Hospital Medical Records

Starting The Process of Investigating a Crime

This article is designed to be for a target audience. If you are missing a loved one who died in the hospital, particularly in the last 3 years you NEED to get the medical records that are associated with your loved one. If you were in the hospital and were injured or felt threatened while you were there, you seriously should be getting your records.

In terms of Covid, many people who survived their hospital stay have said they felt a pervasive sense of evil. We know from the family members of the victims that the medical records show blatant disregard for humanity. Why this is the overall impression or even a fact is not clear. Is it possible that knowing that no one in a medical setting, acting as a health professional, was liable for any misfeasance or malfeasance due to the enacting of the PREP Act? Do these professionals succumb to their own biases as it relates to viewing Covid patients as contagious or showing disdain and anger for their vaccination status? Regardless as to the why, there are almost 1000 stories on the COVID-19 Humanity Betrayal Memory Project | Documenting crimes against humanity (chbmp.org) database, while not all are visible to the public, they are there and they reflect the blatant negligence and/or brutality these patients suffer.

Due to the anxiety of their stay or the loss of their loved one many have been unable to face the retrieval of the medical records. You can do this by mail, you do not necessarily have to go to the hospital. They may attempt to force you but if you provide them with all of your documentation you shouldn't have to. Your request may be met with stonewalling, that is normal, because one of the first things that happened was the Centers for Medicare and Medicaid Services (CMS) issued multiple waivers to hospitals, one waiver allowed them nearly unlimited leeway to slow walk records retrieval. Do NOT let that dissuade you. If you are next of kin you should have the right (state laws may differ) to have a full disclosure.

In this example the attorney is advising based on the laws in Arkansas, but he stresses each state is different.

On August 4, 2023 this news article was released related to a recent cyber-attack on a hospital system. It doesn't indicate that any patient records were damaged or stolen, but will the next “cyber-attack” be on your hospital? It doesn't matter if it's a real cyber-attack or a manufactured explanation, this would be very concerning.

https://www.cbsnews.com/news/prospect-medical-cyberattack-california-pennsylvania-hospital/

You MUST treat your case as if it's a criminal investigation. Everything should be documented. Writing letters and using the postal system is tedious, but it is trackable. All responses will be in writing, with signatures, on letter head. If you do end up in court these documents are invaluable. Save everything and file it somewhere safe. Never send your only copy to your attorney or record reviewer, you have to fight for these documents, make sure you always have your own copies.

Adapt these instructions to suit your case, but I will assume that you are looking for the records of a loved one who has passed.

First decide what type of records you want. Paper copies are bulky and generally arrive stacked neatly but the pages sometimes aren't numbered and it appears that someone just randomly stacked them in 2 and 3 page groupings with no rhyme or reason.

Digital copies will be necessary for sharing with attorneys and reviewers. My personal opinion is jump drives, thumb drives or flash drives, depending on what they call them are preferable. If any space is left after they load the records on it you can still put more documentation on the drive. Billing, copies of letters, etc. Some will offer CD's, which is fine if you have a CD reader. I had to get an external drive to read it, then I downloaded it to my computer and saved copies on flash drives for both my sons in case my house burned down or got blown away in a tornado. The salespeople at Best Buy or similar stores can help you get an external reader that works with your computer, usually for around $50.00 or less.

In my case the paper records were just over 3500 pages and they cost under $35.00, same hospital for the CD was around $8.00 after mailing. The other hospital ignored my request for digital, shipped paper, 567 pages, invoiced me for $12.31.

Go to your hospital's website, usually under “Patients” you will find a sub heading of “Patient Records”. They will usually instruct you there. I have had to request records for 2 patients, one hospital had a form to submit, the other just had a basic paragraph explaining that requests go to a certain office. You should really write a letter to accompany the form. Just like any business letter, it will have your name and address, their name and address and the date. Supply the name of your loved one, their birth and death dates and the last 4 numbers of their social security number as well as their address at the time of their hospital stay. State your relationship to the patient. You will be asking for ALL records, there is a template at the end of this article that you can copy and paste into your letter specifically stating what “All” means. Attach a copy of the death certificate, don't count on them knowing or caring that the patient is deceased and isn't asking for themselves. Prove who you are and your relationship, a copy of your birth certificate if you are a child of the patient, your marriage certificate if you are their spouse, copies of driver’s licenses, if you shared an address help, they also provide proof of your identity. For example, in my case I sent copies of my license and my husband's license, his death certificate and our marriage license stating I was his spouse. For my father's records, copies of my driver's license, my birth certificate, my marriage certificate and his death certificate stating I was his only daughter. These were sent to different hospitals in different states. Both hospitals complied. In both instances I included my phone number and asked to be called so I could pay for the records, one hospital called me the other one simply mailed them with an invoice.

