Short Answer

Send a written records request and a signed medical authorization that clearly identifies the physical therapy provider, treatment location, and date range. If the therapy practice is affiliated with a hospital or healthcare system, ask whether its centralized medical records department actually maintains those records; affiliation alone does not mean one request will cover both facilities. Request the therapy chart and itemized billing records separately, preferably in electronic form.

Start by Identifying Who Maintains the Physical Therapy Records

The first step is to determine whether the physical therapy provider is part of the same legal organization as the healthcare facility where you received other treatment. Providers that share a name, building, patient portal, or referral system may still keep separate records.

Contact the healthcare system’s health information management or medical records department and ask:

• Does your department maintain records for the physical therapy location?
• Is the physical therapy provider part of the same organization or an independent practice?
• Will one authorization cover both facilities?
• Does the therapy practice use a separate records vendor or billing office?
• Where should the request be sent, and is there a facility-specific form?

Record the name of the person who answered, the date of the conversation, and any request or confirmation number. If the centralized department does not hold the therapy records, ask for the name and contact information of the correct records custodian.

What to Include in Your Written Request

A precise request can reduce delays and incomplete responses. Use the provider’s required form when available, but read it before signing. A request will usually need:

• Your full name and any prior name used during treatment.
• Your date of birth and other identifying information reasonably required by the provider.
• The physical therapy facility’s name and treatment location.
• The approximate first and last dates of treatment.
• A clear description of the records requested.
• Your preferred delivery format, such as secure electronic files.
• The name and address of the person or law firm authorized to receive the records.
• Your signature and the date of authorization.

North Carolina medical information is confidential and generally requires the patient’s authorization before it is released to a law firm or another designated recipient. The authorization should identify what may be disclosed, who may receive it, and when the authorization expires.

A law firm may prepare and transmit the request, but the provider will ordinarily require an authorization signed by the patient or an authorized legal representative. Avoid sending more personal information than the provider reasonably requires, and use the provider’s secure upload, portal, fax, or mailing process.

Request the Complete Therapy Chart, Not Only Visit Summaries

For an injury claim, a physical therapy chart may contain more than a list of appointments. A request should be specific enough to include the available records for the relevant treatment period, such as:

• The initial physical therapy evaluation.
• Daily treatment and progress notes.
• Documented symptoms, functional limits, and treatment goals.
• Measurements and recorded changes over time.
• Referrals, orders, or treatment plans in the therapy file.
• Attendance, cancellation, and discharge information.
• Home program documents maintained in the chart.
• Communications with referring providers that are part of the record.

Ask for an electronic copy when practical. North Carolina recognizes electronic medical records, and the legal responsibilities concerning access and confidentiality generally apply to electronic records just as they do to paper records.

Ask for Billing Records Separately

Medical records and billing records are often stored in different systems. Receiving treatment notes does not necessarily mean you received a complete account of the charges.

For claim documentation, make a separate request for:

• An itemized statement showing each date of service.
• Charges, payments, adjustments, and the current balance.
• Available claim or billing forms associated with the therapy services.
• Any written notice identifying a records vendor or separate billing company.

Compare the dates on the bill with the dates in the therapy notes. If a visit appears in one set but not the other, follow up with the records custodian. This comparison can reveal a missing note, an incomplete date range, or records held under a different facility name.

Can the Provider Charge for Copies?

A North Carolina healthcare provider may generally charge reasonable copying and handling fees within the limits established by N.C. Gen. Stat. § 90-411. Different rules may affect certain electronic patient-access requests or workers’ compensation matters, so the amount can depend on who made the request, its format, and the type of claim.

Before paying an unexpected invoice, confirm whether it covers records, bills, a narrative report, or another service. A provider-created narrative is different from a copy of the existing chart and may involve a separate charge.

What to Do If the Response Is Incomplete or Delayed

Keep a copy of the signed authorization, the request, proof of delivery, invoices, and every response. If records do not arrive, contact the records department and provide the request date and confirmation number.

If the response contains only hospital records and no therapy notes, do not assume the therapy file is empty. Ask the records department to confirm in writing whether:

1. The physical therapy location was included in the search.
2. The requested date range was entered correctly.
3. The therapy records are stored under another provider or facility name.
4. A separate request must be sent to the therapy practice or its vendor.

If treatment is ongoing, the first production may not include later visits. Consider requesting an updated set after additional treatment or discharge. Maintain a simple treatment list with each provider’s name, location, dates of service, and records-request status.

A records request does not automatically pause a lawsuit deadline. If an injury claim may be approaching a legal deadline, do not wait for the provider’s response before seeking legal guidance.

How This Applies When the Therapy Provider Is Affiliated With the Healthcare Facility

When a patient receives care at a healthcare facility and also sees an affiliated physical therapy provider, the centralized records department is a reasonable place to start. The law firm should confirm the arrangement rather than assume the department controls both charts.

The request should name the physical therapy facility separately, identify its location, provide the therapy date range, and expressly ask for physical therapy notes and billing records. If the centralized department says it does not maintain those materials, the next step is a separate request to the therapy provider or the records vendor identified by the healthcare system.

After receiving the response, compare it with appointment reminders, portal messages, discharge paperwork, receipts, and insurance explanations of benefits. Those documents can help identify treatment dates or provider names that are missing from the production.

When Wallace Pierce Law May Be Able to Help

Wallace Pierce Law may be able to identify the correct physical therapy records custodian, prepare an appropriately limited authorization, track the request, and follow up about missing treatment notes or bills. The firm can also organize records by provider and date so the available documentation can be evaluated in the context of a North Carolina personal injury claim.

This process may include comparing the physical therapy chart with other medical records, billing statements, appointment information, and claim correspondence. Whether particular records support a claim depends on their contents, the surrounding facts, and applicable North Carolina law.

Talk to a Personal Injury Attorney in Durham

If your question involves injuries, insurance, fault, medical documentation, settlement paperwork, or a possible deadline, speaking with a licensed North Carolina attorney can help clarify your options. Call 919-313-2737 to discuss what happened and what steps may make sense next.

Disclaimer: This article provides general information about North Carolina personal injury law based on the single question stated above. It is not legal advice and does not create an attorney-client relationship. It is not medical advice, tax advice, or insurance policy interpretation. Laws, procedures, and local practice can change and may vary by county. If there may be a deadline, act promptly and speak with a licensed North Carolina attorney.