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Frequently Asked Questions


What is a Valid Authorization?


Who can legally sign for medical records?


What is included within a medical record and what should I request?


When should I expect to receive my medical records?


Is there a fee to obtain my records?


What is a Valid Authorization?

The Health Insurance Portability & Accountability Act (HIPAA) sets the standard for a valid authorization to release information.  The following elements must be included for a HIPAA-compliant authorization:

  • Name and date of birth or social security number
  • Statement of who is authorized to release records and who is authorized to receive records
  • Purpose of Disclosure
  • Type of information to be disclosed
  • Psychiatric records or infectious diseases (i.e. HIV, Hepatitis C, TB, ECT.) must be clearly marked or checked before they will be released
  • Statement acknowledging the patient’s right to revoke or cancel authorization
  • Statement indicating the patient’s right to refuse the release of information
  • Statement that information disclosed pursuant to the authorization may be subject to re-disclosure and is no longer protected under this authorization
  • Statement that will not condition treatment on patient providing authorization
  • An expiration date
  • Signature of patient or patient’s representative

 

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Who can legally sign for medical records?

  • The Patient and / or anyone who is named as a decision maker or attorney-in-fact under a healthcare power of attorney signed by the patient.

 

  • If the patient is deceased, a certificate of appointment issued by the Probate Court identifying the requestor as the executor or executrix of the patient’s estate. A death certificate may also be provided which lists the requestor as the next of kin.

 

  • If the patient is under the age of 16, the patient’s parent may sign.

 

  • If the patient is 16 years of age or older, the parent can sign if the parent authorized the treatment which is recorded.

 

  • If the patient is 16 years of age or older and authorized their own treatment, then the patient must authorize the release of information regarding the treatment.

 

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What is included within a medical record and what should I request?

The following provides a brief summary of the various parts of the medical record which may help to identify information to request:

 

  1. Discharge Summary:  A summary of an inpatient stay.  This report identifies the reason for the admission and narrates the patient’s course during the stay.  Diagnoses, operations performed, medications prescribed and condition at discharge are all items of inclusion.
  2. Operative Notes:  A summary of a procedure preformed on the patient.  This report identifies the procedure, pre & postoperative diagnoses, the surgeon, indications and findings.
  3. Laboratory Results:  Analysis of blood or urine and surgical pathology reports or biopsies which document tissue examinations, among others.
  4. Radiology Report:  This is a report summarizing the findings of images or scans as viewed by the radiologist.  If you would like the actual film, please call our film library at (413) 794-4625.
  5. History & Physical:  A medical history which includes the present chief complaint, history of the present illness, past medical history, personal history, family history and a review of systems.
  6. Consultation Report:  A report outlining the opinion about the illness or condition from a practitioner other than the attending physician.

 

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When should I expect to receive my medical records?

The HIM department will comply with the request within thirty (30) days of receipt (or sooner if required by law).  If the information requested is not maintained on site, the HIM Department will respond within sixty (60) days of the date of the request. 

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Is there a fee to obtain my records?

No fee will be charged for records sent to a health care provider at the request of the patient for the purpose of continuing care.  

 

Any other copies requested by the patient or copies to attorneys, insurance companies, subpoenas or Workers Compensation will be charged $0.74 per page for pages 1 – 100 and $0.38 per page for pages 101 and greater.  Payments may be made in the form of cash or check; credit cards are not accepted.

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