Who Does the Patient’s Chart Legally Belong To?

In personal injury and mass tort cases, attorneys frequently need access to their client’s medical records to build strong legal claims. 

These records serve as vital evidence in demonstrating the nature, extent, and impact of injuries, which is essential in securing fair compensation. 

However, the legal landscape surrounding medical records ownership and access is complex and governed by federal and state laws. 

Understanding who legally owns a patient’s chart, how patients and attorneys can access these records, and the costs associated with doing so is crucial for attorneys in this field.

Legal Ownership of Medical Records

Information and Physical Record

Regarding medical records, there’s a distinction between the ownership of the information and the physical records themselves. The patient owns the information in the medical chart, such as diagnoses, treatment notes, and health history. 

This data, classified as Protected Health Information (PHI) under the Health Insurance Portability and Accountability Act (HIPAA), grants patients specific rights, including access and control over who can view their records.

However, while patients own the information, the physical or electronic medical record, whether stored as paper charts or in electronic health records (EHRs), is typically owned by the healthcare provider or the facility that created it. 

This could include hospitals, clinics, or individual physicians. Medical providers are considered custodians of these records and are responsible for maintaining, storing, and safeguarding them against unauthorized access.

Federal Laws and Regulations

HIPAA is the primary federal law governing the ownership and handling of medical records. It is mainly established to protect patient privacy while ensuring patients can access their medical records. 

It also grants patients the legal right to request access to their health information, including inspecting, copying, and sharing it with third parties, such as their attorneys.

Moreover, HIPAA also sets strict standards regarding the confidentiality and security of PHI, primarily when records are handled electronically. The law ensures that healthcare providers and electronic health record vendors maintain high-security standards to protect sensitive patient data from breaches or unauthorized disclosure.

While HIPAA lays the foundation for patient rights and data protection, other federal laws, such as the HITECH Act (Health Information Technology for Economic and Clinical Health Act), also play a role, particularly in promoting and regulating electronic health records. 

HITECH encourages the use of electronic health systems, aiming to make the sharing and accessing of medical records more efficient while maintaining robust privacy protections.

State Laws and Variations

Although federal laws like HIPAA govern the fundamental rights to access and control medical records, state laws can differ significantly regarding medical record ownership, patient rights, and the processes for obtaining these records. These state-specific variations can affect how attorneys handle record requests in personal injury and mass tort cases.

For instance, response times for record requests may be shorter in certain states. While HIPAA provides a maximum of 30 days for healthcare providers to comply with requests, some states require a response within a shorter period, such as 10 to 15 days. Attorneys should be aware of the mandated timeframe in their jurisdiction to avoid unnecessary delays and ensure compliance with federal and state regulations.

In some cases, state laws offer broader access to medical records than what is provided under HIPAA. For example, while HIPAA allows patients to access and request corrections to their records, certain states go a step further, offering additional protections that may include more detailed disclosures or rights to obtain mental health records, reproductive health information, or even substance abuse treatment records, which are often subject to stricter privacy protections under federal law.

States also vary in terms of the costs associated with obtaining medical records. Some states, like California, may cap healthcare providers’ fees for producing documents, ensuring that costs do not overburden patients and their legal representatives. 

Others, like Texas, impose specific limits on the per-page fees providers can charge for copying records while allowing reasonable labor costs for compiling and delivering records.

In certain circumstances, states may allow patients to request their medical records free of charge. For example, in New York, patients can receive copies of their records at no cost if they apply for government benefits like Medicaid or Social Security Disability Insurance (SSDI). 

In other states, such as Minnesota, providers must offer free copies of records if they are being used to support a patient’s claim for veterans’ benefits. Attorneys should research state-specific exceptions that could reduce or eliminate client costs.

Additionally, some states mandate specific procedures for requesting medical records. In Illinois, for example, requests for medical records must be in writing and sent via certified mail. At the same time, states like Florida may require notarized authorization forms, mainly when sensitive health information is involved. Follow these state-specific procedures to avoid delays or even denial of access to medical records.

For attorneys handling personal injury and mass tort cases, knowing the state-specific regulations governing medical records is critical to ensuring they can efficiently obtain the necessary documentation. 

