Although our system is working towards a consolidated electronic medical record, we aren’t there yet (or even very close)!

Owning and Organizing your Personal Medical History (and that of other family members) will improve communication with your health care providers and improve your care as well as your understanding about your own health.

While each of your health care providers keeps a record of his or her treatment of you, they don’t always know what other health care providers are doing.

Today you are the best source of personal health history a your provider has available and your provider is relying on you to provide that information.

Why should you have ownership of your Personal Medical History?

Avoiding medical error (which can be deadly)and prescription drug interactions.

When you share your medical and treatment history with your provider, especially treatments you have received from other providers for other medical conditions, you give them the tools they need to provide the right medical advice without putting yourself at risk for over treatment and conflicting medications.

Avoiding duplicate medical services and duplicate charges.

You also avoid duplicate medical services, for instance, the doctor who treats you for diabetes should be told if you have just been to your family doctor for an annual medical exam. It’s likely that some of lab tests done for your annual physical would be the same tests done to review your diabetes treatment. By sharing your history across your providers you can avoid not only the pain of an extra blood draw but also additional out-of-pocket costs for duplicate lab tests and procedures.

You are a parent

If you are a parent, one of the best ways you can ensure good health care for your child is to keep a medical record of vaccinations, growth and development, childhood illnesses, surgeries, blood type, allergies, and medications, along with the names and addresses of health care providers who provided care. You or your child’s pediatrician might not always be around to provide this important information.

You have family members and loved ones

In an emergency situation, you may be the one who must provide vital information about prior illnesses, injuries, medications, and allergies. Due to the emergency, you may be sick or injured yourself, or too upset to recall needed information. So plan ahead and organize health records for each family member you care for before an emergency occurs.

You are a caregiver for an elderly parent or a disabled partner

Your elderly parent or disabled partner may be unable to share medical history with providers themselves for a variety of reasons and you may be called on to help coordinate that information. If this situation doesn’t exist now, it may happen in the future. Being prepared will help your loved ones to get the best medical care and will help to reduce the stress you have as the caregiver.

Compiling a comprehensive family medical history can play a role in helping you prevent illnesses for which you are at risk.

While illnesses such as heart disease, cancer, or diabetes may not always be preventable, there are important things you can do to reduce your risk and minimize their impact. Knowing that your mother has heart disease and osteoporosis will heighten your awareness in research findings about the benefits and risks of calcium, hormone replacement therapy, weight control, and exercise.

Charting your family’s medical history, and learning your health risks, can provide the incentive to develop healthier habits that will improve the quality of life now and as aging progresses.

As you collect and review medical records you will start to see the “big picture” of your health care story. This can help you plan lifestyle changes, excersize programs and help you to plan for improvements in your health and chart progress towards your goals.

Your personal medical history should include basic information about you.

  • Current legal name and any other names you may have used in the past
  • Birthdate
  • Blood type
  • Height and weight
  • Amount you exercise per week
  • Current medicines taken and dose
  • Past medications taken that were discontinued due to side-effects or allergic reaction
  • List of vitamins/supplements you take, including dose
  • Family doctor’s name, address and phone number
  • People to contact in case of an emergency, including home, work, and mobile phone numbers; home and work addresses; and e-mail addresses
  • Allergies (including foods, animals, and medicines)
  • Glasses or contacts wearer, if applicable
  • Health insurance information, including name and social security number of primary person insured if it isn’t you
  • Current list of immunizations and dates given
  • Routine test results (cholesterol, blood pressure, blood sugar)
  • Hereditary conditions in your family history
  • List and dates of significant illnesses and treatments besides breast cancer (include childhood diseases such as chicken pox, mumps, etc.)
  • Eye and dental exam records
  • Living will, advance directives or medical power of attorney
  • Organ donor authorization

How to Collect Your Personal Medical Information

Thinking about collecting all your medical information can seem overwhelming and daunting. But don’t feel like you have to get all this information right away. It’s a big job that you can work on a little at a time.

A good way to start is to ask for a copy of your most recent records EACH time you visit a doctor or medical facility. Typically they will copy the notes, recommendations and results of the services and advice given at that appointment without a copying charge to you.

After you organize those, you can collect earlier records on a timetable that’s right for you. Still, you’ll have to be proactive and ask for your records to collect all the information you need.

