How to Request Copies of a Medical Record

Autorización para el uso o divulgación de información médica protegida (PHI)

Complete an Authorization

a.   A formal written request must be completed.  The following information is required to process the request:

• addressed to the facility that is to release the information
•  address of the facility/person that is to receive the information
• patient's full name, including previously used names, address, date of birth and social security number
• specify the information and date(s) of service to be released 
• specify the reason the information is to be released 
• instructions on pick-up or mailing information 
• date of request 
• patient's signature

b.       For your convenience, blank authorization forms are available on this page by clicking on the link above.  They are also available in the Health Information Management (HIM) department. Completed authorizations may be returned via fax, mail or hand delivered, contact information is below. 

Signature on Authorization

a.         If the patient is unable to sign due to a physical or mental disability, the authorization shall be signed by the guardian or personal representative named by the court.  If there is no guardian or personal representative, the person named in the medical power of attorney may sign the authorization.  Please provide appropriate legal documentation.

b.         Minors:  If the patient is under 18 years old, the authorization shall be signed by the parent or guardian. Minors (15-17) consenting to their own treatment for mental health services must authorize the disclosure of their medical information. Emancipated minors (15-17) who are married, in the military or have sole responsibility for his/her own support shall authorize disclosure of their own medical information.

c.         If the patient is deceased, the authorization shall be signed by the personal representative/executor of the estate appointed by the court. Please provide appropriate legal documentation.  If no such person exists, the authorization will be signed by the heirs of the deceased (surviving spouse, adult child, parent, adult grandchild, adult sibling.)  Heirs must provide an affidavit explaining the nature of the relation to the deceased and how this makes him/her an heir of the deceased and state that to the best of their knowledge no personal representative has been appointed to the estate of the deceased.  Additionally, if the deceased did not expire in an Exempla Healthcare facility, a death certificate must be provided.

Processing Requests

a.       It is recommended that records be complete before release, however, incomplete records may be released.

b.       If medical information is needed for continuum of patient care, it will be made available to the requesting physician according to his/her instructions.

c.        The HIM department will process most requests within 7-10 working days. Walk-in requests that can be printed electronically may be processed depending upon the workload and availability of the information.

d.       Information can be mailed or picked up personally.  Department policy does not allow faxing information to patients, insurance companies, attorneys or others outside the healthcare profession.

X-ray Films

The HIM Department can provide the written interpretation of an X-ray.  To obtain the actual X-ray film, contact the Medical Imaging department.  For directions, go to the Information Desk at the main entrance and ask for directions to Medical Imaging.

Copy Charges

According to Colorado State Statutes, reproduction of record charges are $14 for pages 1-10 and $0.50 for pages 11-40 and $0.33 for every additional page.  Microfilm/fiche copies are $1.50 per page.

Health Information Management Department

References:

• Exempla Policy - Release of Protected Health Information 10-ADHI-1002
•  Colorado Hospital Association Consent Manual and Guide to Release of Information
• Colorado State Statutes, Standards for Hospital and Health Facilities, 6CCR 1011-1, Chapter 2, Part 5.2.3.4 27-10-120.5, 27-10-120, 27-10-103