Understanding these nuances helps attorneys advocate more effectively for their clients, as they can avoid common pitfalls related to timelines, costs, and procedural requirements. Attorneys well-versed in state laws can also leverage their knowledge to expedite retrieval, negotiate with healthcare providers, and reduce their clients’ financial burden. 

By familiarizing themselves with federal and state regulations, attorneys can ensure they are fully prepared to navigate the legal and procedural challenges of obtaining medical records for litigation. This knowledge is precious when dealing with interstate or multi-state cases, where varying laws might apply depending on where the medical treatment was provided.

Patient Rights Regarding Medical Charts

Right to Access

Under HIPAA, patients have the legal right to access their medical records, whether in physical paper documents or electronic health records (EHRs). 

This right applies to all healthcare providers, including hospitals, clinics, private practices, and third-party record keepers. Patients can request copies of their medical charts or ask to view the records in person, and healthcare providers must comply with this request within 30 days. 

However, some states have more stringent laws that mandate shorter response times, typically between 10 and 15 days, depending on the jurisdiction.

Patients also have the option to request their records in various formats, including paper or electronic, and providers are required to honor the patient’s preferred format if it is readily producible. 

In cases where the requested format isn’t available, the provider must work with the patient to agree on an alternative format. This flexibility ensures patients have the most convenient and accessible way to review their health information.

However, specific circumstances require access to medical records to be restricted. 

One such scenario is during public health emergencies when releasing certain information could threaten the patient or the general population. For example, infectious disease outbreaks or bioterrorism situations might prompt healthcare providers to limit access to protect broader public health concerns. 

Additionally, in cases of mental health or substance abuse treatment, records may be withheld if there is a concern that accessing the information could lead to harm to the patient or others. This can include withholding portions of documents related to psychiatric diagnoses, confidential communications with mental health professionals, or sensitive treatments that could trigger negative responses.

In personal injury cases, attorneys typically need full access to their clients’ medical charts to accurately assess injuries, treatments, and potential long-term effects on the client’s health and well-being. These records are vital for building a solid case and calculating damages, including medical costs, pain and suffering, and lost wages. 

Attorneys should advise clients to submit formal written requests for their medical records as early as possible. This ensures that delays in obtaining records don’t hinder the case’s progress. 

When making a request, it is essential to specify precisely what information is needed, especially if only a portion of the medical records is required. 

For example, in cases where the injury relates to a specific incident or body part, requesting only the relevant medical records may be advantageous, avoiding unnecessary time and costs associated with retrieving the entire patient history.

In situations where patients cannot submit the request themselves, such as incapacitated or under guardianship, authorized representatives, including personal injury attorneys with proper authorization, can submit the request on their behalf. This ensures that records can still be obtained even when the patient cannot manage the process directly.

Patients also have the right to appeal a denial of access. If a healthcare provider refuses to release certain records, the patient (or their attorney) can challenge this decision by requesting a review of the denial. The healthcare provider must have a licensed healthcare professional who wasn’t involved in the initial denial review of the case. In many instances, the decision to withhold records may be reversed.

Right to Amend

Patients are also granted the right to amend their medical records if they believe the information needs to be more accurate or complete. This is particularly important in personal injury cases, where incorrect or incomplete medical information can impact the success of a claim.

To amend a record, the patient typically submits a written request to the healthcare provider detailing the information they wish to change and providing any supporting documentation. The provider must respond to this request, although they may deny the amendment if they believe the current information is accurate. 

If denied, patients can still request that their statement of disagreement be included in their record, ensuring that their position is documented.

Right to Request Disclosure

Patients can request that their medical records be disclosed to third parties, including personal injury attorneys. 

This is done through a written authorization form, which is crucial to ensuring legal compliance with HIPAA. These forms typically specify the records to be disclosed and can either be broad, granting access to all medical information, or limited to specific treatments or periods.

Healthcare providers must release the requested records as long as the authorization form is valid and completed correctly. Attorneys should ensure clients submit the proper forms promptly to avoid unnecessary delays.

Obtaining Medical Charts for Personal Injury Cases

Obtain Client’s Written Authorization

Before personal injury attorneys can access a client’s medical records, they must obtain written authorization. This authorization is a legal requirement under HIPAA and is crucial to protecting patient privacy while allowing attorneys to gather necessary evidence.

