Requesting medical records

Requesting Medical Record facebook postRequesting medical records

Edited by Jennifer Dudenhoeffer

Requesting medical records does not have to be confusing if you are somewhat prepared for the task. We want to reduce some of this confusion by offering some helpful tips.

When your law practice involves a client injury in the workplace injury, medical negligence, medical product defect, or even slips and fall or car accidents, obtain and review medical records.

The first thing your law office wants to do is create a checklist, which explains to your staff what types of records they should either request or what they should expect to receive once the  request is made.  This checklist should include; Medical Abbreviations, the International Classification of Diseases (ICD) and the International Classification of Diseases, Clinical Modification (ICD-9-CM).  It is worth noting here that the ICD and ICD-9-CM are books.  Therefore, our office has copies of them and our checklist merely advises the user to refer to the books during the records review portion of case development.  In addition, the checklist should contain the local rules pertaining to requesting medical records.  Presumably, all states have a section in the Rules of Civil Procedure outlining the rules which your office must adhere to when requesting medical records. Your checklist should contain a list of the components in the medical records.

Your checklist should also contain a list of items you should collect from the client to ensure you have all the information required to successfully obtain the medical records.  During the interview with the client you need to obtain a complete medical history.  If the client has EOBs and other billing information, you will want to collect those .  You should obtain the pharmacy billing records prior to and subsequent to the incident in question, and have your client bring these for the initial interview. They will contain a thumbnail sketch of the patient’s medical care prior to the incident in question, identify prescribing/healthcare providers and document medication taken (such as pain medication) to aid in supporting damages.

Remember; during the interview with the client you will need to obtain a signed authorization to request the records and talk to any billing departments, etc. Some things to remember when you or paralegal meet  with the client – you will need to collect all the insurance information and make copies of all insurance cards and policies.

You will want to train your paralegals to use the information on the EOBs to locate billing and medical records. Some facility, and hospitals use independent contractors for the billing. Remember, you will need to send a separate request for each billing department.

Hopefully, our overview and checklist for requesting medical records will help you streamline your internal office procedure.

Look for our next blog entry what to look for when reviewing requested medical records.



Holly Sheriff

A Self-Employed Virtual Paralegal, Business Coach, Public Speaker who just so happens to have CP! Dream Big-Believe and Do™ This blog and its writer are not held liable for any content that is republished or used by others. This blog has been edited by Jennifer Dudenhoeffer. Any personal information is made private and cannot be shared by third parties. . This blog is not intended to be legal advice. Further, this blog is the personal opinions of the writer and is not intended to be a legal analysis of any legal topic and should not be used as a substitution of an attorney or legal advice. If you have come to this blog with a specific legal issue or problem, you should seek the advice of a licensed attorney of your own choosing.