Medical Records | MaineHealth (2024)

The fastest and easiest way to submit a request is through MyChart, the MaineHealth patient portal. If you don't have a MyChart account, this video will help you sign up. Call 855-255-2300 for MyChart assistance.

Most MaineHealth patient medical records are available at no cost through MyChart. If you don't have a MyChart account, this video will help you sign up. Call 855-255-2300 for MyChart assistance.

To request medical records through MyChart:

  1. Log in to MyChart.
  2. Click Your Menu in the top left corner
  3. Look for the My Records section and click Request My Records
  4. Follow the instructions to complete your request.

Your medical records will be delivered to your MyChart account within seven to ten business days. Records that require a provider’s approval for release may take longer.

Fees for paper copies:

There may be a “reasonable cost-based fee” for copying protected health information in accordance with the State of Maine or New Hampshire Statutes. The exact fee amount will not be determined until the request has been fulfilled, at which time an invoice will be sent. In some cases, fees may be required prior to releasing the records requested. We accept payment by check, exact cash or credit/debit card.

There is no charge for:

  • Records delivered electronically through MyChart
  • Paper records that are sent directly to another health care provider

To request medical records by mail, fax or email:

  • Download and print the MaineHealth Authorization to Release Protected Health Information form.
  • Complete, sign and date the form.
  • Include a legible photocopy of a valid photo identification (your driver’s license, military ID or state issued ID).
  • Submit all completed and signed documents to MaineHealth via MyChart, email, mail or fax:
    • MyChart: Log in to MyChart
    • Email:RecordRequests@MaineHealth.org
    • Mail: Health Information Management Department, 301C US Route One, Scarborough, ME 04074.
    • Fax: 207-761-3092

Please allow us time to process your request. Requests are usually completed within 7-10 days but may take up to 30 days. We will contact you if your request will be delayed or if we cannot fulfill your request.

Please note:

  • Your medical records will include protected health information related to care at all MaineHealth locations.
  • You must complete ALL FIELDS on our Authorization to Release Protected Health Information form per the form instructions. If any information is missing from the form, or if the form is not signed and dated, your request may be delayed or returned.
  • Authorization requests signed by your legal representative must also include a copy of one of the following documents:
    • Legal guardianship papers
    • Advance directive or health care power of attorney, for patients unable to make health care decisions
    • Designation of a personal representative, which allows the representative to act on the patient's behalf with regard to personal health information

Fees for paper copies:

There may be a “reasonable cost-based fee” for copying protected health information in accordance with the State of Maine or New Hampshire Statutes. The exact fee amount will not be determined until the request has been fulfilled, at which time an invoice will be sent. In some cases, fees may be required prior to releasing the records requested. We accept payment by check, exact cash or credit/debit card.

There is no charge for:

  • Records delivered electronically through MyChart
  • Paper records that are sent directly to another health care provider

For immediate continuity-of-care requests, you or your health care provider may submit a request to have your health information sent directly to another health care provider's office.

If your health care provider is submitting the request, they should:

  • Create a written request on their business letterhead
  • Write "STAT" at the top of the request
  • Note the patient's name, date of birth, date of service and health information being requested
  • Fax the written request to 207-761-3092

If you are submitting the request, please:

  • Complete our Authorization to Release Protected Health Information form
  • Complete, sign and date the form.
    • Enter the health care provider's office and contact information in the Release Information To section
  • Include a legible photocopy of a valid photo identification (your driver’s license, military ID or state issued ID).
  • Write "STAT" at the top of the completed form
  • Fax the completed form and photocopy to 207-761-3092

Note: Please mail all subpoena-related documents, non-patient directed requests, and/or audit requests to:

Health Information Management Department
301C US Route One
Scarborough, ME 04074

To request the medical records of a deceased patient:

Records can be released to anyone whom the patient authorizes (in writing) to receive them. If an expiration date is not noted, the authorization is valid for one year.

All imaging results (computed tomography (CT), magnetic resonance imaging (MRI), ultrasound, etc.) are available for release to patients*, providers or medical offices via Nuance PowerShare.

  • The easiest and fastest way for providers and medical offices to request radiology records and images is directly through PowerShare.
  • MaineHealth has a single PowerShareaccount that covers all MaineHealth locations.
  • Radiology records and image requests may also be faxed to 207-662-6044 or emailed to filmlibrary@mainehealth.org

* Patients who would like to receive their imaging electronically through PowerShare should submit their request through MyChart, or complete an Authorization Form and email or fax it to the Film Library. Be sure to include your email address.

Please call 207-662-2328 for assistance with urgent requests.

