Why These Records Matter
Medical records and itemized bills help show what care was provided, when it was provided, and what it cost. In an injury claim, they are often used to connect the incident to the treatment (timing and symptoms), document the course of care, and support damages like medical expenses and time missed from work.
What to Request
- Core documents: Treatment records for the relevant date range (visit notes, evaluations, diagnostic reports, therapy notes, discharge/after-visit summaries), and itemized billing (billing ledger and/or claim forms used for billing).
- Helpful add-ons: Imaging reports (and, if needed, imaging files), operative reports (if any), work status notes/restrictions (if any), and proof of payment or account statements showing balances/adjustments (when relevant to the claim).
How to Request Them (General Steps)
- Identify the holder: Confirm whether records and billing are handled by the provider’s medical records department, a separate billing office, or an outside records vendor. (It is common for records and billing to be handled by different contacts.)
- Authorization: Include a signed authorization that allows the provider to release the requested records to the law firm. Under North Carolina law, confidential medical information is generally released only with the patient’s authorization (or other lawful authority). See, generally, N.C. Gen. Stat. § 8-53.
- Follow-up: Keep a simple log of what you sent (date/time, email address used, what was attached, and any response). If the provider confirms receipt, ask for an estimated processing window and the preferred way to handle any invoice for copying costs.
What to Include in a Strong Records Request Email
- Patient identifiers: Patient full name, date of birth, and (if the provider requests it) medical record/account number.
- Purpose (high-level): State that the records are requested for an injury claim/legal evaluation. Keep it factual and brief.
- Date range: For example, “date of incident through present,” or another clearly defined range.
- Scope of records: “Complete treatment records” and/or a checklist of specific categories (notes, reports, therapy, imaging reports, etc.).
- Billing request: Ask separately for an itemized statement and/or billing ledger, not just a balance due.
- Delivery instructions: Where and how to send (secure email, portal, encrypted link, or mail). If the provider will only email, ask what security method they use.
- Copy fees and invoicing: Ask the provider to advise of any copying charges before processing (or to send an invoice). North Carolina allows providers to charge record copy fees up to certain maximums. See N.C. Gen. Stat. § 90-411.
- Signature/authority confirmation: Confirm that the authorization is signed by the patient (or legally authorized representative) and is current.
What the Authorization (HIPAA Release) Should Cover
Providers often reject authorizations that are missing required elements or are too vague. A practical authorization usually includes:
- Who the patient is: Name and date of birth (and other identifiers if required by the provider).
- Who may release records: The specific provider/facility (or “any and all treating providers” if the form is designed that way).
- Who may receive records: The law firm name and contact information (and sometimes a specific person or department).
- What can be released: A clear description (e.g., “complete medical records and itemized billing for the date range”). If the provider uses category checkboxes, check what you need.
- Date range: Start/end dates or “through present.”
- Purpose: A short purpose statement (e.g., “evaluation and pursuit of an injury claim”).
- Expiration: An expiration date or event (for example, “one year from signature” or “conclusion of the claim”).
- Patient signature and date: And, if signed by a representative, the representative’s authority (e.g., parent/guardian for a minor, personal representative for an estate, or other lawful authority).
What to Do If Records Are Delayed, Missing, or Incorrect
- Document the chain: Save the sent email, attachments, and any “received” confirmation. If you resend, label it clearly as a duplicate submission.
- Confirm scope: If you receive a partial chart, ask what categories were excluded (for example, billing, imaging, or therapy notes) and whether they come from a different department/vendor.
- Ask about corrections: If demographics or dates are wrong, ask the provider what their process is for requesting an amendment or correction to the record. (Outcomes and timing vary.)
- Consider counsel coordination: When multiple providers/vendors are involved, a coordinated request plan can reduce gaps and duplicative fees.
How This Applies
Apply to your facts: Because the provider asked for the request by email, the safest approach is to send (1) a short cover email identifying the client, date range, and exactly what you want (records and itemized bills), and (2) a signed authorization that clearly names the provider and your firm as the recipient. In the same email, ask the provider to confirm any copy charges and the secure method they will use to return the records.
What the Statutes Say (Optional)
- N.C. Gen. Stat. § 8-53 (patient medical confidentiality) – medical providers generally release confidential medical information with the patient’s authorization or other lawful authority.
- N.C. Gen. Stat. § 90-411 (record copy fees) – allows providers to charge record copy fees up to stated maximums in many situations.
Conclusion
To request medical records for an injury claim in North Carolina, send a clear written request plus a signed authorization that identifies the patient, the provider, the records/bills requested, the date range, and where the provider should send the documents. If the provider prefers email, confirm the secure return method and ask about any copy charges up front. One practical next step is to standardize your authorization and request template so providers receive the same complete package each time.
