The medical record review for legal purposes

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medical record review

Obtaining and reviewing medical records is one of the most essential parts of the discovery process when a claim involves physical injury. In pharmaceutical mass torts, for instance, the medical records are specifically important for documenting the prescription history against alleged consumption and use of drugs.

When the attorneys are requesting medical records, they can ask for the following from the plaintiff’s counsel:

  • List of providers which is inclusive of the names of the physicians, pharmacies, hospitals, or clinics
  • HIPAA “authorization for disclosure of protected health information” form. Each of these forms must include the claimant’s signature and date, language from the Act authorizing record release, and name and address of facility or provider.
  • If the patient is deceased, plaintiff’s counsel may prepare the form internally or may utilize a form prepared by the defense counsel for the client’s signature.
  • Generally, these forms are typically valid for one year unless otherwise indicated.
  • Additional information regarding HIPAA and the right to access medical records can be found of the website.

 You might need extra documents for medical record review in case of legal proceedings such as:

  • Medical record request letter: This letter outlines the formal request for records. The main information listed in the letters includes claimant’s name, social security number, and date of birth.
  • Billing and radiology records: Some medical facilities may require a separate request for billing or radiology records. This information can typically be derived by calling the facility directly.
  • Certification of records: Documents which support the certification of medical records by the appropriate facility representatives which should also be included with the request. It is necessary to certify the records provided to the requesting party and the other is utilized when no responsive records are identified.
  • The other necessary documents needed in the facilities may also require a copy of the claimant’s death certificate, POA, or the driver’s license of signee.

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