Medical Record Copy Policy

EFFECTIVE OCTOBER 1, 2011

Our office will charge a flat $25.00 for all Requests for Medical Record Transfers and/or Copies.

According to the Texas Medical Board:
"The physician shall be entitled to payment of a reasonable fee prior to release of the information unless the information is requested by a licensed Texas health care provider or physician, if requested for purposes of emergency or acute medical care. In the event payment is not included with the request, within ten calendar days from receiving a request for the release of records for reasons other than emergency or acute medical care, the physician shall notify the requesting party in writing of the need for payment and may withhold the information until payment of a reasonable fee is received."  From Texas Medical Board Website, Copied October 1, 2011
  1. Request MUST be made in writing.
  2. Request should include name of child(ren) along with date(s) of birth.
  3. Request should indicate that you are the Mother/Father -or- Legal Custodial Guardian of the named minor(s)
  4. Request should include address for where to send medical records.  OUR OFFICE DOES NOT FAX OR EMAIL MEDICAL RECORDS.
Note for Legal Custodial Guardians - Our office must have on file a copy of legal documents stating that you are in fact the Guardian of the minor.  If you have previously provided these documents to our office then we can comply with the request.  If we do not have copies of the documents on file, then the request is not a valid request and we will not respond to the request other than a letter stating that we can not comply with the request pending receipt of the necessary documents.
 
Special Notes for Shot Record Only Request
  1. Same as above but include a FAX NUMBER as we will FAX a single page SHOT RECORD.
  2. There is no charge for sending just a shot record.
Sample Written Request for Release of Medical Records
Your Name
Your Address
Your City, State Zipcode
Contact  Phone Number        <---- In case we have problems and need to contact you.

Date

To: Teri Perryman, M.D. Prof. Assoc. -or- {other physician office}

I {state your name} am requesting as the mother/father of the below named child(ren) a copy of my child(ren)'s medical record(s) to be sent to {name of where we are sending records [Teri Perryman, MD, PA], [Self], [Other Physician Office]} for the purpose of _________________________ {i.e.transfer of medical care, continued medical care, moved out of area, personal copy}.

My child(ren)'s names and dates of birth that I am requesting these copies for are:

Childs Name #1, Month/Day/Year
Childs Name #2, Month/Day/Year
etc.
 
{Include either of the following:}
{Please call me at (xxx) xxx-xxxx and I will come by to pick up the medical records when they are ready.}
- or -
{Please mail the medical records to:
Name (i.e. Your Name, Teri Perryman, MD, other physician office)
Address
City, State, Zipcode}

I am enclosing a total of $xx.xx which represents your office charge of $25.00 per medical record copy/transfer.

Sincerely,

Signature

Please note that this sample letter can be used for requesting records from our office or any other physician office.  Simply fill in the approprate information as indicated.  Instead of using "To: Teri Perryman, M.D., Prof. Assoc." you could simply insert another physicians office name.  In the area for providing information on where to send records you can simply fill in your personal information, for a personal copy of records, our office information or the name of another physician office where the records need to go. 

The above is just a sample of wording and some offices may ask that you use a "form" from their office or another physicians office.  Under Texas State law and Texas Medical Board rules there is not a requirement for the use of any "form", only that any request for release of medical records must be made in writing.  Under Federal HIPAA Privacy Act, there is a requirement, for any "form" used by an office to request medical records or disclosure of protect health information to provide notification to the person filling out the form certain "standard" HIPAA required elements. Such elements are related to use of the disclosed information, length of time the request is good for, how to terminate the request, further disclosures and scope of previously provided authorizations.  If you are not using a "form" provided by an office then the HIPAA notifications are not required.

We are not attorneys or HIPAA compliance officials.  This is the understanding our office has of this issue.  The laws, rules, regulations and any and all other requirements for release of medical records can change at any time, with or without notice.  Our office will always strive to remain current in our internal use and disclosure of protected health informaton and medical records, but our website may or may not have been updated.