Releasing Medical Records
Medical records are a peculiar type of
business record. The physical record(paper, microfilm, or something else) belongs to the physician making therecord or the employing clinic. The information belongs to the patient in thesense that the patient has a right to control the release of the information toself and others. Some states limit the patient's access to potentially damagingpsychiatric information, but in general the patient has a right to theinformation in the medical record. The
parent or legal guardian of minors andthe guardian of an incompetent adult may
exercise this right on behalf of theminor or ward.The physician does not need the patient's permission to report communicablediseases, unusual outbreaks of illness,
child abuse, violent injuries, or otherlegally reportable conditions. In most other situations, the physician shouldnot release information from the patient's chart without the patient's writtenpermission. At the first patient encounter, the physician should have thepatient sign an authorization to release information as necessary for thepatient's treatment. This includes release to consulting physicians,laboratories, and other
health care providers.The physician must always have the patient's permission to release informationfor nontherapeutic purposes--for example, collecting
insurance, determining jobfitness, documenting sick leave, and other situations in which the release ofinformation is not related to the patient's medical treatment. The physicianshould ask the patient to sign a written authorization to release thisnontherapeutic information. The written permission should be dated, state towhom the information is to be released, which information may be passed on tothat party, and when the permission to obtain information expires.With the growing concern over AIDS-related discrimination, some patients willnot authorize the release of their medical information to third parties. If thepatient refuses to release information to consultants or other necessarymedical care providers, the physician may not be able to manage the patient'scondition properly. (This is the same ethical dilemma as a patient who refusesnecessary medical treatment.) The physician has no right to release theinformation without the patient's permission. Conversely, the patient may notcoerce the physician into rendering improper care. The physician should informthe patient of the problem and document this in the chart. If the physicianrefuses to treat the patient on this basis, the patient must be informed of themedical rationale for this refusal.A physician has a duty to ensure that information is released only to properlyauthorized individuals. Assume, for example, that a patient has signed anauthorization to release information to an employer. The physician can legallyrelease information to the employer, but he or she must ensure that the personrequesting the information is the one authorized to have it. This might requirethat the information be sent to the personnel department rather than be givento a caller on the telephone.If someone presents an authorization that the patient has signed, the physicianshould endeavor to determine if the release is valid. If the release is over afew months old or appears irregular, the physician should attempt to contactthe patient before releasing the information. If the patient cannot be located,the physician should contact the person seeking the information and try toverify the authenticity of the release. If the physician is still suspicious,he or she should request the person seeking the information to have the patientcontact the physician.A physician has a right to charge a nominal fee for a copy of the patient'smedical record. This fee should reflect the actual charge for copying thechart. If the patient is indigent, the physician should provide the chart at nocost. Under no circ*mstances should the physician attempt to hold the charthostage for an unpaid medical fee or to prevent the patient from seeking careelsewhere. This is bad public relations and may cause the patient to sue toobtain the record.
FAQs
Yes, you have the right to access your medical records upon written request to your doctor. The doctor must allow you to view your records on-site during business hours within five business days of your request. Copies must be provided within 15 days of request, or 10 days if you agree to receive a summary.
What is the proper protocol for releasing and transferring medical records? ›
How to send medical records to a new doctor (or get a copy for yourself)
- Talk to the new provider to determine what type of records they need. ...
- Visit or call your current physician. ...
- Submit the records request. ...
- Wait for the transfer to complete. ...
- Keep the records safe.
According to HIPAA, patients have a right to their medical records within 30 days of a request; failure to provide them is a HIPAA violation. Losing a device or record that exposes patient records to unauthorized actors is also a HIPAA violation.
Who decides whether a medical record can be released? ›
The patient is the one who ultimately decides whether a medical record can be released, according to HIPAA regulations. Although medical professionals manage these records, release authorization lies with the patient.
What triggers a mandatory release of the medical record? ›
Mandatory disclosure of information
Under the CMIA, medical information must be released when compelled: by court order. by a board, commission or administrative agency for purposes of adjudication. by a party to a legal action before a court, arbitration, or administrative agency, by subpoena or discovery request.
What process do you follow when a patient requested the release of their medical records? ›
Provider may obtain a valid authorization form signed by the patient for the release of records. This is the provider's HIPAA authorization that patients in the office routinely sign to obtain their PHI. To be valid, the authorization form must contain the elements and statements required by the HIPAA Privacy Rule.
What is the golden rule of documentation in a medical record? ›
This case reinforces the “Golden Rule” that one should never document a medical record until the medical care has been completed. The lesson is short and simple: documentation should reflect the action(s) taken.
What type of consent is needed to release medical information? ›
Under California law, most disclosures of your medical information require your written consent and must be limited to the specific purposes you authorize.
What form is used to allow the release of their medical records? ›
A HIPAA authorization form, also known as a HIPAA release form, is a document that individual signs for their health provider before the entity may use or disclose their protected health information (PHI).
Can we refuse to give the patient their records? ›
HIPAA provides patients with a legal, enforceable right to see and receive copies of their medical information and other health records upon request from their healthcare providers. 1 This includes seeing the “original chart review” instead of a photocopy or a summary page.
Protected health information (PHI) cannot be shared under HIPAA. So what exactly is considered PHI according to HIPAA? It's information that can identify a particular patient, including health records, lab reports, bills, or even verbal conversations.
Is releasing the patient's medical information without the patients written approval? ›
Your doctor, insurance company, and other healthcare providers have to ask for your written permission before they can release your personal health information. This is true unless the release is for the purpose of treatment, payment, or healthcare operations.
What are three things you should not add to a medical record? ›
The following is a list of items you should not include in the medical entry:
- Financial or health insurance information,
- Subjective opinions,
- Speculations,
- Blame of others or self-doubt,
- Legal information such as narratives provided to your professional liability carrier or correspondence with your defense attorney,
Process for Releasing PHI
- Recording, Tracking and Verifying the Request. The process begins when the patient submits a request to release information. ...
- Retrieving Patient's PHI. ...
- Safeguarding Patient's Sensitive Information. ...
- Releasing Patient's PHI. ...
- Completing the Request and Preparing an Invoice.
What is an ethical physician to do when a patient provides pertinent information but insists that it be kept "off the record?" While there is an expectation of confidentiality between doctor and patient, there are instances when a patient will only reveal certain information if the doctor agrees not to record it in ...
What information must be on the authorization form for the release of patient? ›
A description of the information that will be used/disclosed. The purpose for which the information will be disclosed. The name of the person or entity to whom the information will be disclosed. An expiration date or expiration event when consent to use/disclose the information is withdrawn.
What is necessary to release a patient's record to the patient's insurance company? ›
Due to state and federal privacy laws, an insurance company must obtain a claimant's written permission in order to access medical records. While an injury victim has the right to refuse permission, doing so will almost certainly result in denial of the insurance claim.
What are the requirements needed to release copies and or information of medical records in accordance with 42 CFR Part 2? ›
Part 2 requires each disclosure made with written patient consent to be accompanied by a written statement that the information disclosed is protected by federal law and that the recipient cannot make any further disclosure of it unless permitted by the regulations (42 CFR § 2.32).
What should be included in requests to release health records? ›
How to fill out a health or medical record release form
- Patient information. Whose health records do you want? ...
- Clinic, hospital, care provider. ...
- Date of Services. ...
- Information to be released. ...
- Receiving party or destination of records. ...
- Purpose of release. ...
- Expiration date or duration of consent. ...
- Release instructions.
