Patient Record Requests: What Is Proper Release Protocol?

Medical practices frequently receive medical record release requests from multiple sources, including subpoenas, attorney letters, and patients themselves. Below are answers to several frequently asked questions by patients. Click here for a protocol on patient record requests.  

  • Patient requests must be written without requiring a "formal" release form. Include signature, printed name, date, and records desired.
  • Release a copy only, not the original.
  • The physician may prepare a summary of the medical record, if acceptable to the patient.
  • A cost-based fee may be charged, presently 25 cents per page maximum, which includes labor. A clerical fee of $15 may be charged, but there may be exceptions to this fee.
  • Another provider's records within your record may be released, especially when used to develop a treatment plan.
  • Specific laws require additional specific authorization to protect the medical record of the diagnosis and/or treatment of the following patient conditions: minors, HIV, psychiatric/mental health conditions, and alcohol/substance abuse. If a patient does not authorize the release of this information, the office must declare in writing the following: "This disclosure does not contain patient medical information, if any, that is protected by special state and/or federal confidentiality laws and which cannot be disclosed without specific written consent." Once the requesting party has been given notice that this information may be withheld from the release, the burden of obtaining the patient's consent shifts to the requesting party.

Click here for a Medical Record Release Form. Ensure patient confidentiality! 

[Webinar] Patient Safety Beyond the Exam Door: Managing Your Medical Office and Staff
CAP's General Counsel Gordon Ownby will analyze real life medical malpractice claims that arise from the inner workings of the medical office. Physicians can't do it all themselves, and sometimes their office staff go beyond the scope of their duties. Mr. Ownby will show examples of why protocols, training, and staying aware of what is going on in the medical office are important to reducing risk.

Authored by CAP Risk Management

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.