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How to request medical records when you’ve been a victim of medical malpractice

EMR

If you are concerned about a medical error that occurred at a hospital, it is imperative that you request the medical records so that an experienced medical malpractice attorney can evaluate your case without delay.

Many patients and families have a difficult time requesting their medical records because they just don’t know how to request them or, if they have figured out how to request them, they still haven’t received them from the hospital.  If this is you, The Moses Firm is here to help!

If you need your medical records to have your case evaluated, it is important to do to the following:

  1. Find the hospital’s webpage that gives specific instructions on how to request medical records from that hospital (see below for links);
  2. Include a cover letter that requests a (1) CERTIFIED (2) COMPLETE (3) COLOR (4) PDF copy of all the medical records they maintain for the patient, regardless of whether the earlier hospitalizations pertain to the medical error or not–more is better. (Samples are below.);
  3. Download and complete the “authorization” or “release” for the medical records;
  4. Request the itemized billing; and
  5. Request all imaging studies on a disk.

It is imperative that you specifically request an electronic/PDF copy of the medical records.  As a result of consumer-friendly federal laws that protect a patient’s right of access to their own health information by limiting the cost of electronic medical records, most hospitals only charge $6.50 for an electronic/PDF copy, which can also be conveniently emailed or mailed to you on a disk or jump drive.

If you don’t specify that you want an electronic/PDF copy of the medical records, they will print the medical records on paper and send you a bill for hundreds or thousands of dollars, depending on the number of pages.  This is how the medical records vendors make their money.  So be sure to specify in the cover letter and on the release itself that you want an electronic/PDF copy of the medical records.

Please note that the complete medical record from a hospital is VERY DIFFERENT than the documents available on the patient portal or on “MyChart”.  These online portals only contain a minuscule fraction of the actual medical records; look nothing like the actual medical record that the physicians are familiar with; and are almost always unhelpful.  So don’t waste your time.

Be aware that most hospitals outsource their medical records responsibilities to vendors that process thousands medical records requests annually and, in our experience, patients and families must repeatedly follow-up with these vendors to obtain their medical records.  So it is important to confirm that they not only received the request, but to follow-up with them regularly to ensure that the request is being processed in a timely fashion.

Federal law requires hospitals to produce medical records within 30 days of the request, 45 CFR § 164.524(b)(2).  But many hospital and their vendors violate federal law routinely and take 60-90 days, and sometimes longer, to produce medical records.  If you have not received your medical record in a timely fashion and you have documented proof of your repeated efforts to obtain your medical records without success, you can file a Civil Rights Complaint with the U.S. Department of Health and Human Services using this link:

https://www.hhs.gov/hipaa/filing-a-complaint/index.html

HHS has imposed hefty fines against many hospitals for their failure to timely comply with proper requests for medical records.  You can see the recent fines by HHS here:

https://www.hhs.gov/hipaa/for-professionals/compliance-enforcement/agreements/index.html

We hope you found this information helpful.  If you would like The Moses Firm to evaluate your case, please reach out to us at (404) 721-1050 or contact us through our website at www.themosesfirm.com.

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Sample Cover Letter, Version 1

 

[Requestor’s Name]

[Address]

[City, State, and Zip Code]

 

[Date]

 

[Hospital’s Name]

[Address]

[City, State, and Zip Code]

 

          RE:      Patient:                     

                      DOB:                         

                      SSN:                           XXX-XX-

                      Dates of Service:      

 

Dear Sir or Madam:

I was a patient at your facility and am requesting (1) a CERTIFIED, COMPLETE, COLOR, and PDF-copy of my medical records; (2) all imaging studies on a CD; and, (3) the corresponding itemized bills.

Please be sure provide these medical records in an electronic/PDF format pursuant to the requirements of the HI-TECH Act as set forth in 42 U.S.C. § 17935(e)(2) and 45 C.F.R. § 164.524(c).

I have enclosed a signed authorization for the release of my medical records.  Thank you for your help.

Sincerely,

[Signature]

[Requestor’s Name]

 

***

Sample Cover Letter, Version 2

[Requestor’s Name]

[Address]

[City, State, and Zip Code]

 

[Date]

 

[Hospital’s Name]

[Address]

[City, State, and Zip Code]

 

          RE:      Patient:                     

                      DOB:                         

                      SSN:                           XXX-XX-

                      Dates of Service:      

 

Dear Sir or Madam:

I am the surviving spouse and next-of-kin of [PATIENT NAME] who was a patient at your facility.

I am requesting (1) a CERTIFIED, COMPLETE, COLOR, and PDF-copy of his/her medical records; (2) all imaging studies on a CD; and, (3) the corresponding itemized bills.

I have enclosed a copy of the Death Certificate that identifies me as his/her _____.]

Please be sure provide these medical records in an electronic/PDF format pursuant to the requirements of the HI-TECH Act as set forth in 42 U.S.C. § 17935(e)(2) and 45 C.F.R. § 164.524(c).

I have enclosed a signed authorization for the release of my medical records.  Thank you for your help.

Sincerely,

[Signature]

[Requestor’s Name]

 

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Links to Metro Atlanta Hospital’s Medical Records Request Pages

 

Here are some links to the medical records request pages for the the largest hospital systems in metro Atlanta.

WellStar

https://www.wellstar.org/for-patients/request-medical-records

Piedmont

https://www.piedmont.org/patient-tools/request-records

Northside

https://www.northside.com/patients-visitors/request-medical-records

Emory

https://www.emoryhealthcare.org/patients-visitors/medical-records.html

Southern Regional Medical Center

https://www.southernregional.org/patients-visitors/medical-records/

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