psychotherapy notes. Psychotherapy notes are notes taken by a mental health professional during a conversation with the patient and kept separate from the patient’s medical and billing records. The Privacy Rule also does not permit the provider to make most disclosures of psychotherapy notes about you without your authorization.

Correcting information
If you think the information in your medical or billing record is incorrect, you can request that the health care provider or health plan amend the record. The health care provider or health plan must respond to your request. If it created the information, it must amend the information if it is inaccurate or incomplete. If the provider or plan does not agree to your request, you have the right to submit a statement of disagreement that the provider or plan must add to your record.

For further information on this topic, please refer to 45 C.F.R. §§ 164.508, 164.524 and 164.526, and OCR’s Frequently Asked Questions.