How to Obtain Your Own Medical Records
As of 1/1/2020, record keeping companies are allowed to charge attorneys’ requesting medical records for their clients as much as $1.00 per page plus other fees. Our law firm, as well as others, developed a system which has saved our clients a lot of money. As one of the legal assistants in our office, I let our clients know we front the costs but the costs are their responsibility and by obtaining their own records they usually save a lot of money. My attorney, Susan B. Ramsey, is also a registered nurse. She created a template “client request letter”. The request letter is designed to be sent directly from the client asking for records, images, notes, etc. in electronic form. The client can send to the facility/doctor along with a HIPAA compliant medical record authorization, asking for their records which they are entitled to. As the legal assistant, I create the letter & fill out all the information on the HIPAA authorization so all the client has to do is sign & date both documents. However, you can do the same to get your records.
Some medical facilities will let you fax or email the records request while others want you to mail it. In some instances, we have found some clients need more help than others to accomplish this process. We did have a client that could not read nor had printer access. In that situation, I mailed her the letter, HIPAA authorization & a stamped envelope to the facility so that her granddaughter could help her and mail the letter & Authorization from her house. I put our fax number on the letter. Usually, the records are faxed to our office. If the facility sends the records to the client via share file, drop box or email, I just have them forward the email to me and I take care of it. If the facility mails the client a CD of the records/images, then they will mail it to our office. I also go over with the client how to follow up with the facility after 2 weeks and can even provide a script on what to say. This does take time, but I really get to know the clients. Consequently, they are more trusting with our team,very appreciative for the help & the savings.
*Please see below a Client Letter Template & HIPAA Compliant Medical Record Authorization for you to get your own records:
City, State Zip
Name of Facility
ATTN: RECORDS CUSTODIAN
City, State Zip
RE: Name: Individual Name or Personal Representative
SSN: Individual or Deceased
DOB: Individual or Deceased
DOS: Dates of Records Requested
Dear Records Custodian:
Pursuant to HIPAA and HITECH, I hereby authorize your designated medical custodians or database custodians to use and/or disclose my protected health information (PHI), in electronic format, as detailed on the enclosed HIPAA Authorization, p. 3.
Please note that I would like a complete electronic copy of the requested records, chronologically in electronic PDF format, so that the text is searchable. The records should be produced directly from the Electronic Medical Record system, not produced from a third-party vendor (such as Record Connect, MRO, IRM or CIOX). Color entries should be preserved in color. I am also requesting that you preserve an active copy of the electronic medical records.
I am requesting that these records and invoices be sent directly to my attention at the above address and/or email. I would prefer an emailed link to download my medical records. I will accept a CD or flash drive.
The requested information is to include all pertinent medical records and may include alcohol, substance abuse and mental health records in accordance with Public Act 56, 1973 and in compliance with Title 42 of the Code of Federal Regulations, Part II. You are also authorized to release all information pertaining to billing records, as well as all reports, records and data pertaining to testing, care, treatment, reporting and research associated with a communicable disease, or a serious communicable disease or infection.
The Health Information Technology for Economic and Clinical Health (HITECH) Act provides that any fee you may impose for providing a copy of an electronic health record shall not be greater than the entity's labor costs in responding to the request for the copy. 42 USC 17935(e)(2). HIPAA also precludes you from charging a retrieval fee as well. 45 CFR 164.524(c)(4)(iii). I request you follow these laws in your invoices for the requested records.
If any of the above records are available only as paper copies, and have never been made into an electronic format, please identify the record and provide the cost of digitizing and/or copying these records to me before sending a copy of the records.
I understand that PHI used or disclosed pursuant to this letter may be disclosed by the recipient and may no longer be protected by the Federal Privacy Rules. I understand that authorizing the disclosure of PHI is voluntary. I also understand that I may refuse to provide authorization to PHI and that refusal to provide authorization PHI will not affect a patient’s ability to obtain treatment, payment for services, or eligibility for benefits.
Consent to release these records will continue unrevoked until the purpose for which the consent was given shall have been accomplished. This consent is subject to revocation at any time following my written notice to you.
Should you have any questions or concerns, please contact me. I thank you for your prompt assistance and cooperation in this matter.
Name of Patient or Personal Representative of the Estate
AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION
(Complies with HIPAA, 45 CFR §164.508 & §164.524)
Patient Name: ______________________________________ Social Security Number:_________
Date of Birth:___________________________________
- I hereby authorize the use or disclosure of my health information as described below:
_______ Entire medical or dental record, including patient history and background information, complaints, reports of examination or treatment, diagnosis, laboratory reports or results, consultation reports, medication list, x-ray and imaging reports, and any other document relating to my medical care or treatment at any time.
_______ Entire inpatient or outpatient hospital chart or treatment records
_______ Only the following limited records or information:_________
_______ X-ray and imaging reports.
_______ Billing Statement for Services provided.
- The following individual or organization is authorized to make the disclosure:
- I understand that the information in my health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental
health services, and treatment for alcohol and drug abuse. Initial_______
- This information may be disclosed to and used by the following individual or organization:
For the purpose of:__________________________________________________________________
- I understand I have the right to revoke this authorization at any time. I understand if I revoke this authorization I must do so in writing and present my written revocation to the health information management department. I understand the revocation will not apply to information that has already been released in response to this authorization. I understand the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. Unless otherwise revoked, this authorization will expire on the following date, event or condition: 1 year from date signed below. If I fail to specify an expiration date, event or condition, this authorization will expire in six months from the date signed, as indicated below.
- I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment. I understand I may inspect or copy the information to be used or disclosed, as provided in 45 CFR 164.524. I understand any disclosure of information carries with it the potential for an unauthorized re-disclosure and the information may not be protected by federal confidentiality rules.
- It is agreed that a photo static copy of this authorization shall have the same force and effect as the original of this authorization.
- In accordance with the provisions of 45 CFR §164.524(c)(3)(ii), I specifically request that copies of my medical records be transmitted to my attorney identified in paragraph 4 above, as my designee, and mailed to the address shown in that paragraph, and that the records be provided in electronic format (PDF format on CD media), as required by 45 CFR §164.524(c)(2)(ii).
We hope this helps!
Jamey H. Szerdi has been a legal assistant at Romano Law Group for over 9 years. She got her Bachelor’s Degree in Elementary Education from Spalding University in Louisville. KY. Jamey went on to teach Earth Science to 6th graders at Crystal Lake Middle School in Pompano Beach, FL. She was very active with her students & co-chaired the Broward County Science Fair during her teaching career. While she and her husband John were raising their 3 children , Jamey continued to volunteer at the local schools working in the classrooms assisting teachers, students & parents. In 2011, Mr. Romano hired Jamey knowing she loved to help people. She started in the Mass Tort Department to work closely with clients, helping them get through the whole process of a Mass Tort lawsuit. For the last 2 years, Jamey has been working with Susan Ramsey, RN/Esq. assisting in Medical Malpractice, Substance Abuse Treatment Center litigation and Mass Torts.