The first thing to do is to contact all your doctors’ offices and treatment facilities and ask for copies of your records. Some offices may keep electronic records that you may be able to access yourself. If not, copies will have to be made for you.

You will have to fill out an authorization form that allows your medical information to be released. Parents of children under age 18 will sign for those children, however your spouse or children between ages 18 – 26 will have to sign their own authorization for release of medical, dental and Rx records.

Be aware that most offices and facilities do charge for copies of records. The charge can only include the cost of copy supplies and labor, as well as postage if you would like the records mailed to you. It’s a good idea to ask when you’ll receive copies of your records — it can take up to 60 days for the information to arrive.

As you move forward, ask for copies of reports, test results and other newly created records while you’re in the doctor’s office. By asking for a copy as you and your doctor are discussing the record, it’s less likely that you’ll be charged for it.

On an annual basis, you can go to your pharmacy and ask them for a printout of all of the prescriptions filled with them for you for the year. An authorization form to release this information will be required.

Keeping and coordinating your records can be as simple as having a 3 ring binder for each family member with copies of the medical history as it is collected or you can get more sophisticated.

The American Health Information Management Association, an organization for medical records professionals, has created a step-by-step guide to help people create personal health records. You can find out more by going to

Don’t worry, there’s an app for that!

You can also find a wide assortment of internet applications such as Google Health and or you can purchase personal health information software such as, Minerva Health Management Software to help you manage your records.

Avoid Hospital Overcharges

Hospital bills are next to impossible for consumers to understand, and – intended or not – consumers are overcharged,by some estimates, to the tune of $10 billion a year. Nevertheless, experts say you can take these steps to make sureyou’re not taken for a ride:

  • If your hospitalization isn’t for an emergency, check your insurance policy to find out just what it will cover and how much it will pay. Be sure to carefully review the section on “exceptions and exclusions.” It will tell you what your plan will not cover.
  • Phone the hospital‘s billing department and ask them what you will be charged for the room, and just what the room charges cover. If tissues aren’t included, for example, bring your own. One woman’s hospital charges included $129 for a box of tissues.
  • Ask your doctor to estimate your cost of treatment. Also, ask if you can bring your regular prescriptions from home to avoid paying for medications administered at the hospital.
  • Make sure that everyone who will be treating you participates as an IN-Network provider in your insurance plan if at all possible. This includes – the surgeon, anesthesiologist, radiologist, pathologist, and anyone else you expect to treat you.
  • If you can, keep a log of tests, medications and treatments. If you are not able, ask a friend or loved one to do it for you.
  • At some point you will receive an explanation of benefits (EOB) from your insurance company. It will say, “This is not a bill.” Don’t toss it. Examine it. It will tell you how much the hospital is charging, what your insurance plan will cover, and what you will have to pay out of your own pocket to deductibles and co-payments.
  • Never pay your bill before leaving the hospital – even if you’re told it is required. If the hospital insists on some payment, offer to pay 10% of the bill and explain that you want to review the itemized bill as well as allow time for the bill to be sent and processed by your insurance company so you are paying the final discounted bill after insurance benefits have been applied.
  • When you get your bill, read it carefully. Compare it to the log you made, to the EOB, and to the estimate of costs you requested before you were admitted.
  • If there are items you don’t understand, call the billing department and your insurer, and ask them to explain.
  • Don’t accept bills that use terms like “lab fees” or “miscellaneous fees”. Demand an itemization. If you don’t get satisfaction from the hospital billing department, appeal in writing to the hospital administrator or patient ombudsman.

If you’re still scratching your head, ask for an itemized bill as well as your medical records to confirm whether or not you received the treatments and medications you’ve been billed for. Every state now requires hospitals to provide itemized bills.

If you find an Error in your bill:

  • Contact the hospital’s business office or patient accounts supervisor immediately. Explain the errors you found in your bill and don’t let them talk you out of your claim with platitudes like, “Don’t worry, your insurance will cover it.”
  • Advise your insurance company of the errors.
  • Put everything in writing and keep copies.

If you need help:

Contact Gabrielle Warner, Contact Alliance of Claims Assistance Professionals (ACAP) at 877-275-8765 OR Visit their web site at and click on the Professional referral section.