Confidentiality, Privacy and Security

Protocol/policy for request from federal agency for medical records

  • 1.  Protocol/policy for request from federal agency for medical records

    Posted 12-02-2020 12:53

    [Posting on behalf of @Kim Sherwood]

    Good afternoon,  I am seeking guidance on a situation that has been presented to me by my medical records department.  I work for a substance abuse treatment facility in Maryland.  We have received a faxed request from a federal agency for medical records on a previous patient.  The release provided has been signed by the patient.  My question is does anyone have a protocol/policy in place to adhere to such a request?  Is there a certain federal requirement that mandates this type of request? Any guidance anyone has will be greatly appreciated.

    Kim Sherwood, M.S.M.
    Compliance Manager  



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    Annessa Kirby
    AHIMA
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  • 2.  RE: Protocol/policy for request from federal agency for medical records

    Posted 12-02-2020 13:27

    My question would be, if you have a signed release from the patient, why wouldn't you provide them with the requested records?

     

    Becky Kilen, MS, RHIA, CHPS

    GHS Privacy Officer | Manager of Privacy

     

    GUNDERSEN HEALTH SYSTEM 

    1900 South Avenue | Mail Stop:  AVS-001

    La Crosse, WI  54601

    Phone:  (608) 775-3549 | Fax:  (608) 775-4706

    rakilen@gundersenhealth.org

     

    Privacy Office: (608) 775-7439 | PrivacyOffice@gundersenhealth.org

     

    http://connect.gundluth.org/hipaa/home

     

     

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  • 3.  RE: Protocol/policy for request from federal agency for medical records

    Posted 12-03-2020 01:13
    Hi Kim,
    Those records are likely covered under 42 CFR Part 2 regulations and as such, there are very specific requirements for a patient "consent" form as it is referred to therein.  I would start there and be sure you have a valid consent form.  These are a little different than the HIPAA Privacy Rule's "authorization for use and disclosure" provisions.  I'm providing a link here for these regulations.  Also providing a link to the SAMHSA site which is a good one to keep for reference on these records and their protections.  (42 CFR Part 2 - CONFIDENTIALITY OF SUBSTANCE USE DISORDER PATIENT RECORDS)
    LII / Legal Information Institute remove preview
    42 CFR Part 2 - CONFIDENTIALITY OF SUBSTANCE USE DISORDER PATIENT RECORDS
    View this on LII / Legal Information Institute >

    SAMHSA - Substance Abuse and Mental Health Services Administration

    SAMHSA - The Substance Abuse Mental Health Services Administration remove preview
    SAMHSA - Substance Abuse and Mental Health Services Administration
    View this on SAMHSA - The Substance Abuse Mental Health Services Administration >


    Hope this helps.  Best regards.



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    Joe Gillespie, MHS, RHIA, CHPS
    Senior Privacy / Security Consultant with tw-Security, LLC
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  • 4.  RE: Protocol/policy for request from federal agency for medical records

    Posted 12-03-2020 09:43

    Hi,

    I'm not that involved in ROI, but you may want  to review SAMSHA.

    The FR issued a ruling August 2020:
    https://www.federalregister.gov/documents/2020/07/15/2020-14675/confidentiality-of-substance-use-disorder-patient-records

    Hope this can help you. When it comes to substance abuse and mental health records, I would think their sensitivity have specific protocols to follow that are more strict than medical records. SAMSHA sections 42 U.S.C. 290dd-2(b), (c) and (f)

    I would suspect or hope that the entity who receives a fax would have a specific policy forbidding faxed receipt for a patient's medical record that includes substance abuse howbeit the patient signed it.
    Good Luck!



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    Kelly Randell
    DRG Analyst
    [G2 Corporation]
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