Medical Records2As a medical malpractice attorney, I have the pleasure of speaking with potential clients who believe they are a victim of medical or dental malpractice nearly every day. One of the first questions I always ask them is, “Did you get a copy of your medical records yet?” Amazingly, a very common response that I hear from them is “I asked for my records, but they won’t give them to me.” That is unfortunate because while there are requirements that a patient has to follow to request and receive his or her medical records, a patient is entitled to a copy of their own medical or dental chart.

Indiana Code section 16-39-1-1 provides that “on a patient’s written request and reasonable notice, a provider shall furnish to the patient or the patient’s designee . . . a copy of the patient’s health record used in assessing the patient’s health condition.” That means that if the request is in writing and gives the health care provider reasonable notice, the provider is required to give you a copy of your records.

How do I comply with a written request?

The best way to comply with this written request is to ask the provider is he or she has a records request form that they use. Most hospitals have their own form. If you are given such form, complete the form fully to ensure that there are no delays in the process caused from you. If the provider does not have such forms, you will need to make a written request of your own. Pursuant to Indiana Code Section 16-39-1-3, your written request needs to include 1) the name and address of the patient, 2) the name of the person requested to release the patient’s record, 3) the name of the provider, 4) the purpose of the release, 5) a description of the information to be released, 6) the signature of the patient or patient’s legal representative, 7) the date the request is signed, 8) a statement that the request is subject to revocation at any time, except to the extent that the action has been taken in reliance on the consent, and 9) the date the request will expire if not previously revoked. While many providers will still give you a copy of your records without all of the above details, they certainly have a right to tell you no if your written request does not include all of the above information.

Who can request my records?

If you are competent and over the age of 18, you can request your own medical and dental records. If a patient is incompetent or under 18 years, the request can be made by a parent, guardian or custodian of the patient. If the patient is deceased, the records can be requested by the personal representative of the patient’s estate. If there is no personal representative, the spouse of the deceased may make the request. If there is no spouse, a child of the deceased or the parent, guardian, or custodian of the child may make the request.

What can I expect to be included in my records?

Many times the challenge for patients isn’t obtaining their medical record, the challenge is obtaining a full and complete set of their medical record. Your records should include progress notes, any imaging you have had done, such as CT scans or x-rays, billing information and insurance claims. If you are requesting records from a hospital, those records should not only include your doctor’s progress notes and orders, but should also contain your admission and discharge papers, you nursing records, your lab results and any additional testing you had done. It is important to include a specific list of the above in your written request. It is also important to note that a provider is allowed to charge a reasonable cost for making and providing copies of records for patients, and many providers will require payment up front.

Remember, there is a statute of limitations to file a medical or dental malpractice claim. In Indiana, that statute of limitations ends two years after the date of malpractice. If the two year date of your malpractice passes, you may have waived your rights to bring a case. If you believe you have a possible medical or dental malpractice, contact a medical malpractice attorney as soon as you can.

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