Request by Patient

Category: Medical Records Release of Information

Date: March 2003

Reviewed/Revised: April 2013

Policy

Requests for copies of records must:

1. Be IN WRITING, dated and signed by the requester (patient/guardian).
2. Include the name of the patient whose records are requested.
3. Identify the program or person who is to make the disclosure.
4. Identify the nature of the information requested and the limitations (or lack thereof) as to the information which is to be released.
   
   Note: When the patient’s medical record contains information relating to psychiatric treatment or counseling, drug or alcohol treatment or AIDS treatment or testing, the request must SPECIFICALLY authorize release of this information in order for it to be released. The office and/or practice manager will determine whether the release is sufficient. If the release is not sufficient the patient should be contacted and requested to send an authorization which will satisfy EVMS Medical Group requirements.
   
   
5. Include evidence of the authority of the requester to receive such copies and identification of the person to whom the information is to be disclosed. If the requester is the patient’s guardian, proof of guardianship (a court order bearing a judge’s signature and the seal of the court) must be presented.
6. Be submitted within ninety (90) days of the signature of the requester or it shall be considered null and void.
7. Include the COMPLETE name and address of the physician, patient, hospital or other entity to whom the information is to be released.
   
   NOTE: For the convenience of our patients, EVMS Medical Group has created an Authorization to Use or Disclose Medical Record Information which (if properly completed) will satisfy EVMS Medical Group requirements for written authorization. A facsimile or photocopy of the original release shall be accepted as if it were original. In addition, a non-EVMS Medical Group authorization is sufficient provided the release satisfies the requirements outlined in 1. through 7. above.

Procedure

Within fifteen (15) days of receipt of a request for copies of medical records, the provider shall:

1. Furnish such copies to any requester authorized to receive them;
2. Inform the requester if the information does not exist or cannot be found;
3. Notify the requester if the provider does not maintain a record of the information and provide the name and address, if known, of the provider who maintains the record;
4. Deny the request on the grounds that;
   1. The release of the records to the patient would in the opinion of the provider be injurious to the patient’s health or wellbeing and this is stated by the provider in the record.
   2. The requester has not established: (1) his authority to receive the records or (2) proof of his identity.
   3. The law does not permit this disclosure.

The original request and documentation of the disposition of the request should be retained in the record. A copy of the request should be sent to the requester with the records unless the request lists information which the patient specifically declines to release. When the patient declines to release specific information:

• The medical record should be copied.
• All information on the copies which the patient declines to release should be marked through with black marker.
• Copies should be made of these copies.

These copies may be released with a cover letter (see Response to Request for Medical Records) stating that this is an incomplete record and that questions may be directed to the patient.