Your patient has requested the release of his or her medical records. You can find a sample Authorization for Use and Disclosure of Medical Information Release Form on our website. (Click here to download the form.)
The Cooperative of American Physicians, Inc. has revised this form to include the information emboldened below:
"To release information regarding my medical history, illness or injury, consultation, prescriptions, treatment, diagnosis or prognosis, including x-rays, correspondence and/or medical records including those from my other health care providers that the above named health care provider may hold, by means of mail, fax, or other electronic methods."
Under the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule, one of the rules addresses whether a health care provider may disclose protected health information about an individual to another provider, when such information is requested for the treatment of a family member of the individual. For example, an individual who has obtained a genetic test may request that the health care provider not use or disclose the test results. If the health care provider agrees to the restriction, the information could not be shared with providers treating other family members who are seeking to identify their own genetic health risks.
Genetic Information has been added to the checklist below:
I also consent to the specific release of the following records:
Drug/Alcohol/Substance Abuse___(initial)
Tests for Antibodies to HIV ______(initial)
Psychiatric/Mental Health _______(initial)
HIV Diagnosis/Treatment _______ (initial)
Genetic Information _________ (initial)
Authored by
CAP's Risk Management & Patient Safety Department
If you have questions about this article, please contact us. This information should not be considered legal advice applicable to a specific situation. Legal guidance for individual matters should be obtained from a retained attorney.
Have you received your $100 incentive checks yet?
If you wish to check your status or enroll in the Risk Management Institute incentive program, e-mail the physician's membership number and/or first and last name to: llopez@CAPphysicians.com or call 800-252-7706, extension 8502.