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Questions About Medical Records

What is a medical record?

It is a record of the information during the course of a patient’s treatment. It includes a variety of information in a variety of formats (written, electronic, x-ray film, etc.), including:

  • Personal
  • Financial
  • Social and
  • Medical information.

Your medical record serves as:

  • A basis for planning your care and treatment
  • A means of communication for the healthcare professionals contributing to your care
  • Legal documentation describing the care you received
  • Verification of services and treatment covered by your insurance
  • Basic data for health research and education

How long will you keep my medical record?

By Florida Law, medical records must be retained for a minimum of eight years. Most records are retained longer.

Getting copies

Please note

Records are released upon completion and after the patient is discharged.

How can I obtain a copy of my medical record?

Request a copy from the appropriate medical records office. Forms are also available in each of the walk-in offices. Your request must include the following:

  • Patient’s full name
  • Date of birth
  • Patient’s telephone number
  • Name, address, and telephone number where the records are to be sent
  • Purpose of the request
  • Specific items or dates of service needed
  • Any restrictions on the request
  • Date of the request
  • Signature of the patient or, if the patient is a child, the parent or guardian
  • Date this authorization expires (authorizations must be less than one year old)
  • If signed by a personal representative, a description of his/her authority to act for the individual and a copy of the document giving that authority.

How long does it take to get copies of my medical record?

We will provide a copy or a summary of your health information, usually within 30 days of your request. Most record requests are fulfilled within 7 business days.

How will I receive my medical record?

We will be glad to release the records to you through the MyUFHealth portal, email, CD or on paper.

  • Please provide an email address on your release form and once the records are prepared, we will release to your preference.
  • We do not fax medical records, except in an emergency to another health care provider.

Can I see my medical record online?

Yes, we can provide records to you via a secure website in PDF format. For this option, you must complete an Authorization for Use or Disclosure of Protected Health Information and provide a valid and legible email address. You may be charged a fee for these records. You may also view portions of your record through myufhealth which offers patients personalized and secure online access to portions of their medical records at no cost to you. For more information and to sign up, please go to ufhealth.org/myufhealth.

Is there a charge for copies of my medical record?

Under Florida law, you may be charged a fee of up to $1 per page for each page copied. You can save money by asking for specific documents or a record abstract (all recent major reports) rather than the entire record. The copying fee is waived for copies provided directly to a healthcare provider for continuing medical care.

Confidentiality and access

Are medical records confidential?

The information found in medical records is confidential. Patients confide in their physicians because they are assured of this confidentiality and might not share the necessary personal information if this privilege did not exist. Healthcare workers are mandated by law and by professional standards to protect patient confidentiality. There are also state and federal laws to protect information related to specific diagnoses such as psychiatric/psychological, treatment of substance abuse (drugs and alcohol), and AIDS/HIV.

What can I do if I suspect that someone is looking at my medical record without a professional reason?

You should report this to the privacy officer appointed by your healthcare provider.

UF Health Shands Hospitals - call the Privacy Office at:

  • Gainesville locations: (352) 627-9050
  • Jacksonville locations: (904) 244-1979
  • Leesburg & Spanish Plaines locations: (352) 323-5356
  • St. Johns & Flagler locations: (904) 819-4221

UF Health Physicians Clinics

  • Call the UF Privacy Office at 1-866-876-4472

Who can access my medical record?

We are required by law to maintain the privacy and security of your medical record. We will not use or share your information, other than as described in our Joint Notice of Privacy Practices (NPP), unless you tell us we can, and you may change your mind at any time.

Consent

Your record is the physical property of the hospital. However, the patient controls the release of the information contained in the record. Consent to access medical records must be less than one year old. In general, you must give permission for anyone, other than a member of your healthcare team, to have access to your medical record. By law, your records may be disclosed without your permission under certain circumstances such as in response to a subpoena or court order, to certain government and regulatory bodies, to someone who holds your power of attorney, to someone you have designated as your healthcare surrogate, to another healthcare provider for continued care, and to your healthcare insurer to obtain reimbursement for your care.

By law, only the adult (age 18 or older) patient or a legally designated representative has the authority to release the information contained in a medical record about them, regardless of who is paying the bills. Legally designated representatives include court-appointed guardians or others with power of attorney for the patient. For children under age 18, only a parent or court appointed guardian may authorize release of medical information. Unless parental rights have been severed by the court, both parents in a divorce may access their children's medical records.

The next of kin or personal representative of the estate may request those records. It may be necessary to verify that the patient has actually died and the identity of the next of kin.

Is an Authorization for Release of Information “good” forever?

Valid authorizations are good until revoked or they expire. It is important to note that once a release request has been fulfilled and additional records are requested, a new release form must be completed.

How secure are computerized medical records?

Computer-based medical records are as safe as paper records and are covered by the same laws. There are technical safeguards for the protection of computerized data as well as procedures for identifying and punishing violators.

How can one of my outside doctors get copies of my medical records?

Another healthcare provider (for example, a physician, nurse practitioner, or physical therapist), who is treating you can request copies of your health information at any time. It may be necessary to verify that this provider is currently treating you. The healthcare provider should submit a request in writing.

Corrections

There is some incorrect information on my medical record. How can I get it corrected?