I need some legal advise. Can anyone help me?

[Wise Doubter]

I have a situation that I need some help with. I would like to obtain some medical records from a psychologist office.

On Sept 30 2005, my 25 year old step-son committed suicide. He did have a learning disability but he did not show ANY tendencies. He didn`t lose a job, break up a relationship, or anything of that nature. Totally out of the blue.

He was seeing a psychologist during this time. He had seen him - G. Grubbs, the day prior to his suicide. His grandmother picked him up from his appointment and said he seemed in good spirits- joking, laughing etc.

His Mother would like to see the doctors notes from the office visits so she can try to make some sense of this, and come to some sort of closure.

He did not have any estate to speak of.

We called the Dr and asked to access the records. He said that we would need to write a letter. We did.

Now he is saying that, because he is/was an adult, his mother doesn`t have the right to access his records.

Is this so ?? How can we legally go about obtaining her deceased son`s medical records?

Thank you in advance for any suggestions


on edit: the autopsy did not show any signs of drugs or alcohol.

[sonias]

1. My condolences on the loss of your step son

I don't know anyone off the top of my head, but I'll ask around and get back to you on this thread. I would think that logically you have the right to your next of kin's records, especially your son, no matter how old he was.

Good luck with the search.

Sonia

[Wise Doubter]

8. Thank you

[MagickMuffin]

2. I believe it is the law (HIPAA) for family to access his records

anyway I know that when my father in law was in the hospital, we were allowed to access his records, we signed forms and everything. I don't know if your case would be considered different.

I too am sorry for your loss, I know this must be a difficult time for you and your family. My thoughts are with you and your family.

Here's some info on HIPAA. I don't understand it all, and wish you the best of luck in the task of getting closure by requesting your loved ones records.

HIPAA: 165.1.Medical Records.
(a) Contents of Medical Record. Each licensed physician of the board shall maintain an adequate medical record for each patient that is complete, contemporaneous and legible. For purposes of this section, an "adequate medical record" should meet the following standards:

(1) The documentation of each patient encounter should include:

(A) reason for the encounter and relevant history, physical examination findings and prior diagnostic test results;

(B) an assessment, clinical impression, or diagnosis;

(C) plan for care (including discharge plan if appropriate); and

(D) the date and legible identity of the observer.

(2) Past and present diagnoses should be accessible to the treating and/or consulting physician.

(3) The rationale for and results of diagnostic and other ancillary services should be included in the medical record.

(4) The patient's progress, including response to treatment, change in diagnosis, and patient's non-compliance should be documented.

(5) Relevant risk factors should be identified.

(6) The written plan for care should include when appropriate:

(A) treatments and medications (prescriptions and samples) specifying amount, frequency, number of refills, and dosage;

(B) any referrals and consultations;

(C) patient/family education; and,

(D) specific instructions for follow up.

(7) Billing codes, including CPT and ICD-9-CM codes, reported on health insurance claim forms or billing statements should be supported by the documentation in the medical record.

(8) Any amendment, supplementation, change, or correction in a medical record not made contemporaneously with the act or observation shall be noted by indicating the time and date of the amendment, supplementation, change, or correction, and clearly indicating that there has been an amendment, supplementation, change, or correction.

(9) Records received from another physician or health care provider involved in the care or treatment of the patient shall be maintained as part of the patient's medical records.

(10) The board acknowledges that the nature and amount of physician work and documentation varies by type of services, place of service and the patient's status. Paragraphs (1)-(10) of this subsection may be modified to account for these variable circumstances in providing medical care.

(b) Maintenance of Medical Records.

(1) A licensed physician shall maintain adequate medical records of a patient for a minimum of seven years from the anniversary date of the date of last treatment by the physician.

(2) If a patient was younger than 18 years of age when last treated by the physician, the medical records of the patient shall be maintained by the physician until the patient reaches age 21 or for seven years from the date of last treatment, whichever is longer.

(3) A physician may destroy medical records that relate to any civil, criminal or administrative proceeding only if the physician knows the proceeding has been finally resolved.

(4) Physicians shall retain medical records for such longer length of time than that imposed herein when mandated by other federal or state statute or regulation.

(5) Physicians may transfer ownership of records to another licensed physician or group of physicians only if the physician provides notice consistent with §165.5 of this chapter and the physician who assumes ownership of the records maintains the records consistent with this chapter.

(6) Medical records may be owned by a physician's employer, to include group practices, professional associations, and non-profit health organizations, provided records are maintained by these entities consistent with this chapter.

http://www.drjohnbaker.com/texasmedicalrecords.htm

http://www.dshs.state.tx.us/hipaa/default.shtm

http://www.oag.state.tx.us/notice/hipaa.pdf

[Wise Doubter]

7. Thank you

[Horse with no Name]

3. I don't believe you can legally obtain these records

Since your son was a legal adult.
However, one thing you can do is hire an attorney to subpoena the records as legal next of kin. Sometimes just a letter will do it.
However--psychiatrists keep very cryptic brief notes to protect their client's confidentiality in situations such as this. You won't find much there.
One thing that I will tell you.
If he seemed to come out of his depression and was in good spirits, it is probably because he had made up his mind to commit suicide and found peace with that within himself. I doubt seriously that the medical record will reflect anything different.
Very rarely depressed people kill themselves. They can't generally motivate themselves to do so. When they are coming out of the depression is when you have to worry most.
I am very sorry for you and your wife's loss and will keep you in my thoughts for healing from this tragedy. I can't imagine what it is like to lose a child.