MaineHealth does not maintain birth certificates. Birth certificates can be obtained from the City or Town Clerk’s office in your area or, via the Maine or New Hampshire Vital Records offices.

Maine

New Hampshire

To request a medical record amendment:

  • Complete our Request for Amendment of Protected Health Information form.
  • Submit all completed and signed documents to MaineHealth via MyChart, email, mail or fax:
    • MyChart: Log in to MyChart
    • Email:RecordRequests@MaineHealth.org
    • Mail: Health Information Management Department, 301C US Route One, Scarborough, ME 04074.
    • Fax: 207-761-3092

Please see ourNotice of Health Information Privacy Practices for more information on the amendment process.

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Medical Records | MaineHealth (2024)

FAQs

Can you list 3 things you would find on a medical record? ›

Medical records are the document that explains all detail about the patient's history, clinical findings, diagnostic test results, pre and postoperative care, patient's progress and medication.

Are medical records always accurate? ›

Are your medical records accurate? Probably not! Unfortunately, your health records likely include mistakes about some aspect of your health and/or your medical and family history. Whether your doctors use Electronic Health Records (EHRs) or paper records, the risk for mistakes is real.

What makes a medical record complete? ›

A medical record is considered complete if it contains sufficient information to identify the patient; support the diagnosis/condition; justify the care, treatment, and services; document the course and results of care, treatment, and services; and promote continuity of care among providers.

How to get a diagnosis removed from medical records? ›

Once you identify something you want to change, contact your healthcare provider and request a form for making amendments. Be clear with your request. Upon receiving it, your provider will have 60 days to act on your request. Your provider is not required to make the requested change.

What not to put in a medical record? ›

The following is a list of items you should not include in the medical entry:
  • Financial or health insurance information,
  • Subjective opinions,
  • Speculations,
  • Blame of others or self-doubt,
  • Legal information such as narratives provided to your professional liability carrier or correspondence with your defense attorney,

What is shown in medical records? ›

A health record (also known as a medical record) is a written account of a person's health history. It includes medications, treatments, tests, immunizations, and notes from visits to a health care provider.

Is it OK to look at your own medical records? ›

You can make a written request to either review or obtain a copy of your medical records pursuant to Health and Safety Code sections 123100 through 123149.5. You can view these laws on the California Legislative Information website.

Are medical records hearsay? ›

Medical records and statements of history, diagnosis and treatment contained in medical records actually meet the definition of hearsay.

What if there is wrong information in my medical records? ›

If you find a serious error in your medical records, be sure to contact your healthcare provider immediately to get it fixed. If there is a non-serious error, like your address or phone number is incorrect, you can correct the error with a pen by crossing it out. Then, write the correct information next to it.

What is the golden rule of documentation in a medical record? ›

One of the”Golden Rules” of documentation is that the medical record be prepared as contemporaneously with treatment as possible to avoid confusion and to ensure accuracy. The defense of malpractice lawsuits has taught us that juries often assume that undocumented events never happened.

Which of the following is not considered part of the medical record? ›

A prescription is not considered to be part of the medical record.

What is an incomplete medical record? ›

Incomplete medical records refer to patient health documents that lack essential information or documentation, making them insufficient for accurate patient care, legal purposes, or medical decision-making. Such records may miss critical data, such as diagnosis details, treatment plans, or necessary signatures.

Will my doctor know if I go to another doctor? ›

If I go see a doctor, can that doctor see my medical records from another doctor? No doctor discloses the identity and records of the concerned patients without that person's permission. So less likely that other doctor will know unless you tell him.

Can a doctor hide a diagnosis from a patient? ›

Except in emergency situations in which a patient is incapable of making an informed decision, withholding information without the patient's knowledge or consent is ethically unacceptable.

Are mental health diagnoses permanent? ›

The good news is, the answer is a big fat NO. It's essential to understand that a diagnosis is not a life sentence. It's a snapshot of a person's mental health at a particular point in time. Just like a weather report doesn't predict perpetual rain, a mental health diagnosis doesn't predict an unchanging future.

What three pieces of patient information should the medical record contain? ›

In conclusion, the patient medical record should include the patient's personal data, current medications, and medical history.

What are the contents of the health record? ›

This personal information includes details such as: The patient's medical history. Applicable diagnoses. Historical and ongoing medications, including over-the-counter and alternative treatments.

What are common records kept in a medical office? ›

Medical Record Keeping Definition

These records may include information on illnesses, medical conditions, lab results, immunizations, screenings, biographical data, and documentation of services.

What are the two most common medical records? ›

Paper-based medical records and electronic medical records are the two most common types of medical records.

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