Why These Records Matter
Medical records help show what care was provided, when symptoms were reported, and how the provider connected the complaints to the incident. Billing statements help show the charges and, in many cases, what amounts were actually paid or still owed. In an injury claim, missing records or incomplete billing can slow down evaluation and negotiations because the documentation is the backbone of both “injury” and “damages.”
What to Request
- Core documents: Complete treatment records for the relevant date range (office notes, intake forms, diagnoses, orders, test results, and discharge/visit summaries).
- Billing documents: An itemized statement of charges, billing ledger/account history, and any standard billing forms used for insurance billing (if available).
- Helpful add-ons: Proof of payment/receipts (if any), and any explanations showing adjustments or write-offs (often important when a health plan was involved).
How to Request Them (General Steps)
- Identify the holder: Confirm whether the records are kept by the provider’s office, a hospital system, or a third-party records vendor. Billing may be handled by a separate billing company.
- Authorization: Use a signed authorization that is complete and current (many providers reject authorizations they consider “stale”). Make sure it clearly lists (a) what is requested (records and itemized billing), (b) the date range, and (c) where to send the documents.
- Follow-up: If the provider asked for email, send the request to that email address and keep proof of delivery (sent email, read receipt if available, and a PDF copy of what was sent). If there is no response, follow up in writing and by phone, and keep a log of dates, names/titles, and what was said.
What to Do If Records Are Delayed, Missing, or Incorrect
- Send a “clean” second request: Re-send the authorization and request as a single, easy-to-process packet. In practice, delays often happen because the office cannot match the request to the patient, the date range is unclear, or the request went to the wrong department.
- Escalate within the office: Ask for the records custodian, office manager, or the person responsible for medical records requests. Confirm whether a fee quote is required before release. North Carolina law allows providers to charge copying fees up to limits set by statute.
- Be specific about billing: “Billing statements” can mean different things. If you need an itemized list of charges (not just a balance due), say so. For hospitals and ambulatory surgical facilities, North Carolina law addresses a patient’s right to request an itemized list of charges.
- Document everything: Keep a simple timeline showing (1) the date you sent the request, (2) the method (email/fax/mail/portal), (3) who you spoke with, and (4) what the office asked you to do next. This record helps if you later need to show the court you made reasonable efforts.
- Consider formal process after suit is filed: If the claim moves into litigation, subpoenas are commonly used to obtain records when a provider will not voluntarily produce them. This is often the most direct way to require production, but it typically comes after filing suit and following court rules.
How This Applies
Apply to your facts: Because the provider told the firm to submit the request by email, the first step is to confirm the email address is correct and that the email included a complete authorization and a clear request for both records and an itemized billing statement. If there is no response, the firm can send a second written follow-up (again by email, and optionally by another method) with a clear deadline and a request to confirm receipt. If the office still does not respond, escalation to the records custodian/office manager is often the next practical step, and a subpoena may be considered if litigation is filed.
What the Statutes Say (Optional)
- N.C. Gen. Stat. § 90-411 (Medical record copy fee limits) – Allows providers to charge copying fees up to statutory maximums for producing medical records.
- N.C. Gen. Stat. § 131E-91 (Itemized hospital charges on request) – Requires hospitals and ambulatory surgical facilities to provide an itemized list of charges upon a patient’s request.
Conclusion
If a medical office does not respond, the most effective approach is usually procedural: confirm the request went to the right department/vendor, re-send a complete authorization and a clear list of what you need, and document each follow-up. If the office still does not produce the records and billing, escalation inside the practice may help, and a subpoena may be the next step once a lawsuit is filed. Preserve your paper trail and address delays early.
