How to Request Your Medical Records: A Step-by-Step Guide
Getting your records is a critical first step. A complete set of files is the primary evidence used to evaluate your case. Follow this process to ensure your request is handled correctly under federal and Florida law.
Step 1: Identify All Providers
List every healthcare provider you have seen before and after the suspected error. This includes physicians, specialists, hospitals, urgent care clinics, imaging centers, labs, and pharmacies.
Step 2: Draft a Formal Written Request
Submit a signed, dated, written request to each provider’s “Medical Records Department.” Ask for your “designated record set”; that’s all records used to make decisions about you, including medical and billing records; so you don’t get a trimmed chart.
Use this specific language in your letter:
“Please provide my complete designated record set for the dates of service listed, including clinician and nursing notes, orders, labs, imaging reports, operative notes, consults, care plans, discharge summaries, and all billing records (UB-04/HCFA-1500), in electronic PDF (or other mutually agreed readable e-format). This request is made under 45 C.F.R. § 164.524.”
Step 3: Understand the Timing, Fees, and Format
- Timing: The provider must act on your request within 30 days. One 30 day extension is allowed but requires a written reason and a new due date from the provider.
- Fees (HIPAA): You can only be charged for the cost of copying labor, supplies, and postage. No search or retrieval fees are permitted. There is also no fee to fulfill an access request via a certified patient portal’s View/Download/Transmit functions.
- Form & Format: You have the right to choose the format, such as PDF, secure email, or portal download, if the provider can “readily produce” it. If not, you must agree on a readable alternative.
Florida Copy-Cost Quick Reference (for Patients)
- Hospitals/ASCs (Fla. Stat. § 395.3025): ≤ $1.00/page (paper); ≤ $2.00/page (non-paper, e.g., microfilm); ≤ $1.00 per year searched. Sales tax and postage may also apply. There is no charge if the copy/search is for continuing medical care.
- Physician offices (F.A.C. 64B8-10.003 / 64B15-15.003): $1.00/page for the first 25 pages, then $0.25/page. The actual cost may be charged for x-rays and other special media.
- Note: HIPAA trumps higher state fees for search/retrieval; those may not be charged to the individual.
Sending Records Directly to Your Lawyer
You can direct a provider, in a signed and written request, to send your records to a third party like our law firm. After the 2020 Ciox court decision, federal regulators explained that the patient rate fee limits generally apply to copies you receive for yourself and do not automatically cap fees for all third party directives. We will advise you on the most cost efficient route to get records for your case.
How to Read Your Medical Records
Once the records arrive, your goal is to organize them into a clear timeline.
- Organize and Index: Create a master digital file. Sort all documents chronologically, regardless of the provider. Keep an index of what you’ve received.
- Scan for Key Information: Review progress notes, physician’s orders, medication administration records (MAR), and operative reports. Look for inconsistencies or timeline gaps, but do not try to draw medical conclusions on your own. Note that psychotherapy notes are generally excluded from the patient right of access, but most other clinical notes are included.
- Ask Questions Securely: It’s fine to ask your providers questions about your records via a patient portal or email. HIPAA permits electronic communications as long as reasonable safeguards are in place.
What to Do If a Provider Refuses to Release Records
If a practitioner won’t release your records, the Florida Department of Health suggests sending a certified letter restating your request. If you still have no response after 30 business days, you can file a formal complaint with the DOH.
Frequently Asked Questions (FAQ)
How long do providers have to send my records? They have 30 days to act on your request. One 30-day extension is allowed if they provide you with a reason in writing.
Can I be charged for my own records? Yes, but fees are limited to the reasonable, cost-based expense of copying labor, supplies, and postage. No search or retrieval fees are allowed, and there is no fee for using a certified portal’s “View/Download/Transmit” feature.
What are Florida’s copy costs? For hospitals/ASCs, it’s ≤ $1.00/page (paper), ≤ $2.00/page (non-paper), and ≤ $1.00/year searched; continuing-care copies are free. For physician offices, it’s $1.00/page for the first 25, then $0.25/page.
Can my records go straight to my lawyer? Yes, with a signed, written directive from you. However, the fee rules for third-party requests are nuanced after a recent court ruling; ask us which route minimizes cost/time.
Legal Authority & Sources
HIPAA Right of Access (timing, fees, form/format, portals): HHS “Individuals’ Right under HIPAA to Access their Health Information”; 45 C.F.R. § 164.524.
Designated Record Set: 45 C.F.R. § 164.501; HHS guidance.
Florida Hospitals/ASCs Copy Charges + Continuing-Care No-Charge: Fla. Stat. § 395.3025.
Florida Physician-Office Copy Charges: F.A.C. 64B8-10.003 (MDs); F.A.C. 64B15-15.003 (DOs).
Third-Party Fee Nuance: OCR notice re: Ciox Health, LLC v. Azar.
Attorney Bio: Jorge L. Flores, Florida Bar No. 53244, has been representing families in Miami Dade for over 30 years.