Get a copy of your full record

1. What you are entitled to ask for

You have the right to your full record, which the law calls the designated record set. It is wider than most people ask for and wider than most release forms offer:

• The medical record, notes, orders, results, imaging reports, medication administration, care plans, assessments.
• Anything else used to make decisions about you, wherever it is kept.

Ask for the electronic form you want. If they keep it electronically and you ask for it that way, they have to give it to you that way when they readily can. A searchable file is easier to use than paper.

45 CFR 164.524(c)(2)(ii), the form and format rule.

2. The deadline, and the one extension

30 days from when they receive the request. They may take one more 30 days, and only if they tell you in writing, before the first 30 days are up, why and when you will have it. There is no second extension.

So put the date on your request, keep a copy of it, and note the day it arrived. A dated request shows when the 30 days began.

45 CFR 164.524(b)(2)(i) and (b)(2)(ii).

3. In a nursing home, the deadline is far shorter

If the care was in a certified nursing facility, the resident's right runs on hours, not weeks: the records must be available to look at within 24 hours, excluding weekends and holidays, and you can get copies after two working days' notice.

42 CFR 483.10(g)(2), and where both apply the shorter one counts.

4. Ask about fees

The office may ask a fee for copies. Ask what it is, and who to call if you think it is wrong.

5. What to put in the request

Keep it short, and include:

• The patient's full name, date of birth, and the record or account number if you have one.
• The dates you want, a specific admission, or a range. "Everything" invites a slow answer.
• The words designated record set.
• The format: electronic, machine readable, on a drive or by secure download.
• That you are asking under your right of access, 45 CFR 164.524.
• Where to send it, and the date.

Send it to the health information management or medical records department, not to the ward and not to the doctor. Keep proof it arrived.

If you ask for someone else, send proof you may act for them: a healthcare power of attorney, guardianship papers or, if they died, executor papers. A missing proof is the most common reason a request stalls.

6. If they refuse

Some refusals are allowed and some are not, and the letter must say which.

They can refuse outright, with no right of review, for a short list: psychotherapy notes kept separately, information compiled for a legal proceeding, and a few narrow categories such as certain research and confidential-source material. Note what is not on that list: an open complaint, a dispute with the facility, or their preference.

They can refuse on safety grounds, that access is reasonably likely to endanger someone, but then you have the right to have that refusal reviewed by a licensed health professional who was not involved in the decision, and they must tell you how to ask for it.

Any refusal must be in writing, in plain language, saying the reason, how to have it reviewed if it is reviewable, and how to complain.

45 CFR 164.524(a)(2) and (a)(3).

7. If they stall

Do these in order:

1. Write again, naming the date of your first request and the 30 day rule. Ask for the name of the person handling it.
2. Ask the facility's patient relations office in writing. In a hospital, a written complaint is a grievance, and a grievance has to come back to you in writing with a name, the steps taken and the result.
3. Complain to the HHS Office for Civil Rights. It is free and online. The usual limit is 180 days from when you knew of the problem (45 CFR 160.306).

Your state may have its own rules, and your state agency or a lawyer can say which ones apply. Find your state.

See who has to answer

8. When they arrive

• Keep the original file exactly as it came, untouched, and work on copies.
• Check it is complete while your request is still open. Missing dates, a gap in the medication chart, imaging reports without the images, no nursing notes for a shift, ask again while the request is still live.
• If something in the record is wrong, you can ask for it to be corrected. They have 60 days. If they refuse, you can add a statement of disagreement to your record. That is a separate right.

How to ask for a correction