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Ellen Klepac
Ellen Klepac
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Elusive Medical Records and Not-So-Reconstructive Surgery

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Trying to get your medical records from your doctor after a procedure may not be a cakewalk, but even an unsuccessful effort to do so may wind up working out in your favor.

This was the case for patient Shannon Zakaib, according to wvrecord.com. Zakaib consulted with plastic surgeon Dr. Augusto Portillo after having both breasts removed in a bilateral mastectomy. Portillo performed her reconstructive surgery in May 2008, but when Zakaib tried to schedule follow-up appointments, she was told that Portillo was no longer practicing because he was ill. She eventually discovered that Portillo’s medical license had been suspended for refusing to produce patients’ medical records, failing to do so, or falsifying those records.

Zakaib’s efforts to obtain her own records were equally unsuccessful until she consulted another surgeon, Dr. Jeffrey Thaxton, in September 2010. While reviewing those records, Thaxton learned that Portillo had implanted the wrong medical devices.

Zakaib was forced to undergo additional reconstructive surgeries and is now suing Portillo’s estate for his negligence. The doctor died in October 2010.

Luckily, Zakaib was able to get help from a reliable doctor to obtain her medical records and ultimately discover the medical malpractice involved in her initial reconstructive surgery. If you’re having trouble getting your own medical records, note the following points from About.com’s “Patient Empowerment” series:

  • Be aware that the federal law concerning medical records, Health Information Portability Accountability Act (HIPAA), is lengthy and involved, and not always understood properly by medical providers. Do your own research in advance.
  • You may be charged for your medical records, but your doctor’s office cannot refuse to give them to you if you can’t afford to pay. The best way to avoid having to pay for them is to ask for a copy every time you visit your doctor.
  • If your doctor does not have a records request form, mail or drop off a letter that includes your name, Social Security number, date of birth, address, phone number, e-mail address, the type of record you’re requesting, how long you’ve been seeing your doctor, and how you would like to receive your medical records (via mail, email, fax, etc.). Be sure to sign it.
  • Note that the length of time medical records must be kept varies by state – older records may not be available.
  • Also note that state laws vary regarding how soon your doctor has to provide your records. You may be able to view them immediately in your doctor’s office; you may have to wait up to 60 days. Click here for “Your Medical Record Rights in Ohio.”

Lastly, keep in mind that obtaining copies of your medical records is one of the most proactive ways to take control of your health and avoid the dangers of possible medical malpractice.