La loi vos droits

Health Care Users and Professionals

Access to Medical Records

Jocelyne is puzzled. She didn’t think her life insurance questionnaire would be so detailed! Jocelyne remembers most of her medical history but not necessarily all the treatments and illnesses that might be important to her insurer. She would like to consult her medical file to make sure she has all the information. She wonders whether she is allowed to, and what to do if the medical clinic refuses to let her see it.

In this Infosheet, Éducaloi answers the most common questions about access to medical records and what to do if your request for access is refused.

What is a personal file?

The expression “personal file” also refers to personal information. There must be a serious and legitimate reason for a doctor to have a file on you. Also, the personal information it contains must be necessary for the purpose of the file.

Any information about you that can identify you is considered personal information. It doesn’t matter whether the information is kept in a paper file, computer system or voice recording–it’s still personal information.

Who can access my medical records?

As a general rule, only you have access to your medical records. Other people, such as the professionals and staff members who treat you, can access your file if allowed by law, or if you have given them your permission.

For example, the law allows the heirs of a deceased person to access his or her medical records if they need this information to exercise their own rights. The same is true for the beneficiary of your life insurance policy or retirement plan.

Also, if you file a lawsuit and your claim is related to your physical or mental health, the other party can request access to relevant information in your medical records.

How can I get access to my medical records?

If your file is in a private clinic

The clinic must let you see your file. The only way for you to obtain access is by sending a written request to the clinic.

The doctor has 30 days after receiving your request to respond. If you wish, you can then make an appointment to consult your medical records at the clinic.

The clinic is allowed to charge a reasonable fee if you want to copy all or part of your records.

If your file is in a hospital

If your file is in a hospital, you can make your request in writing or in person to the staff member in charge of access to records. You can get this person’s name and contact information by calling the hospital directly, or by contacting the Commission d'accès à l'information  (http://www.cai.gouv.qc.ca/09_listes_des_responsables/01_pdf/Index_Persons_Responsible_Access_Public_Bodies.pdf) (access to information commission) or Services Québec  (http://www4.gouv.qc.ca/en/Portail/Citoyens/Evenements/aines/Pages/consulter-dossier-medical-organisme.aspx).

There is no specific deadline for answering your request, but the hospital must let you see your file as soon as possible.

The hospital is allowed to charge a reasonable fee if you want to copy all or part of your records.

Can I be refused access to my medical records?

A hospital or clinic can refuse to let you see your file in specific situations provided by law. For example, your request will be refused if the doctor believes that access to the information in the file may have serious effects on your mental or physical health.

What can I do if I am refused access or if my request goes unanswered?

If the private clinic does not reply within 30 days of receiving your request, or if your request is refused, there are two things you can do: First, you can complain to the professional order  (http://www.educaloi.qc.ca/en/loi/other_infosheets/103/) concerned by filing a complaint with the “syndic” of the order. Please refer to the Infosheet entitled “Complaints Against Professionals.” Second, you can complain to the Commission d’accès à l’information  (http://www.cai.gouv.qc.ca/index-en.html) by asking for an examination of a disagreement  (http://www.cai.gouv.qc.ca/06_documentation/01_pdf/eng-formulaire%20de%20mesentente.pdf).

The staff of the Commission is available if you need help with the application.

If the Commission finds that no agreement is possible between you and the professional, it will examine the complaint itself. After it has investigated the complaint, it will inform you and the professional of its conclusions in writing, along with the reasons for its decision. It can order the professional to give you access to your file or correct the personal information it contains. The professional then has 30 days to do this. The Commission can also refuse your request and instruct the professional not to give you access to the file.

If your file is in a hospital

If the hospital does not respond or refuses to give you access to your file, you have a few options:

• Ask the Commission d'accès à l'information to review the hospital’s refusal  (http://www.cai.gouv.qc.ca/06_documentation/01_pdf/eng-formulaire%20de%20revision.pdf).
  
  
• Ask a judge of the Superior Court or the Court of Québec to review the hospital’s decision. The costs and procedures are the same as for a normal legal action. For more information, please refer to the Côtécour section at http://www.educaloi.qc.ca/en/cotecour/.
  
  
• Challenge the hospital’s decision before the Tribunal administratif du Québec  (http://www.taq.gouv.qc.ca/en/ ) (administrative tribunal) within 60 days of receiving the refusal.

If my medical records contain incomplete or inaccurate information, what can I do?

First, you must send a written request to the hospital or clinic outlining what you want corrected or added. A hospital has 20 days from the time it receives your request to respond. A clinic has 30 days. If they refuse to make the corrections or do not answer within the time limit, you can contact the Commission d’accès à l’information  (http://www.cai.gouv.qc.ca/index-en.html).

Can my employer access my medical information?

Under very specific circumstances, your employer can access some of your medical information. For example, if you are absent from work for a period of time due to illness, your employer may ask you to provide a medical certificate justifying your absence. However, only the person in charge of personnel and personnel-related decisions (for example, the human resources director) is allowed access to this information.

Also, your employer can ask you to undergo a medical examination if he or she has reason to believe you are not physically able to do your work. Your employer would then have access to the report of that examination.

However, an employer cannot require you to provide a copy of your medical records during the hiring stage. He or she can only evaluate your physical or psychological ability to perform the job by asking you questions or asking you to undergo a specific medical examination.

Can my family access my medical records without my consent?

As a general rule, if you are 18 years of age or older, your family can’t access your medical records without your consent.

However, if you are incapacitated  (http://www.educaloi.qc.ca/en/loi/senior_citizens/411/ ) (you become unable to take care of yourself and your property), the person you designated in a mandate in case of incapacity  (http://www.educaloi.qc.ca/en/loi/senior_citizens/52/) your tutor or your curator can have access to your records.

After your death, your potential heirs and your legal representatives have the right to access information in your file if this is necessary for them to exercise their rights. The same is true for the beneficiary of your life insurance policy or your retirement plan.

The spouse (or partner), parents, grandparents, children and grandchildren of a deceased person also have a right to information in medical records about the cause of death, unless the deceased included written instructions in his or her medical records refusing these relatives access. However, this refusal cannot prevent a blood relative of the deceased from verifying the existence of a genetic illness or other condition that runs in families.

I am a minor. Do I have a right to consult my medical records? What about my parents?

In theory, only people 14 years of age or older have independent access to their medical records. A person under 14 can, however, have access to the file through a lawyer during a legal proceeding.

Generally, parents have access to their child's medical records if the child is under 18. However, the hospital has no right to reveal the contents of the medical file belonging to a minor who is 14 years old or older if the child refuses and if the doctor believes that giving the parents access might harm the child’s health. If the doctor determines that access to the information will not be harmful to the child, the parents can have access to the file even if the teen refuses.

If a child below the age of 14 is subject to a measure under the Youth Protection Act, the healthcare institution will not allow the parents to access the file if, after consulting the Director of Youth Protection, it determines that communication of this information might be harmful to the child.

Useful Links :

1. Commission d’accès à l’information website  [http://www.cai.gouv.qc.ca/]