Medico-Legal Guidelines Appendix E

Appendix E

Sample Letter Requesting Medical Records

Date

Health Care Provider or Facility Name and Address
Attn: Medical Records Custodian


RE: Names: "John Patient"
DOB:
SS#:

Dear Medical Records Custodian:

Please be advised that this law firm has been authorized to obtain the medical records of "John Patient". Enclosed is an authorization for the release of medical records. ¹

[Optional] If the case involves a personal injury liability claim, the letter must so indicate and should reference the statutory charges at the time:

These records are sought with regard to a personal injury liability claim. N.C. Gen. Stat § 90-411 (2005) sets the maximum charges permissible for medical records requested in personal injury liability claims as follows: "The maximum fee for each request shall be seventy-five (75) cents per page for the first 25 pages, fifty (50) cents per page for pages 26 through 100, and twenty-five (25) cents 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."

Please forward to the office of the undersigned counsel the following items:

1. A complete copy of all medical records, as defined in the 2005 Medico-Legal Guidelines², including laboratory reports, interpretations of all diagnostic images and studies, and all other information in your possession regarding "John Patient";


2. All billing information, including ledger cards, insurance claim forms, etc., whether stored on paper or in electronic format, as the same pertains to medical services rendered to "John Patient". (For additional information, see Appendix A-1); and


3. All correspondence, whether stored on paper or in electronic format, to and from any other person or entity concerning "John Patient".

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