Authority Vice Chancellor for Student Affairs Title Release of Medical Information Classification REG11.45.6 Policies, Regulations and Rules PRR Subject Student Health Services (SHS) Contact Info Director of Student Health Services (SHS) (919)-513- 3285 History: First Issued: September 5, 2002. 1. Regulation: No medical information may be released without proper authorization from the patient or legal guardian, currently dated and signed, unless there is a statute otherwise. 2. Procedure: 2.1. Disclosure of Confidential Information 2.1.1. Who Can Release Confidential Information Requests for patient medical information that involve sending copies of parts of the medical record or completing insurance forms will be under the direction of the Medical Records Supervisor. The Medical Staff, Nursing Service, Administration, or the Ancillary Departments, verbally or by facsimile, may handle other requests as long as these guidelines are followed. The Medical Director or University Counsel shall be consulted in case of doubt. 2.1.2. Requiring Patient Consent 2.1.2a. Authorizations Written authorization for release of information, including releasing diagnostic tests to outside ordering physicians must be requested from the patient. Possible uses of the information should be explained to the patient. It should be explained to the patient that granting consent is strictly on a voluntary basis. A North Carolina State Student Health Services authorization will not be considered valid if the signature date is more than one year old. An original authorization is preferred, although copies are acceptable if clear and legible. If the patient is under 18 years of age, the parent or guardians written authorization is required to release medical information. An authorization should contain all of the following information: 1. Patient's name 2. Name of facility releasing the information 3. Name of the individual or institution that is to receive the information 4. Specific type of information requested 5. Signature of patient or authorized representative whose relationship is stated 6. Date consent is signed 7. Statement that the consent can be revoked at any time 2.1.2b. Person Who May Sign Consent For Release of Information: 1. Adult patients (18 years of age and older) who are mentally competent. 2. The Legal guardian or other person with lawful authority to act on the patient's behalf, for a patient who is not mentally competent. 3. Minor patients (17 years of age or younger) under the following conditions: When seeking services for the prevention, diagnosis, and treatment of sexually transmitted disease, pregnancy, abuse of controlled substances or alcohol, and emotional disturbance When a member of the armed forces When married or divorced When consenting for release of information to his/her own attorney When emancipated by a decree issued by a court of competent jurisdiction 4. A personal representative (administrator, executor, or executrix) of a deceased patient if the estate is being settled or next of kin of a deceased patient in the case of an unadministered estate. If several siblings are the next of kin, all signatures are required. Probate Court documents designating the administrator, executor or executrix is required prior to the release of medical information if an estate is being settled. In the event the estate is unadministered, a notarized statement designating the next of kin will be required. 2.1.2c. Request for Medical Information Requiring Patient's Authorization: 1. Armed forces 2. Attorneys 3. Employer of patient 4. Health departments (except as required by law) 5. Insurance companies 6. Law enforcement or investigative agencies 7. News media 8. Parents 9. Physicians and hospital personnel if copies of the medical record are requested (please refer to requests by telephone and emergency/urgent needs-Section I.C.1.) 10. Social Security agencies 11. University personnel 12. Veterans' Administration 2.1.2d. Authorizations for release of patient information must be placed in the medical record and a notation made as to what information was sent, to whom it was sent, the amount charged, the date sent, and the name of the employee answering the request. 2.1.2e. When the information is released, a cover letter or form that states it is confidential medical records and may not be disclosed to anyone other than the person(s) listed should be sent with the information. 2.1.2f. Parent's Requests Parents do not have a right to medical records if a student is 18 years and older and is competent. If parents call, staff should suggest that the parent have the patient request the medical information from their Provider. If there is a written request and authorization from the patient, to release their medical records to the parent, Student Health Services staff may release the records after receiving Provider approval. The patient is encouraged to only release information for a specific date of service unless the patient has acute medical problems that require extended treatment. Exception: Where the student is under 18 (except conditions noted in I.B.2.C.) or legally not competent, the parent of guardian may obtain medical records. In this case the student should be given advance notice of the request. In certain situations such as records related to sexual activity, psychological counseling, drug use etc, it may not be advisable to provide parents records. When in doubt, the University Counsel should be contacted for advice. 2.1.3. Not Requiring Patient Consent 2.1.3a. Patient Care: 1. In the case of an emergency where the patient is unable to authorize release of his medical information or when time does not permit obtaining such a release, needed information will be released so that a sound determination of appropriate emergency treatment may be rendered. The name and professional title of requestor must be documented in the medical record. If in doubt as to authenticity of the caller, call the facility back for proper identification and then release the requested information. 2. All Student Health Services staff shall have access to medical records necessary to treat or assist with the treatment of the patient. Student Health personnel must not, however, disclose information they learned in the care or treatment of any patient without the consent of the patient. All staff must sign a confidentiality statement. 2.1.3b. Government Agency: Any request by a government agency or person who claims legal authority should be referred to the Office of Legal Affairs if it does not satisfy I-B-2. 2.1.3c. Statistical Information: Information that which does not identify an individual patient may be reported for statistical purposes. 2.1.3d. Research: As long as the identity of the patient is not revealed, contents of the medical record may be disclosed. Approved purposes include scientific research, management and financial audits, and quality improvement programs. Research requests usually require administrative approval and must be done in accordance with university policy and federal regulations. 