ABOUT THIS FORM
In a personal injury case one of the very first things a lawyer needs to do is obtain all of the client’s relevant medical records. The form below is a sample letter to a client’s medical provider requesting medical records. This letter specifically requests in electronic format and cites to the relevant federal laws (e.g., the HITECH Act and the CURES Act) which obligated providers to transmit health information to a properly designated third party.
[DATE]
VIA FACSIMILE: 410-555-5555
ACME Regional Hospital
12634 W. Greene St., RM 210
Baltimore, MD 21202
ATTN: Medical Records & Billing
Our Client: Jane Doe
SSN: 123-12-3455
DOB: 1/1/1979
Service Dates: [accident – present]
Dear Sir or Madam:
This office represents Jane Doe the above-named patient of yours, and as shown by the enclosed HITECH authorization, who has individually requested their medical records and bills from you, and has specifically directed and authorized you to send those medical records and bills directly to me.
Pursuant to the HITECH Act, 42 U.S.C.A. § 17935(e)(1), the CURES Act, and its implementing regulations, 45 CFR 164.524(c)(4)(i), my client is requesting their medical records, to include a complete copy of their medical chart, all records, radiology images, and all itemized statements in an electronic format only.
Please be aware that the HITECH Act, as clarified by the CURES Act, applies to requests by third parties, like our law firm, just the same as it applies to requests by patients: “if requested by an individual, a covered entity must transmit the copy of protected health information directly to another person designated by the individual.” Federal Register January 25, 2013 Vol. 78 No. 17, p. 5634. Please also note that the ONC’s CURES Act Final Rule, 85 FR 25642, with an effective date of June 30, 2020 abrogated the third-party-request rule articulated in Ciox Health, LLC v. Azar, 435 F. Supp. 3d 30 (D.D.C. 2020). In other words, refusing access to a patient’s EHI is not allowed and the same rates apply to third parties as do to patients.
The records should include, if applicable, their Hospital admission face sheet; Discharge summary; Admission history and physical; Progress notes; Orders; Consultation; Radiology reports; Lab values; Graphic vital signs; Anesthesia record; Operative reports and notes; Pathology reports; Recovery room; Nurses notes; Medication records; Outpatient records; Emergency room records; Special diagnostic tests; Imaging Discs, and Fetal strips.
We are not requesting paper copies. Do not bill us for paper copies. The HITECH Act and its regulations do not allow you to bill for paper copies when an electronic copy has been requested. We will not hesitate to file a complaint with the Department of Health & Human Services (HHS) if you violate the law by improperly applying the paper copies rate for electronic records.
Please fax, email, or call us with the amount you intend to charge before sending the records. If you follow the HITECH and CURES Act rules, we will pay our bill promptly. In accordance with Maryland’s Annotated Code, Health General Title, §4-309, we are requesting the records within twenty one (21) working days of this request.
If any of the above records and/or bills are available only as paper copies, and have never been made into an electronic format, please identify the record and provide the cost of copying.
[signature]
FAQS: Requesting Client Medical Records
How do I obtain medical records for a client?
First, you need to get a signed authorization from the client. Then you will need to contact each individual healthcare provider and ask about their specific requirements and procedures for obtaining records. Finally, you will need to send a formal letter requesting the client’s medical records (such as the form letter above).
Can a doctor or healthcare provider refuse a request for medical records?
Under Maryland law, a healthcare provider cannot refuse to provide medical records when properly requested by a patient or authorized representative. This is true even if the patient has unpaid medical bills owed to the provider. Similar rules apply under federal law.
What can you do if a doctor refuses to release your medical records?
If a doctor or healthcare provider refuses to give you access to your personal medical records they may be in violation of federal and state law. If this happens you can file a HIPPA violation complaint against the provider. The complaint should be filed with the Health and Human Services Civil Rights Office.
How long are healthcare providers required to retain patient medical records?
Under HIPPA, healthcare providers are obligated to retain all patient records for a minimum of 6 years. In practice, however, most providers will maintain patient records for much longer.