Medical Records

Medical Records

Under North Carolina law, a person’s medical records are property of the healthcare provider who created them. However, a patient has rights to get copies and/or inspect the records of his medical care. The patient may need them to provide to a different doctor or healthcare provider to help with additional medical care. Legal actions such as medical malpractice or personal injury also may require an inspection of the medical records to determine damages, pre-existing conditions, or causes of injury. Medical malpractice actions in North Carolina require an expert review all the medical records available before even starting a lawsuit. The federal Health Information Portability and Accountability Act (HIPAA) gives patients the right to obtain a copy of their medical records from any medical provider, with a few exceptions. According to HIPAA, you may request

  • Your own medical records;
  • Someone else's records if you are a designated representative with power of attorney or or otherwise written permission to act as their representative in accessing records;
  • Someone else's records if you are their legal guardian;
  • Your children's medical records, unless the child has consented to medical care and parental consent is not required under NC law, the child gets medical care at the direction of a court, or the parent agrees that the minor and the medical provider have a confidential relationship;
  • Records of deceased persons in certain circumstances. If you are the personal representative of an estate — either designated by a will or appointed by a court to settle a deceased person's affairs — HIPAA gives you access to the deceased's medical records. In addition, if you are related to a deceased person and certain information in that person's medical file relates to your own health, HIPAA lets you access that information.

HIPAA gives patients the right to get copies of all of their medical records except for psychotherapy notes, information the provider is gathering and compiling for lawsuits, and medical information that the provider believes could reasonably endanger your life, your physical safety, or the safety of another person. If the provider denies your request for medical records, it should provide you with a denial letter giving the reason. In such cases, you may be able to appeal the denial. In addition, the North Carolina Medical Board provides that a physician has a duty to release a copy of the patient’s medical record to the patient or a representative of the patient even for purposes of personal injury or medical malpractice investigations and lawsuits. 

HIPAA requires medical providers to provide copies of medical records within 30–60 days of your request. The North Carolina Medical Board requires the records to be provided in a “timely manner.”

In personal injury and social security cases, the health care provider is limited by statute as to the amount they can charge for copies. Currently, the maximum fee for each request shall be seventy-five cents (75¢) per page for the first 25 pages, fifty cents (50¢) per page for pages 26 through 100, and twenty-five cents (25¢) for each page in excess of 100 pages, provided that the health care provider may impose a minimum fee of up to ten dollars ($10.00), inclusive of copying costs. However, if they do charge for medical records, they waive any right they have for a lien on any proceeds from any lawsuit. For records requests for other reasons, the healthcare provider can charge a “reasonable cost-based fee.”

When it comes to identifying which medical records you want, you can be general or specific. Sometimes, patients want their entire medical file. But if you’ve seen the doctor over a long period of time and don't want to pay for copies of every immunization and preventative visit for the last 20 years, it might make sense to specify which part of the record you want. Some hospital will provide a “digest” which includes the most important parts of a record including operative notes, admission and discharge reports, lab reports and radiology reports. Even if you request a full record, you usually will not get copies of actual X-rays or CT scans. You have to request those specifically. You can also narrow your request by specifying records that cover treatment over a certain time period. Billing information is usually kept separate and is not considered part of the medical record, so if you want your bills, you need to specifically request that.

Once you get your medical records, you may notice they include reports from third-party providers, like specialists or radiologists. The documents from the third-party provider are what your doctor received, but they may not constitute all the medical records that the third-party provider's office has on you. If you need more information from the third-party provider, make a separate medical record request to that provider.

 -Bradley A. Coxe is a practicing attorney in Wilmington, NC who practices in Personal Injury, Car Accidents, Medical Malpractice, Contract and Real Estate disputes, and all forms of Civil Litigation.  Please contact him at (910) 772-1678.