Physicians often receive requests from their patients for a medical letter, form, or report to prove to the patient’s employer, institution, or insurer a valid reason for taking time away from work or school, or to obtain disability benefits or a pension. Patients may also require a treating physician’s report to seek compensation for physical and/or psychological injury. Physicians have an ethical and legal obligation to provide a timely, factual report on patients they have cared for, even if they have not recently seen or examined these patients and cannot provide an updated report. (Note: This module does not cover independent medical evaluations (IMEs), expert opinions, or mandatory reporting.)
Good practice guidance
Requests for a treating physician letter or report are often made in person (as when a patient being examined asks for a “sick note” or for completion of an insurance company form). Requests for medico-legal reports (as when a patient’s lawyer requests a summary of their condition) are typically made in writing and usually state the purpose of the report. It is important to remember that patients, employers and insurers will be relying on the objective information you provide to make decisions for the patient that can include benefits, adjusted workplace environments, sick leave, etc.
Physicians should be aware of the standards or guidelines of their medical regulatory authority (College) concerning the completion of medical reports. If you provide misinformation, or erroneous or unfounded opinions, employers and insurers who have relied on such representations may commence a legal action for damages against you or complain to your College. Your College may consider the provision of untruthful information, the provision of information beyond the scope of the patient’s consent, or the inappropriate delay in producing medical certificates or reports to be professional misconduct.
Your reports should aim to be FAST: Factual, Authorized, Solid and Timely.
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The aim of a treating physician’s report is to provide facts, not opinions. Opinions are typically provided as part of independent medical examinations or in expert reports.
Respond only to the specific questions asked. Don’t speculate on what lawyers, employers or others need. Provide only factual information within your expertise, without bias or conflict of interest.
Do not feel bound by check boxes that force you to a “yes” or “no” judgment. If you are uncertain, are unable to answer a question or if it is outside your area of expertise, it is appropriate to indicate, “I don’t know”.
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The answers you provide should be supported by the medical record but should contain only information the patient authorized to be released. If the patient has placed restrictions on what they have authorized you to cover, indicate areas where restricted information is relevant to your response and/or results in an incomplete response. Discuss with the patient that you may have to note the restrictions in your response.
Requests for a letter, form, or report can come from many different sources including the patient or a substitute decision-maker (SDM), the legal guardian of a child or an incapable adult, or from a third party such as a lawyer, insurance company, or government agency. For simple matters and in cases where the letter will be provided directly to the patient while in the office, verbal consent is sufficient. Document that a note was provided and keep a copy of it in the medical record.
For more complex matters, or when the report or letter is to be sent directly to a third party, obtain express written consent from the patient before sending the report or letter. If consent is obtained from a SDM, it is prudent to keep a copy of the legal document confirming the SDM’s authority to act on behalf of the patient in the medical record.
If the patient has died, consent should be obtained from the executor or trustee of the estate, after confirming their authority to act.
Written authorization should state:
- to whom the report is to be sent
- the time period the report should cover
- the subject matter to be addressed
- when the report is required
If you feel you cannot make the deadline, notify the requester at your earliest opportunity.
Only content authorized by the patient, SDM or executor/trustee of the patient’s estate should be released. Often, requests for reports or forms are received directly from insurance companies. If you are uncertain as to what the patient, SDM or executor/trustee has authorized, contact them and document your discussion in the medical record.
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Your report should be based on facts and be sound. Before you write your letter or complete a form, review the medical record and base your report on that information. Do not speculate.
Occasionally, patients may ask for a letter about their state of health at a time when you did not personally assess them and may ask you to make statements that you cannot corroborate. In such cases, you may choose to write, “the patient reports that…”, and clarify that you did not assess them in real time.
If your report, based on the facts in the record, does not align with the patient’s expectations, explain your professional obligation to be factual and objective. This discussion should be documented in the medical record.
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Medical letters, forms and reports should be provided in a reasonable time period. Your College may have a recommendation for the timeline, usually within 30 business days, but it may be shorter. If you cannot comply with the timeline, contact the requester to alert them to the reasons for a potential delay and to negotiate a solution.
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Physicians may be entitled to charge a fee for providing a medical letter, form, or report. The fee should be reasonable given the time spent examining the patient, reviewing the medical record, and preparing the report. It is prudent to also consider the patient’s ability to pay.
Colleges and medical associations may provide some guidance on what constitutes a reasonable fee. If a patient refuses to pay or is unable to pay, do not hold back the report or the requested documents. Physicians have a duty to prepare a medical report on a patient they have treated.
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Insurance companies often request that copies of medical records be sent along with forms a physician has completed. In that case, only provide records that are authorized by the patient, and only provide a copy of the record (not the original).
Patients may not realize the extent of information you may have within their medical record. If the information requested (or the authorization provided) is broad and applies to material that is particularly sensitive and unrelated to the situation, it is prudent to clarify with the patient what their wishes are. The patient may wish to adjust their consent to prevent the release of the unnecessary content. If a request covers “all medical records” and you are providing only a portion of your records at the patient’s request, you should discuss the implications of this with the patient and document this discussion in the medical record. The response to the requesting party should include that the records provided cover only what the patient has authorized for release.
Health information about another identifiable person, should generally be redacted.
Physicians may charge a fee for transferring a medical record. You should discuss the fee with the patient or the third party prior to providing the records. Fees should not exceed the amount of reasonable cost recovery and should reflect the patient’s ability to pay.
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Patients may become upset if they feel they will be denied financial assistance or workplace accommodation based on your report. Physicians may feel intimidated or even bullied when they cannot provide a supportive report based on the facts within the patient’s medical record.
If safety is not an immediate concern, stay calm, professional and non-confrontational—focus on the issues, not the personalities. Be respectful, and empathize with your patient’s concerns. Try to negotiate a mutually agreeable solution, but do not compromise on your need to honour the facts as documented in the medical record. Document your discussions in the medical record.
If the patient becomes aggressive or you believe there are imminent, serious safety concerns for you, your staff or other patients, call the police. In a hospital, follow the hospital protocol. A report to police should include only the information necessary for the police to address the threat, such as the name of the threatening individual and the nature of the incident. Avoid divulging any further patient medical information, if possible.
Document the abusive behaviours clearly and factually. Request any other health professional who witnessed the behaviour to document what they saw or heard.
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