2.1.3e. In-State and Federal Court Orders: The courts are empowered to authorize disclosures that would otherwise be prohibited. This will be by subpoena or subpoena duces tectum and may be related to a deposition, appearance in court, or to a pretrial discovery. When a medical record has been subpoenaed, the University Counsel shall be notified. Students should be informed of the subpoena and provided enough time for the student to challenge the subpoena unless it is a federal grand jury subpoena, or a subpoena is issued for law enforcement purposes and the subpoena specifies that the student is not notified. Students need at least three business days to respond to the subpoena. If the subpoena gives less than one week, the university counsel should be called about contacting the student. If the court order says to release all the student's record, this means all records regardless of whether they come from another provider. If it says release all records created by NCSU in course of treating the student, only our provider records should be sent. If the situation is unclear, staff should ask the person who issued the subpoena for clarification. If outside providers' records are requested, the outside providers should be contacted in advance so they have time to challenge it. Disclosure of records for substance abuse (alcohol or drugs) patients may occur only in response to a court order and a subpoena as specified in 42 CFR section 2.61 and 42 CFR section 2.2. Records must be mailed to the court by certified mail, return receipt and should be accompanied by an affidavit from the records custodian that states the records are true and accurate copies of authentic medical records maintained by Student Health Services in the course of its business. If a Student Health Services staff member takes the subpoenaed record to court, the following must be observed: 1. Every effort shall be made to have the court accept a copy of the original record. 2. If the judge orders the original be submitted as evidence, receipt must be procured from the Clerk of Court. 3. When in court, the record shall not be reviewed by anyone until submitted as evidence, unless the presiding judge so authorizes. 2.1.3f. Out-of-State Court Order: "Subpoenas issuing from state courts outside North Carolina are usually not binding on Student Health Services. Refer out-of-state subpoenas to the Office of Legal Affairs." 2.1.3g. University Counsel, Risk Management or Professional Liability Carrier In cases where the university may be a target of a lawsuit based on the nature of the records, Risk Management and the university counsel should be notified. Based on the legal opinion, the record may be released to university counsel, Risk Management, or the professional liability carrier without a student's consent to protect the university's interests. 2.1.4. Guidelines For Confidential Information Released To Patient Or Designee When a patient requests to see or receive copies of his/her medical record, the following steps are to be followed: 2.1.4a. A proper written authorization must be received from the patient. 2.1.4b. Identification of the patient must be verified. Verification can be made from the student's ID card or driver's license. NOTE: If the patient authorizes copies of their medical record to be picked up by someone else, staff should ask for driver's license or other information before releasing the records. 2.1.4c. Student Health Services procedure is to send copies of the medical record to another treating physician or medical facility without a Provider's review. If a request is made to release the record to an attorney or insurance company, the medical record is given to the Provider who saw the patient on the requested date of service. In the event the release is in question, the medical record is referred to the Medical Director or designee for release authorization. 1. If the Provider believes that a reading of the medical record clearly might cause adverse effects to the patient, either physically or mentally, and indicates this in writing on the medical release form, disclosure will be refused in the absence of a court order. 2. If the Provider agrees to disclosure, the requested information will be released to the patient, attorney or insurance company. No medical information will be released to the patient, attorney, or insurance company without the prior authorization of the Provider. 2.1.5. If a patient insists on personally reviewing his/her medical records an appointment will be scheduled with a Provider. If a Provider is not available to review the patient's request for medical information, the Medical Director or designee will be asked to assume the responsibility. 2.1.6. Exception: Provider approval is not necessary to release copies of x-rays to patients. A written authorization from the patient is required to release x-rays and laboratory tests. 2.2. Information Received From Other Health Facilities Information received from other health facilities should be treated as confidential under the same guidelines that apply to records created in Student Health Services. 2.3. Excuses To Instructor Physicians on the Student Health Service staff do not provide written excuses. Because of student confidentiality, information can only be released directly by the Counseling Center of Student Health Services in case of crisis or with student's written authorization. See Attendance Regulation 2.4. Original Medical Record Is To Remain on SHS Premises The original or parts of an original medical record shall not be removed from the Student Health Center except upon receipt of a subpoena and court order. Exception: three years after graduation the medical record is considered inactive and is moved to a secure location at Recall, a contracted service in Raleigh. 2.5. Charges For Copies of The Medical Record Minimum charge is $10 up to 40 pages. Additional copies are 25 cents per page. If records are retrieved from the offsite Storage Company, the requester will pay the retrieval cost. Copies of immunization records are provided at no charge. 2.6. Records Released By Facsimile Transmittal Records should only be faxed when mailing would not meet the immediate needs of patient care. Faxing is to be discouraged in situations where time is not of the essence, but it is permissible as long as the patient consents to the fax transmission in writing. The authorization signed by the patient should mention that the records are to be released by fax and that there are inherent risks in faxing records. The confirmation of the fax should be reviewed to verify the records were sent to the correct fax number. 2.7. Verbal Release Of Medical Information Verbal release should be limited to those circumstances when other methods of release cannot be used, such as in an emergency situation. Only the information required satisfying the emergency should be released verbally. A record should be made of the verbal release in the medical record.
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