Medical Records Management



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General Consent and Informed Consent for Health Services can be found in the Consent for Services section of the Administrative Reference Volume II.


AUTHORIZATION FOR USE AND DISCLOSURE OF

PATIENT HEALTH INFORMATION




Authorization to Release Information (Who May Sign)


The guidelines as to who may sign an authorization to release information are those applicable to the signing of consents for services. Consent/Authorization for Services is located in the Core Clinical Service Guide. The “Authorization to Release/Request Patient Information” Form (CH-23) is located in the Core Clinical Service Guide Forms Section.

Exceptions to the Use of Written Release


In the event the local health department has a written agreement(s) with a hospital, private clinic, or primary care center, etc., to provide services which necessitate the sharing of medical information, a written release need not be completed provided the agreement states that confidentiality shall prevail and the patient (or legal representative) has been informed that the information will be exchanged only for the purpose of assuring “appropriate and continuous health care.” Patient records may be disclosed for Treatment, Payment, or Operations without the patient’s written consent. The HIPAA “minimum necessary rule” shall be followed.

  • Other exceptions include:

  • Research studies - Patient authorization is not required if identifying patient information is not released and/or included in research projects.

  • Third party payors - Specifically Medicare and Medicaid. (Permission to share is given when assignment of benefits is properly executed [signature, date, and name of agency providing the information]).

  • Sharing of childhood immunization information among providers.

  • Sharing WIC screens, certification and issuance information with other Kentucky WIC sites.


Other Considerations


  • When releasing the medical record, entries related to protected health, confidential, personal or other sensitive information, such as, STDs, Human Immunodeficiency Virus (HIV)/Acquired Immunodeficiency Syndrome (AIDS), HANDS, alcohol and drug abuse, or psychological/mental problems shall be omitted from the record unless specifically authorized in the written release signed by the patient or guardian.


Exception: Any STD on a child under 12 years of age shall be reported to the local health department or Social Services Office as a possible child abuse case (http://www.lrc.ky.gov/KRS/620-00/030.PDF)

(http://www.lrc.ky.gov/KRS/510-00/CHAPTER.HTM)
KY laws relating to confidentiality of HIV and STDs:

http://www.lrc.ky.gov/KRS/214-00/420.PDF

http://www.lrc.ky.gov/KRS/214-00/181.PDF

http://www.lrc.ky.gov/KRS/214-00/625.PDF

http://www.lrc.ky.gov/KRS/214-00/645.PDF

http://www.lrc.ky.gov/KRS/214-00/995.PDF



  • When confidential information is released over the telephone (e.g., to a physician, a hospital, or in a medical emergency), a reasonable attempt shall be made to verify the identity of the persons and/or facility receiving the information. Such information shall not be given to a patient or parent/legal guardian via telephone.




  • When someone alleges they are the legal guardian or custodian of a child and wishes to see the child’s medical record, the individual must complete a written request for information and provide a copy of the court-ordered document verifying the guardianship or custodianship. The information shall be copied onto a personal immunization record and given to the individual. Other information such as the child’s address and phone number shall not be released. (It should be noted that a non-custodial parent may have a copy of his/her child’s medical record provided that the non-custodial parent’s parental rights have not been terminated.)




  • When medical records are viewed or photocopied for release and the record contains a report and/or correspondence from other agencies, these external reports become a part of the medical record of the receiving agency and may be released as such.




  • The Release of Information form shall serve as the official request of patient information and shall be filed in the medical record (Administrative Section). HIPAA requires a record of any disclosure of patient records be made available to the patient upon request.




  • Workmen’s Compensation - Although consent for release of information is implied, the patient has the right to withhold consent in which instance the health department shall comply. (Workmen’s Compensation proceedings will cease at this point.)

  • Certification(s) - Health departments may be requested to issue a “certification” of a specific service(s) they have provided (e.g., PPDs, to meet occupational requirements). Such certification shall be issued to the patient, who then has the responsibility to advise the employer. (No results of the service(s) shall be released to other than the patient without specific consent.) HIV test results are prohibited from use in employment or eligibility determination for health or life insurance.




  • Upon a patient’s written request, the LHD shall provide without charge to the patient, a copy of the patient’s medical record. A copying fee, not to exceed one dollar ($1) per page, may be charged by the LHD for furnishing a second copy of the patient’s medical record upon request by the patient. For businesses, lawyers and others, the LHDs may charge a nominal and reasonable fee according to their agency’s policy.



Coroner’s Cases


A Coroner is a public official whose duty it is to make inquiry into the causes and circumstances of all sudden, unexplained, unnatural, or suspicious deaths.
The Coroner has authority, according to KRS 72.020, to “take possession of any objects, medical specimens or articles which, in his opinion, may be helpful in establishing the cause of death, and he can make or cause to be made such tests and examination of said objects as may be necessary or useful in determining the cause of death.” KRS 72.415 gives coroners and deputy coroners the authority to “require the production of medical records” in carrying out their duties as peace officers in this state.

Additional Resources


For authorization and Coroner’s exemptions refer to the HIPAA privacy regulations 164.908 and 164.512(c).
http://coroners.ky.gov/, under “Forensic Library”

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