Chapter Ten

Medical Records

It is important for you to retrieve any and all of your medical records. You may have been seen by a private doctor, Clinical Psychologist(s) or a Psychiatrist for any nervous condition. If so you will want to retrieve those records too.

To retrieve any medical records from private doctors simply write a letter to the doctor explaining why you wish to receive copies of your records. Be certain to state in your letter, "I AM AWARE OF EVERYTHING IN MY MEDICAL RECORDS”. An example of this type of letter can be found in Chapter 23 “Example Letters”. Some doctors do not want to turn records over to patients, but according to the law they can not keep them from you.

A private doctor may try to convince you to allow them to send your medical records directly to the VA Hospital. Instruct them not to do so. Tell them they can only send them to you. It is a good idea to telephone the doctors office a few days after you mail your letter requesting your records to be certain they received your request. As you talk with the person on the telephone be certain to write down the date and time you called or better yet, record your conversation on an audio device. Also, ask the name of the person you are speaking with and ask them to spell their last name. This helps convince the person you are speaking with that you are taking notes and you are serious about getting your records promptly. (In some states both parties must me aware the conversation is being recorded.)

You also want to get copies of all your military medical records. If you have ever been at a VA hospital for out patent treatment or admitted for inpatient treatment you want to get copies of these records. If it has been longer than five years since you were treated at a VA Medical Center chances are your medical records have been retired to a Federal storage Facility. That means your records are not kept at the hospital you were last treated at.

Getting your medical records from a Federal Storage Facility is not impossible, but it may take two to three months. It will also take “PERSISTENCE”. You will need to write a letter to the VA Medical Center(s) where you were treated and mark the letter “ATTENTION DIRECTOR OF RECORDS”. Whenever you mail something, mail it Certified Return Receipt Requested. If the VA Medical Center is located in the town you live in we recommend you hand deliver the letter to the Department Head, or Director of Records. An example of this type of letter can be found in Chapter 23 “Example Letters”.

It is always a good idea to have someone sign your copy of the letter you hand carried to them. Ask them to write the date and time on the letter. This type of tactic can really help get action. People don’t like to be held responsible for problems and you just became one by making the person who signed the letter responsible for getting your records. This increases your chances of their certainty to get your records more quickly.

We said you also must be persistence. This means you must go back and check up on the person who is helping you get your records. Give them two weeks in the beginning. Then go back and ask what progress is being made. Be certain to write on your letter, in front of them, the day you returned and whether or not they had retrieved the records. If they tell you to check back next week, write that down, too. Again, this keeps the pressure on for the Records Department to locate your records. If you do not use tactical pressure, you will be shoved to the bottom of the pile.... we guarantee. An example of this type of letter can be found in Chapter 23 “Example Letters”.

One thing we know about the VA System. It moves slow and responds when pressured (tactfully). If the Records Department has not found your records within 60 days, tell them you intend to write a letter to a United States Senator if they believe they cannot retrieve your records in the very near future. Should a US Senator get involved, Records Department will have to jump through hoops because they only have five days to explain why they have been unable to retrieve your records. And remember, you have been writing down all your visits to the Records Department. You have a complete documented history of each time to inquired about the progress and what the response from Records was. As well, the Records Department knows you have this information.

Retrieving other medical records located in a VA hospital is not as difficult. You will need to sign a Form 10-5345 “Request For & Consent To Release Medical Records”. You may also need a Psychiatrist to sign a “Release of Information Act” form. Submit the signed form(s) to Records requesting copies of all medical records. You should be in the PCT Unit Program therefore you should have no trouble getting the Team Psychiatrist to sign the “Release of Information Act” form for you.

Also, it is a good idea to have an “Open” release of Information Act form signed by the Team Psychiatrist in you “Chart”. You “Chart” is your complete set of permanent records which are generally kept in the Secretaries Office at the PCT Unit. An “Open” Release of Information Act form is one which is signed by the Team Psychiatrist, but is not dated. Without a date on the form this allows “You” access to your Chart anytime you want to look at it.

There are two parts to your Chart. The Administrative File and the Medical Records File. The Medical Records File is just that.... all of your medical records. If you have retrieved any retired medical records from Federal Storage or you have medical records from other VA hospitals, be certain all of these records are in your Chart (medical Records File section).

The Administrative File in your Chart deals with letters and correspondence. Such as information about where you live, your income, phone number, etc. Plus, correspondence between the Rating Board, Social Security, Letters from Clinical Psychologists or Psychiatrist, Stressor Letters, etc.

When you want to know if a VA Regional Office 9Rating Board) has requested information about you, it will show up in routing slips which are kept in the Administrative File portion of your Chart. The same is true for Social Security information. You will even be able to know who the Rating Board Officer (on your claim) is by researching your administrative file. You will know the dates(s) information was requested, what information was requested, if and when it was sent and to whom. This file will even reveal whether the information was mailed or hand carried!.

It is always a good idea to review your Chart once a month to be certain no one has put any incorrect information in or removed any information. You can read the progress notes from the Clinical Psychologist(s) and Psychiatrist(s). The Psychiatrist(s) will have entered most of the progress reports. Many Psychologists do not write progress reports to be put into your Chart. After you review your progress reports and read what the Clinical Psychologist(s) and Psychiatrist have written about your condition, you may want to talk with them about their findings.

You can request copies of anything and everything in your Chart anytime you wish. Thus, you are able to maintain a current and complete set of records for yourself. You can request copies of the new information as it is added to your Chart. We recommend every Veteran keep an on going current set of copies of his or her Chart.