Different types of authorization forms exist, depending on the scope of access required. For instance, a general authorization form allows the attorney broad access to the client’s medical history. 

On the other hand, a limited authorization form restricts access to specific medical information, such as records related to the injury in question. Attorneys should work closely with their clients to ensure the correct form is used and the documents are obtained promptly.

Communication with Healthcare Providers

Effective communication with healthcare providers is critical when requesting medical records for personal injury cases. Attorneys should be specific about the types of records they need, as this helps healthcare providers quickly identify and prepare the necessary documents.

Potential challenges, such as delays in obtaining records or high fees for record retrieval, can be mitigated by maintaining open lines of communication and fostering positive relationships with healthcare providers. 

In some cases, attorneys may negotiate fees or request waivers to reduce their clients’ financial burden.

Use of Medical Records in Personal Injury Cases

Medical records play a critical role in personal injury litigation. These records provide a detailed history of the client’s injuries, treatments, and prognosis, which is essential for establishing liability and calculating damages.

Medical records are often used to demonstrate the following:

• The extent of the injury and its impact on the client’s quality of life.
• The cost of medical treatment, including past and future medical expenses.
• The client’s lost wages and future earning capacity due to the injury.

Having comprehensive and accurate medical records strengthens an attorney’s ability to advocate for fair compensation on behalf of their client.

Costs Associated with Obtaining Medical Records

Postage Costs

When patients or their attorneys request copies of medical records, postage costs can be a factor, mainly when dealing with physical records. Healthcare providers may charge for the costs associated with shipping paper charts to attorneys or other third parties. 

However, some states limit the amount healthcare providers can charge for these services. Postage costs may be waived in certain circumstances, such as when the records are requested for legal proceedings or patient care.

Allowable Costs

Under HIPAA, healthcare providers can charge patients or their attorneys reasonable, cost-based fees for providing copies of medical records. These fees may include the cost of labor for copying the records, supplies, postage, and preparing the documents for delivery.

Importantly, HIPAA requires that these fees be limited to the cost of producing the records. Providers cannot charge excessive fees or profit from the record retrieval process. Attorneys should be familiar with federal and state regulations regarding allowable costs to ensure clients are not overcharged when requesting records.

Actual Costs

EHRs can differ in their cost structure. Electronic records are often more affordable to retrieve because they do not require the same labor and supplies as paper records. However, healthcare providers can still charge for the time spent compiling and transmitting the electronic data.

Attorneys should advise their clients about the potential costs of obtaining their medical records and explore options for minimizing these expenses, such as requesting electronic versions whenever possible.

Key Takeaways

Here are some of the key points discussed in this article.

• Patient Ownership of Information

While patients own the information in their medical records, healthcare providers or facilities typically own the physical or electronic documents. The patient’s rights to access and control this information are protected under HIPAA.

• Federal and State Laws

HIPAA establishes the legal framework for patient access to medical records at the federal level. Still, state laws may offer additional rights or impose specific medical record ownership, access, and fee regulations.

• Right to Access and Amend

Patients can request access to their medical charts, including the ability to amend incorrect or incomplete information. However, access may be limited in some scenarios, such as during public health emergencies.

• Authorization and Legal Compliance

Attorneys must obtain written authorization from their clients to access medical records. This process is critical for maintaining legal compliance under HIPAA and protecting patient privacy.

• Medical Records in Personal Injury Cases

Medical records are invaluable evidence in personal injury and mass tort cases. They help establish the nature and extent of injuries, medical expenses, and lost wages. Attorneys should ensure timely and accurate access to these records.

• Costs and Fees

Fees for obtaining medical records must be reasonable and based on actual costs. Attorneys should be aware of allowable fees under federal and state laws and explore cost-saving options such as requesting electronic copies when possible.

Conclusion

For personal injury and mass tort attorneys, understanding the legal ownership and access rights surrounding patient medical records is crucial for building strong cases. 

By navigating the complexities of federal and state laws, attorneys can ensure they secure the medical records necessary to demonstrate the full extent of their client’s injuries and damages. This information is pivotal in achieving successful outcomes and fair compensation for clients.

Attorneys must be well-versed in obtaining medical charts, understand the legal implications of patient rights, and minimize costs to advocate efficiently and effectively for their clients in personal injury cases.

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