If the hospital chooses to slow walk the records, write another letter referencing the first letter, allow about 3 weeks in the event they just randomly mail something to you like they did with me. Always keep a copy of everything. Remember you are documenting a crime scene, your records have to be perfect if you go to court. If you receive a phone call refusing to send the records, ask them professionally to respond in writing. Always make sure you have their full name, including having them spell it. Always ask for their supervisor's name as well as the spelling. If they ask why you can always say that you need to have all contact information in the event your attorney needs to be involved. Make sure you document the date of any verbal conversations including the time of day. The goal is to make them send you a letter with the reason spelled out why they are refusing to cooperate. If you have to go to court you need to be prepared with documentation. Phone conversations become he said, she said.

If you don't have any cooperation from the Records Office you can appeal to the HIPAA Compliance Officer. HIPAA stands for Health Insurance Portability and Accountability Act. There have been reports that this office will light a fire under the Records Department. In many hospitals this office is in the hospital, if your hospital doesn't have one it may be necessary to appeal to a state or county officer, which might be located through your local health department. Simply searching under “HIPAA with your town and state” may bring up the information you need.

You may be told that you have to open an estate in your county/town in order to retrieve the records, again you want that in writing with an explanation of why, is it hospital policy or is it state law? You can always take the response to the local Court Clerk and ask them what you need to do about opening an estate, just to get your loved one's medical records. Sometimes these folks don't want to do paperwork for no reason either and they can be a wealth of information. But start with the HIPAA office before the Clerk's office.

If you have not asked for or received your detailed billing statement, you need it to compare against the records, it will help you locate any anomalies. If you haven't gotten it, sometimes a simple phone call to the Billing Department will get you what you need. I was lucky, they sent me a link, I created a log in and password and boom, downloaded. Many people are having massive headaches, the military appears to be the worst and you might never see the detailed billing from them. Some are finding out that the billing records for their loved one are nonexistent. As if the patient was never there. Despite thousands of pages of records. I am a firm believer in writing a request if the phone call doesn't work. Business like, list all the information, patients name, date of birth/death if it pertains, SS#, full address at the time of service, any account numbers from the initial bill and/or identifying patient numbers from the medical records. If insurance was involved you can reference what type & identifying number. Overwhelm them with documentation. If you were the one receiving the original statement you should have every right to the detailed version. Some families have not received bills, but pursuing some kind of details is valuable, if the billing reflects unknown medications or treatments you will be comparing it to the records.

Medicare, Medicaid or private insurance statements may or may not help. In this case it could be garbage in, garbage out. Because the billing to these organizations is all in code and is sometimes bundled their statements don't usually give you the details on how many injections or pills per day of a given medication. You can decide if you feel their paperwork is important.

Again, I want to stress how important it is to only send copies to attorneys, reviewers or other interested parties. If they get lost in the mail, the attorney turns out to be a jerk or whatever, you don't want to go through all of this again. In 2002 our town was hit by an F-4 tornado, it went right past the courthouse & through the center of town where all the attorney’s offices were, everything disappeared, the only thing left of the bank was the vault. Keep copies everywhere.

Below is the detailed request list you should start with, it is fairly comprehensive but if you have someone you consult with who suggests more items, more is always better. Before posting this list, I added “Pharmacy records incl. lot numbers”. Due to a recall of 2 lots of remdesivir during the late fall of 2021 there are a lot of families wondering if their loved one received either of the lots. Some hospital systems include lot numbers in their records, some don't. This is an attempt to help you get them without having to submit separate requests. You can copy and paste this list into your request letter.

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Courtesy of C19 Widows/Widowers that want Justice

I am requesting all medical records pertaining to_____________________, including, but not limited to the following:

-all ED room records, including all testing

-admission history & physical

-daily progress notes

-all consultation notes, all physicians’ notes, all nurses’ notes, respiratory therapist notes

-nursing notes including reactions to medications administered and treatments performed

-ancillary notes

- therapist notes

-specialist notes (cardiology, neurology, social workers, patient relations, clergy, palliative care, etc.)

-diagnosis 

-medications ordered

-medications given- including dosage amount, frequency, duration & ordering physicians’ name.

