MEDICAL RECORDS

MEDICAL RECORDS DEPARTMENT

Phone: 403.452.0999 ext. 113    Fax: 403.984.5448

Email: [email protected]

PLEASE CLICK HERE FOR RELEASE OF INFORMATION CONSENT FORM

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What is a Medical Record?

A medical record is made up of documents containing medical information regarding your health care. Your medical report belongs to the person or institution that wrote it. Although you cannot take your record without the writer’s permission, you do have a right to access your record and can enforce this right by court order. Some other organizations, including the government, also have a right to access your file.  Know your rights Health Information Act (HIA). If you wish someone to have access to your file, you may give consent in writing. In general, however, the record should be kept private and confidential.

By law, your physician must keep records of all in-patients for seven to ten years. Some physicians, however, keep their records for a much longer time than this.

Patients have the right to the information on their medical records and may request that their medical record information be released to themselves or other third parties for various reasons. The Release of Health Information Brochure (PDF) provides patients with information on release requirements and how to request the release of their health records to common third parties for various reasons. Records of the care patients receive at Caleo Health are kept in strict confidence and are not released without the patient’s written consent, except as required by law.

physicians can refuse to disclose the information in the record to the patient, but only if they reasonably believe there is a significant likelihood that disclosing the information will have a substantial adverse effect on the patient’s physical, mental, or emotional health, or cause harm to a third party. The onus in such circumstances is on the physician to justify denying a patient access to information in their medical record.

Disclosure of Health Information Under the Health Information Act

Consent is required under the HIA to disclose information about a patient, you or someone legally authorized to act on your behalf will be required to provide Caleo with your written consent prior to releasing the specified health information. Caleo has specific requirements for what is contained within a valid consent to disclose health information.

Transfer of Records

Information in medical records may need to be transferred between physicians such as when a patient transfers to another doctor. A copy of the information may be sent directly from the former physician to the new one, or the patient may request to receive the record. The CMPA recommends that physicians not release the original files. Instead, the pertinent information may be transferred by other means such as a report summarizing the relevant entries in the record, or a photocopy or scan of the file may be provided if requested. By law, your physician must keep records of all in-patients for seven to ten years. Some physicians, however, keep their records for a much longer time than this.

MEDICAL RECORDS REQUEST

MEDICAL RECORDS REQUEST – PATIENTS AND THIRD-PARTY POLICY

  • Any and all requests must be accompanied with the appropriate Authorization (Consent) to Release Health Information Form, All consent forms must be signed and dated by the patient or a legal representative.  Caleo Health requires the authorization to include the name of a specific Caleo Health physician(s) or provider(s) in order to release the information, as well as the name of the specific entity, facility or individual(s) to receive the information.
  • Caleo Health can provide a patient or third party with the appropriate Authorization (Consent) Form to Collect Information and/or Authorization (Consent) to Release Health Information Form when necessary.
  • Incomplete Requests will be returned to the requesting party, we will provide details of the missing information to assist with fulfilling the request.

COMPLETE REQUEST

Requests that are complete will be processed. All physicians operating at Caleo Health will have a standing order regarding the processing of any medical document/information requests that are addressed to their name:

  • The request documents will be shared with the physician(s) named on the document for their review.
  • If the request is a chart request only, it will be processed by the Medical Records Department.
  • The chart will be shared with the physician(s) named on the requesting document for their review.
  • If the request contains specific questions or forms to be completed by the physician, the physician will determine an appropriate fee schedule to complete the work. (the fee schedule should adhere to AMA Uninsured Services Fee Guidelines)
  • The requesting party will be notified via fax or SecureMail when the records/documents have been prepared and they will be informed of the fee. Once the fee is processed by the Medical Records Department, the chart/documents/information will be released directly to the requesting party.

MEDICAL RECORDS/DOCUMENTS REQUEST







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    Protected Health Information (PHI)

    The Privacy Rule protects all “individually identifiable health information”

    held or transmitted by a covered entity or its business associate, in any form or media, whether electronic, paper, or oral.

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    What Regulations Influence My Practice?

    • HIA – Health Information Act (2000)-Canada
    • HIPAA – Health Insurance Portability and Accountability Act (1996)-USA
    • HIPAA Omnibus Guidelines – Updated regulations went into effect March 26, 2013 with compliance required by September  23, 2013
    • HITECH – Health Information Technology for Economic and Clinical Health Act & HITECH Safe Harbor –USA
    • PIPEDA – Personal Information Protection and Electronic Documents Act – Canada

    Additionally there is significant Provincial/State legislation as well as professional medical associations that have established very specific guidelines for the handling of patient information.

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For more information please contact the Medical Records Department: email |[email protected] or call |403.452.0999 ext. 113