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Steinlaw, Lawyer
Category: Consumer Protection Law
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Experience:  Consumer law attorney, author of California Debt Blog, top foreclosure attorney
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Medical Records Request by Patients, is there a template you

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Medical Records Request by Patients, is there a template you could suggest, to request notes that include Diagnosis and Treatment Plan. Although most offices are glad to do this when I provide them with one of their forms. However, just now I am in a loop of appropriate wording because I think office staff are genuinely unaware that as a patient I have a right to my own records, this is particularly important to me because it is difficult to remember what a physicians said when in pain. It is in fact the staff of an anesthesiologist and his nurses and administrative staff. The "pain clinic" said they had sent notes to my neurosurgeon and primary care, but I am not scheduled for a follow up any time soon and I requested from both the neurosurgeon's and primary care's staff and they all send me to a medical records number, because they are unsure of releasing another physician's records. I have been going back and forth with records staff (or central voice mail it goes directly into), one for a hospital based fee one for clinical related fee and staff on both thought the other would have the record. In this maze I have managed to pull a fax # XXXXX the hospital (more staff say the hospital than clinic, I have talked to at least 6 people since yesterday).So thought I would fashion my own request . These Medical Records have already referred me back and forth, in ping-pong style. I am trying to be non confrontational but polite and direct and tell them (but they have stopped listening because they even though they call to say they are there to answer questions, I can tell they are expecting yes or no answers and a 45 second call. This culture of guarding the patient from their own records interferes with a patient's care. And I want to put it delicately and politely as I don't think it's a good idea to offend a staff that is putting epidural injections in my cervical spine area.I've asked a voice mail of the hospital to send me any form or guide me to where I can request the anesthesiologists notes from my date of service.] this is a new diagnosis for me, a whole new vocabulary of words and it helps me with one of my treatment modalities to be able to visualize what the bulging disk or herniated disk or various stenosis (2 kinds), and the nerve process. The Anesthesiologist asked what I have done to help and when I told him Guide Imagery he seemed to be righting it down, he asked also if it helped (he appeared to be working through a checklist), I said yes. So I believe he himself would completed "get it" why I want to know as much as possible. But staff is treating me like I am asking for something that has nothing to do with my health care, they seem truly shocked that I am asking for the notes, since they are, after all, about my body and other medical records have taught me that what I remember from an office visit can be different from what I am able to remember a specialist telling me as they work at high speed. I have the neurosurgeon's notes, his staff handed them to me without question, and completely understood when told his staff, right after leaving the exam room and back out to the front desk that I would be going to my primary care in a couple days and she will ask me what he (neurosurgeon) said and told her it kind of went by me in a blur. It jolts train of thought when I was handed a 4 page description of surgical options, which included a metal Frankenstein- like hinge, complete with holes with metal screws going through it. We are not looking a surgical option but that is the most drastic surgical option of anything ever, so it was hard to take in so many new medical-speak. In fact most medical providers do fax me a copy of a test result or office notes. But when I am up against the resistant office, clearly they have been instructed that HIPPA applies and they aren't sure what it means, like it is just easier for them to say no, and I am guessing by the surprise in their voice that I am calling yet again, that saying no, with no rationale besides "we don't do that, you need to call medical records" gets rid of nearly 100% of patients. I am set to have another epidural in early November and I would like to read, for myself, what Treatment Plan is. I realize this is just routine, and probably small problem, compared to other patients they see. However, this is the most serious pain treatment I've ever had. But to me it is huge and understand it more exactly helps me understand and to use relaxation skills when undergoing treatment And, Cognitive Behavioral Therapy is standard modality to treat chronic pain. We are taught, I have been taught, by pain specialists (over the last 15 years for other Diagnoses) that my mind is one of the biggest healing forces available to me & biofeedback & knowing the bio markers for me to see my own progress in managing chronic illness.
Put this on paper and send it to them:



I. What is Being Released: All Information & Records

I/we hereby authorize YOUR NAME, and/or his representative, to review, inspect, have, obtain, copy and receive all information, oral and documentary, including all notes, charts, records, reports, bills, statements, letters, pictures, recordings, and all other documents, depictions, electronic media, and writings , in every form and of every nature, in accord with the accompanying request.

This includes, but is not limited to, financial, credit, legal, police, health, medical, dental, SSA, SDI, insurance, VA, DMV, military, government, employment, education/school, and confidential records from any/all sources whatsoever.

II. Specific HIPPA Requirements

This authorization fully complies with the Health Insurance Privacy and Portability Act (HIPPA). The information and records sought by this authorization and the accompanying request will be used for purposes of my auto collision claim/litigation and preparation therefor (and as may be further explained in the accompanying request). This authorization shall be valid for a period of 90-days unless sooner revoked in writing by me, which I understand I have the option of doing. I have a copy of this authorization. I understand that once the information and records are released it is possible that they will be re-released and not kept confidential, however, no re-release should occur without my consent.

III. Copies Valid; Facsimile Signature Valid; All Forms of Communication Authorized

A copy of this authorization, including one bearing an electronic or facsimile signature, shall be as valid as the original. All methods of communication, including but not limited to facsimile and e-mail, are hereby authorized.

IV. Contact Person for Questions or Information

Please contact me if you should have any questions or concerns.

Steinlaw and other Consumer Protection Law Specialists are ready to help you
Customer: replied 6 years ago.
This is AWESOME!!! Thank you so much. This has so much good language and I can just adapt the part about car collision, since my spine condition arrived out of nowhere and I am just trying to understand more about as it is the most excruiating medical condition I've experienced and symptoms as severe as this keeps a patient motivated more than any one else in the picture. They could be the most caring physician on earth and they still aren't the ones experiencing pain with pretty much every move they make.

May I contact you again with patient issues like this dealing with corrections to medical records, which paperwork almost all offices use, provides a seemingly boilerplate paragraph on my right to submit corrections.

You can contact me again. Just start your question with "For Steinlaw.........."