How to Gather and Submit Medical Records and Bills for Your Injury Claim in NY

Disclaimer: This article is for informational purposes only and does not constitute legal advice. Always consult a qualified attorney for guidance on your specific situation.

Detailed Answer

When you suffer an injury due to someone else’s negligence, you must document your medical treatment and expenses to support your claim. In New York, the basic steps include:

1. Sign a HIPAA-Compliant Authorization
   Under the Health Insurance Portability and Accountability Act (HIPAA), medical providers need your written permission to release records. Use a standard Authorization for Release of Health Information form. Confirm it meets New York’s Public Health Law § 18 requirements: https://www.nysenate.gov/legislation/laws/PBH/18.
2. Request Complete Medical Records
   Submit the signed authorization to each provider who treated you—hospitals, urgent care centers, specialists, and physical therapists. Ask for all notes, imaging reports, lab results, and discharge summaries. Providers have 30 days to comply under New York law.
3. Obtain Itemized Medical Bills
   Request detailed billing statements showing dates of service, procedure codes, provider names, and amounts charged. Itemized bills help establish the cost of each treatment and verify your out-of-pocket expenses.
4. Organize and Index Your Documents
   Group records by provider and date. Create an index or table of contents. Label each section clearly (e.g., “MRI Report – 04/10/2024” or “Physical Therapy Bill – 05/02/2024”). Well-organized materials make it easier for insurers or courts to review.
5. Summarize Key Information
   Draft a one-page summary that outlines your injury timeline, treatments received, and total medical expenses. Include brief descriptions of each treatment and how it relates to your injury.
6. Prepare a Cover Letter for Submission
   Write a concise cover letter addressed to the insurance adjuster or opposing counsel. State your claim number, attach the index, and note that you are providing complete medical records and bills as proof of injury and expenses.
7. Submit Materials to the Insurer or Attorney
   Send your packet via certified mail or secure electronic upload, if available. Retain proof of submission (return receipt or upload confirmation). Keep a complete copy for your records.
8. Follow Up and Respond to Requests
   Over the course of claim evaluation or litigation, the other side may request additional records. Respond promptly by providing any missing documents. Under CPLR § 3121, defendants may also demand access to medical records during discovery: https://www.nysenate.gov/legislation/laws/CVP/3121.

Helpful Hints

• Request records early. Providers often take weeks to process requests.
• Keep both digital and paper copies in a secure folder or cloud storage.
• Check providers’ policies for fees. New York caps copying fees under Public Health Law § 18.
• Note any gaps in treatment and be prepared to explain them (e.g., follow up with your doctor).
• If billing errors appear, dispute them promptly to ensure accuracy.
• Consult an attorney before signing any release that waives your rights.
• Maintain a log of all communications (dates, times, and names of representatives).
• If your claim moves to litigation, coordinate with your lawyer to comply with New York’s discovery rules.