-all imaging reports (reports and interpretations and images on flash drive)

-X-ray imaging of lungs

-CT scans and MRI imaging & reports

-all care/treatment plans

-any surgical notes

-any transfer orders

-all testing results

-dietary/nutrition notes (from the dietician)

-labs/lab results

-specific blood and sputum cultures

-ABGs

-all recorded vital signs

-all scans

-radiology scans & reports

-MAR or eMAR-medication administration -drug chart

-Pharmacy records incl. lot numbers

-any signed consent forms

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Although it's not related to obtaining medical records if you or your loved one received Gilead's Veklury (remdesivir) after 10/25/21 you should be asking for these lot numbers. The recall was announced 12/3/21 and can be found here: https://www.gilead.com/news-and-press/company-statements/gilead-issues-a-voluntary-nationwide-recall-of-two-lots-of-veklury .

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In 2016 Congress passed the 21^st Century Cures Act, which a Philadelphia lawyer couldn't read but it has one short passage that stands out. On page 1182, there is a guarantee of accessibility to patient records by the patient or their designees. Based on that there is a letter called the Cures Letter that informs the doctor or hospital of your right to your records without “information blocking”. This link will give you the entire bill, then you can go to the section you see here if you need to print out the page as proof to the office you are dealing with. As long as you can be described as the patient's designee.

https://www.congress.gov/114/plaws/publ255/PLAW-114publ255.pdf page 1182

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Courtesy of the C19 Widows/Widowers that want Justice

Add your information as needed:

PERSONAL REPRESENTATIVE REQUEST

FOR ELECTRONIC HEALTH INFORMATION

Pursuant to the 21^st Century CURES ACT U.S. PUBLIC LAW 114 -255 12/31/2016

AND 45 CFR 171.302

TO:

DATES OF SERVICE:

RE:

DOB:

I am requesting electronic records of the above-mentioned patient’s treatment and care and all their electronic health data, including billing, lab reports, MyChart notes, radiographic studies, ALL imagery (MRI, X-ray, CT scans, etc.) and reports, for the dates referenced above. All imaging studies shall be provided in original resolution electronic files.

This information is to be sent to me:

ADDRESS:

VIA E-MAIL:

NATURE OF INFORMATION TO BE DISCLOSED

The patient’s personal representative is authorized to obtain any and all records they request, including, but not limited to, health care information or opinions, to view or receive any x-rays, hospital records, physician’s records, or any other health or pertinent information whatsoever.

PSYCHIATRIC AND OTHER SENSITIVE RECORDS

If the patient’s records contain sensitive and private information including, but not limited to the diagnosis or treatment of mental illness, drug and/or alcohol abuse, or contain information regarding the diagnosis or treatment of HIV (AIDS Virus) or other sexually transmitted diseases, I give my specific authorization for these records to be released to:

ADDRESS:

VIA E-MAIL:

PATIENT RATE APPLIES

This is a request under the 21^st Century Cures Act for my Electronic Health Information, and as such, the Patient rate which you charge applies, and not any other rate. If there is a charge for you processing this request, please contact me:

PHONE NUMBER:

VIA E-MAIL:

with the proposed cost. YOU ARE NOTIFIED that the CURES ACT prohibits “information blocking” or treating your patient records as a commodity.

ELECTRONIC COPY IN LIEU OF ORIGINAL

An ELECTRONIC copy of this authorization shall have the same force and effect as the signed original.

REVOCATION OF OTHER RELEASES

I hereby revoke any other authorization for release of health care information, which may have been provided to you by any insurance company or other entity or person. I understand that once the above-named facility discloses health information, the person or organization that receives it may re-disclose it, at which time it may no longer be protected under Privacy laws.

I may revoke this authorization in writing at any time except to the extent that information has already been released. I may refuse to sign this authorization and my refusal to sign will not affect treatment, payment, enrollment, or eligibility for benefits.

EXPIRATION DATE

This authorization expires one year after the date signed.

DATED: ________________ SIGNED: ________________________________________
Personal Representative of Estate

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After all of your hard work, you might still need to open a small estate or hire an attorney. But with all of your hard work and meticulous record keeping it will save him time and therefore save you a little money.

If you would like to donate to the Former Feds Group Freedom Foundation's efforts to support and advocate for the victims of the Covid Hospital Homicides it is a 501(c)(3) and your donation would be greatly appreciated in our outreach efforts. https://formerfedsgroup.org/donate/