[Wise Doubter]

6. Thank you

[Czolgosz]

4. I'm sorry for your loss. The representative of your step-son's estate

can obtain the records. Who is representative of the estate?

[Wise Doubter]

5. I beleieve She is. But, there is some lack of info. I am going to

investigate this. I believe the mortician asked this question , as to whom would be the ROE.

Thanks

[Czolgosz]

10. I can't make any promises, but this might help:

H.I.P.A.A. COMPLIANT HOSPITAL AUTHORIZATION FOR USE & DISCLOSURE OF
INDIVIDUALLY IDENTIFIABLE AND PROTECTED HEALTH INFORMATION (“HEALTH INFORMATION”)


1. PATIENT IDENTIFICATION

PRINTED NAME: ___________________________________________________________________________________

ADDRESS: __________________________________________________________________________________________

DATE OF BIRTH: ____________________________________________________________________________________

2. PERSONS/ORGANIZATIONS AUTHORIZED TO DISCLOSE HEALTH INFORMATION:

LIST PROVIDER NAME – _____________________________________

3. HEALTH INFORMATION TO BE DISCLOSED

FROM: ___ (BEGINNING DATE) TO: _____ (ENDING DATE)

HOSPITAL MEDICAL RECORDS:
_____ Complete Inpatient and Outpatient Health Record
_____ Emergency Room Record
_____ History & Physical Exam
_____ Discharge Summary
_____ Consultation Reports
_____ Progress Notes
_____ Laboratory Test Results
_____ Radiology Reports
_____ Radiology Studies (Films & Images) to Match Attached Reports
_____ Operative Reports
_____ Pathology Reports
_____ Pathology Slides
_____ Photos/Videos/Digital Images
_____ Abstract of Health Record (All Transcribed Physician Reports & Test Results)
_____ Other

HOSPITAL BILLING RECORDS:
_____Complete Inpatient/Outpatient Billing Records

4. DRUG and/or ALCOHOL ABUSE and/or PSYCHIATRIC and/or HIV/AIDS RECORDS RELEASE

I authorize the Record Custodian or organization(s) providing the health information to release my medical or billing records containing information in reference to Drug and/or Alcohol Abuse and Treatment.
Initial one of the following: _____ YES _____ NO

I authorize the Record Custodian or organization(s) providing the health information to release my medical or billing records containing information in reference to Mental Health or Psychiatric Treatment and or Testing.
Initial one of the following: _____ YES _____ NO

I authorize the Record Custodian or organization(s) providing the health information to release my medical or billing records containing information in reference to HIV/AIDS (Acquired Immunodeficiency Syndrome) Testing and/or Treatment.
Initial one of the following: _____ YES _____ NO

5. PURPOSE OF DISCLOSURE/USE: CIVIL LITIGATION

6. TO WHOM AND WHERE TO SEND DISCLOSED HEALTH INFORMATION:
I authorize the disclosure and use of the Health Information described above to the following person(s) or organization(s): _____ (NAME OF REPRESENTATIVE OF THE ESTATE).

7. RE-DISCLOSURE:
I understand the information disclosed by this Authorization may be subject to re-disclosure by the recipients (NAME OF REPRESENTATIVE OF THE ESTATE) and no longer be protected by the Health Insurance Portability and Accountability Act of 1996. The facilities, their employees and officers are hereby released from any legal responsibility or liability for disclosure of the above information to the extent indicated and authorized herein.

8. TIME LIMIT & RIGHT TO REVOKE AUTHORIZATION:
Except to the extent that action has already been taken in reliance on this Authorization, I understand this Authorization is voluntary and that I may revoke it at any time by submitting a notice in writing to the Record Custodian or organization(s) providing the health information. Unless revoked, this Authorization will expire 180 days from the date of signature.

9. RIGHTS & SIGNATURE OF PERSONAL REPRESENTATIVE REQUESTING DISCLOSURE:
I understand that I do not have to sign this Authorization and that my treatment or payment for services will not be denied if I do not sign this form unless specified above under Purpose of Request. I can inspect or copy the Health Information to be used or disclosed. I may see and receive a copy of this Authorization. I authorize the herein named person and/or organization to disclose the Health Information specified above. The information I am requesting may be sent by U.S. mail service, expedited mail services (such as Federal Express, Lone Star, etc.) and/or electronic facsimile in accordance with the provider’s facsimile policy. A facsimile copy, photostatic copy, carbon copy or other copies of this Authorization are intended and shall be treated as an original.


SIGNATURE: (description of authority to act for the deceased person, and a copy of the document, if any, that authorizes you to act as the patient’s personal representative).
________________________________________________ DATE: ____________________________

PRINTED NAME: _______________________________________________

IF SIGNED BY OTHER THAN PATIENT, INDICATE RELATIONSHIP: ____________________________________

THIS AUTHORIZATION WAS SIGNED BY ____________________________________, WHO WAS IDENTIFIED BY PICTURE I.D. ON THIS ___________ DAY OF ______________________, 20________.


_________________________________________________________
WITNESS AND/OR NOTARY PUBLIC.

[TexasThoughtCriminal]

9. As one who has received training in HIPAA...

I know it's a very complex issue. It's easy to get conflicting information on patient privacy rights even from the experts. But I do think I remember hearing that the deceased do not have privacy rights. Of course the psychologist may be bound by other laws or ethics rules than HIPAA. I bet the APA has some guidelines he must adhere to.

My sympathies, and it looks like you'll need some professional legal guidance on this one.