Everyone has the right to request access to their own medical history. It is easy to get a copy by writing a letter to a doctor’s office or hospital. There are several reasons why an individual would write a medical records request letter.
Common Reasons For Requesting Medical Records
• Making an insurance claim
• Changing healthcare provider
• Moving out of state
• Keeping a personal medical record
• Getting a second opinion
• Filing a medical malpractice law suit
To make it easy for the hospital or doctor’s office to find the records, the individual should include as much information as possible such as full name or names if the name changed because of marriage or adoption, date of birth, current address and phone number as well as previous address if that was the address used during the time of treatment. If the individual only wants certain records, they should list the records they want, so they are not charged for records they don’t need.
Medical Records Come From Many Different Places!
Medical records come from many different places along with hospitals and doctors’ offices. Individuals may need to send a letter to labs, private nurses, anesthesiologists, physical therapists, MRI diagnosticians, chiropractors and pharmacies.
The most common records requested from a treating physician are:
• Bills and receipts
• Prescription records
• Vaccination records
• Results of CAT, DKG, DDG, NMR and fetal monitoring tests
• Diagnostic test results
The records most often requested from a hospital or clinic are:
• Admission records
• Emergency room records
• Anesthesiologist’s records
• Discharge records
• Outpatient records
• Pathology reports
• Nurse’s notes
• Pre and post-operative reports
• Therapy records
According to the Health Insurance Portability and Accountability Act (HIPAA) and the Department of Health and Human Service regulations guidelines the doctor or hospital being requested to give medical records may charge a reasonable fee for copying the records. They may also charge for postage if the individual requests the records be sent to a specific address. The guidelines also allow the healthcare provider to respond to requests for records within 30 days with an additional 30 day extension for a good reason. States may also have laws that require a lower fee or time difference for responding.
Medical Release Form
Many doctors and hospitals require that patients fill out a medical release form. The individual should call the office and ask if this is required because it will save time for the person looking for the records, thereby saving time for the individual requesting. The form can be filled out, signed and included in the letter requesting the records.
The records can be sent to the individual’s residence, another doctor’s office or to an insurance company. However, an individual can only request their own medical records. If they want to request a family member’s records, they will need written permission from the family member. If they would like to request the medical records of a deceased person, they will need the permission of the next of kin. Each hospital may have different regulations for handling next-of-kin applications, so the person should call the hospital to find out their regulations.
By Andre Bradley