If you've been injured in any kind of accident, and someone else might have been at fault for what happened, you might be thinking about filing a personal injury claim.
As part of putting your case together—especially if you're negotiating an injury settlement yourself, and putting together a demand letter—you probably want to get your hands on all records related to the medical treatment you received in connection with your accident injuries.
Getting copies usually involves making a written request to your doctor or health care provider and paying copying fees. However, your medical record isn't found in just one file, so how do you draft your records request?
Keep this task simple and straightforward, and learn how to identify and ask for the exact records you want. In this article, we'll explain how to do this.
Defining Your Medical Record
"Medical records" is a general term for all, any, or some of your medical and patient information and documentation. The files making up your complete medical record may come from doctors and other individual providers, hospitals, clinics or labs. They may be written or electronic.
You may need to contact multiple sources for records relating to a certain treatment, illness or accident. For example, many hospital records reflect the need for services and procedures performed by third-party providers, such as anesthesiologists, private nurses, and specialists or consultants. However, the hospital file might not include all of that provider's notes, charts or test results.
The scope of a provider's records may not be complete, either. For example, a chiropractor's records may contain a detailed summary report from an MRI diagnostician, but possibly not the films and charts. A treating physician's records will contain any prescriptions written for a patient, but not the related pharmacy records.
Drafting Your Request
HIPAA (Health Insurance Portability and Accountability Act) and other laws guide medical providers when releasing records, but here's what to include in your request as a starting point:
Identify the patient, whether it's you or someone you represent, such as your child. Include your complete name, along with any alternate names, your social security number, birth date and patient number (which may be different from your account number).
Treatment date or date range, and the nature of treatment. Use this information to limit your request to a certain time, illness or incident. Otherwise, some providers may copy all records, and that may not be what you wanted or needed. Learn more about medical treatment in a personal injury case.
List specific records. You can ask for specific records to avoid charges for items you don't want or need. In your request, use phrases such as:
- "a full and complete copy of all medical records in your possession, including but not limited to (enter a description of the treatment or illness you want records for)," or
- "a full and complete copy of only those records as follows: (enter detailed list of the precise records you want, such as X-rays and diagnostic notes, as well as a description of the treatment or illness connected to the records)"
In a letter to a treating physician you may want to include a request for:
- itemized medical bills, billing statements, and receipts
- office and staff journal, diary and notes
- prescription records
- laboratory tests and evaluation reports
- x-Ray and/or MRI films
- x-Ray and/or MRI reports
- vaccination records
- hospital inpatient visits and treatment records
- CAT, EEG, EKG, NMR, fetal monitor or other test results, and
- results of diagnostic tests.
To a hospital or clinic, you may want to add a request for:
- admitting records
- anesthesiologist's records
- emergency room records
- dietitian's records
- discharge records
- nurse's Cardex
- outpatient records
- pathology reports
- pre- and post-operative reports, and
- therapy records.
Arrange for payment and confirmation before completing your request. You may want to know the extent of the files to be copied and the final copy charges.
Don't expect copies of medical records overnight. Give a provider a reasonable time to respond to your request, such as ten days to two weeks. Priority may be given to certain requests, such as a specialist needing them for a critical patient. Your advance planning and effort pays off when you receive the records you expected with a minimum of delay or mistakes.
If You Already Have a Personal Injury Lawyer
If you've already hired a lawyer to handle your personal injury case (or you plan on hiring one), getting your medical records isn't something you'll need to handle on your own. One of the first things your lawyer will ask you to do is complete and sign an "Authorization for Release of Medical Records" (or similarly-named document). This authorization will let your attorney track down and obtain all medical records relevant to your underlying accident, on your behalf. Learn more about medical records release authorization in a personal injury case.