How to fight backBillSherpa · Updated 2026

How to Request Your Medical Records — and What to Look For

Your medical records are the ground truth of your hospital visit. Every legitimate charge must have corresponding documentation in those records. When a service appears on your bill but not in your records, you have documented evidence of a billing error. Here's how to get your records and what to do with them.

Your legal right to your records

Under HIPAA 45 CFR § 164.524, you have the right to access your own medical records. The provider must respond to your request within 30 days, with one possible 30-day extension if they notify you in writing. They can charge a reasonable cost-based fee for copying, but cannot deny you access to your records.

The records you're entitled to include: physician and nursing notes, operative and procedure reports, lab results, imaging reports, medication administration records, discharge summaries, and any other documentation related to your care.

Exactly how to request your records

1. Call the medical records department. Ask for the health information management department or medical records department. Ask what form they require and how to submit a request. Most hospitals have a standard authorization form.
2. Submit a written request. Even if they accept phone requests, follow up in writing. State your full name, date of birth, date(s) of service, and the specific records you want. Request everything related to your visit — don't limit it to just one type of record.
3. Be specific about what you need. Ask for: all physician notes, nursing notes, operative reports, anesthesia records, imaging orders and reports, laboratory orders and results, medication administration records, and any consultation notes.
4. Ask for the records in electronic format. Under HIPAA, if you request electronic records in a specific format, the provider must provide them in that format if they can do so readily. Asking for a PDF or through a patient portal is often faster than waiting for physical copies.
5. Follow up at day 25 if you haven't heard back. Don't wait until day 31. Follow up a few days before the deadline so you have time to escalate if needed.

What to look for when you get your records

Match every billed service to a record entry

Go through your itemized bill line by line. For each CPT code, find the corresponding entry in your medical records. For a lab test, there should be an order and a result. For a procedure, there should be a procedure note. For a consultation, there should be a consult note. If you find a billed service with no corresponding documentation, that's evidence of a billing error.

Check the dates

Every record entry has a date and time. If a service is billed on a date when the records show you weren't at the hospital, or when no documentation of that service exists, that's a billing error.

Look for "ordered but cancelled" notations

Sometimes tests or procedures are ordered and then cancelled before they're performed, but billing is never notified. Look for orders that were cancelled or marked "not done" in the records — these should not appear on your bill.

Check the visit level documentation

If you were seen in the emergency department, the physician's note should justify the level billed (Level 1–5). A Level 5 visit (CPT 99285) requires documentation of a high-complexity medical decision and a comprehensive examination. If the note describes a straightforward visit, a Level 5 code may be upcoding.

Verify the diagnosis codes

Compare the ICD-10 diagnosis codes on your bill to the diagnoses documented in your physician's notes. Wrong diagnosis codes can cause services to be miscategorised — a preventive visit coded as diagnostic, for example, subjects you to your deductible for a service that should be free under the ACA.