traumatized, not troubled
SURVIVING THE TROUBLED TEEN INDUSTRY
Sample Records Request
SAMPLE RECORDS REQUEST
Fill out this form and send it to your program(s) to request records
Copy, paste, and complete this request letter AND SEND IT to the program’s records department or any other applicable contact.
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SUBJECT: Request for Medical Records in Electronic Format
Hello,
I am writing to request all medical, therapy, and psychotherapy records that are in your custody, possession, or control to me in electronic format, e.g., email, compact disc, etc.
Please email me at [YOUR EMAIL] my complete medical record/chart for me relative to my treatment at [PROGRAM NAME] for all dates of treatment of service specified below and all materials or information, including, but not limited to:
All medical records, physician’s records, psychotherapy records, psychotherapy notes, psychiatrists’ records, therapists’ records, consultation records, operative reports, physical therapy, and other therapy records, and all documents, records, reports, photographs, billings, studies, summaries, interoffice memos, or correspondence relating to the treatment, examination, hospitalization, including but not limited to all physical or psychiatric conditions (seclusion/restraint checklist, legal advisements, doctors’ orders, doctors’ notes, progress notes, 24-hour headcount, intake diagnosis and symptoms, discharge summary, psychologist reports, multidisciplinary notes, nursing progress notes, record log of all staff present while inpatient, medication charts and records, denial of rights for good cause checklist, transport records, etc.); laboratory reports; patient information and history questionnaire; physicals and history; discharge summary; progress notes; prescription and medication records; nurses’ notes; correspondence; consent for treatment; and any other materials (whether written or stored, created or maintained in any other form) relating or pertaining to me, including documents and records received from or that were created by another provider.
Please use the below information for reference.
Name: [YOUR NAME]
Date of Birth: [YOUR DATE OF BIRTH]
Dates of Service: [ESTIMATED DATE OF ADMISSION] to [ESTIMATED DATE OF DISCHARGE]
If you are unable to transfer the medical records by email, I ask that you put them on a compact disc and mail it to [YOUR ADDRESS]. If you cannot put them in digital format, you can mail the paper records to the same address.
The Law
Under the Health Information Technology for Economic and Clinical Health Act (HITECH Act), health care providers are required to provide every patient a copy of their electronic health records, in a format of their choice, at a reasonable cost. Significantly, the HITECH Act preempts state law.
The HITECH Act provides that the individual making the request for protected health information (PHI) can designate a third party to receive the information, i.e., an attorney.
The individual is able to choose the method of production of PHI under the Act, and the regulations state it can be in paper or electronic form.
The personal health information requested by an individual must be provided in the for requested by the individual, including a readable electronic form if the covered entity uses electronic health records. This can be a .PDF, compact disc, or as commented by the Department of Health & Human Services, via email if the individual is warned of the security risk associated with unencrypted email.
Reasonable Cost-Based Fees
Under the HITECH Act, any fee that the covered entity may impose for providing an individual with a copy of electronic personal information shall not be greater than the entity’s labor costs in responding to the request for the copy. The fees must be reasonable and cost-based. What is reasonable and cost-based should be determined on a case-by-case basis.
An entity’s labor costs for providing electronic records can only include: (1) labor for copying, whether in paper or electronic form, (2) supplies for creating the paper copy or electronic media; (3) postage if the individual has requested the information be mailed, and (4) if an individual has requested or agreed to an explanation or summary, the costs associated with preparing an explanation or summary of the PHI.
Deadline for Responding
Aside from some exemptions, a covered entity must act on the request no later than thirty (30) days from the receipt of the request by: (1) providing the requested information, or (2) providing the individual with a written denial of the information.
If you are unable to comply with the thirty (30) day deadline for providing the requested medical records, we ask that you contact us in writing before the deadline expires. In your letter, you must provide a written statement of the reasons for the delay and the date by which you will provide the medical records. Under the HITECH Act, you are only provided one such extension of time.
Penalties for Non-Compliance with the Act
There are substantial monetary fines and penalties for failing to comply with the HITECH Act. The Office of Civil Rights of the Department of Health and Human Services can investigate complaints and levy fines for violations of the Act. If a healthcare provider is found to have “willfully neglected” a provision or provisions of the Act, the Office of Civil Rights of the Department of Health and Human Services will impose mandatory fines of up to $250,000 and up to $1.5 million for repeat or uncorrected violations.
If you do not use electronic medical records, please contact me within ten (10) business days of your receipt of this communication in order to make alternative arrangements for the production of the medical records.
Thank you in advance for your cooperation.
[YOUR NAME]
