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UWHC,

Medical Records,

Departments & Programs,UW Health,Health Information Management

Release of Information (ROI)

Release of Information (ROI) - Departments & Programs, UW Health, Health Information Management

The Release of Information (ROI) section of Health Information Management (HIM) is responsible for the accurate and timely release of copies of medical records to outside requesters (including patients, insurance companies, other physicians/healthcare providers, attorneys, etc). All release of information is done in accordance with Wisconsin State Statutes, federal regulations and UW Health policies and procedures.


Focus

UW Health is now able to release information on DVD. Requesters may obtain information on an encrypted/password-protected disc. They must request the information in this format when submitting the authorization.

Authorizations

Authorizations/Advanced Directives (Medical Records Forms Library) 

Statutes

Wisconsin Statutes

Search Statutes for:

HIPAA-COW

Centers for Medicare and Medicaid Services

Health Information Privacy

FAQ

A patient has requested to view their own medical record. Who should they talk to in order to do this?

WI State Statutes regulate patient access to their medical record which is detailed in UWHC Policy and Procedure 6.13 and/or UWMF Patient Right to Access, Inspect & Copy PHI policy. Simply refer the patient to Health Information Management at 263-6030, Option 3, to schedule a viewing appointment. Viewing of the medical record for both UWHC and UWMF will be held at the UW Health Office Building at 8501 Excelsior Drive.

A patient wants to write a letter to request a release of copies of their medical record. Is this acceptable?

No - the new HIPAA regulations now require certain elements to be included in an authorization. This eliminates our ability to accept a written request that is not included on a compliant authorization.

An attorney called and wants copies of a patient's medical record. What should I do?

Refer the attorney to Health Information Management at (608) 263-6030, option 5.

Are there any special laws regulating release of mental health, AODA, and HIV test results?

Yes. Wisconsin state statutes govern access and disclosure of the above listed protected health information. WI ss. 51.30 governs mental health and AODA, and WI ss. 252.15 governs HIV test results.

Do I need a signed authorization to release copies of medical records to a patient?

Yes.

I have a general question about how to go about releasing copies of patient medical records, who can I call?

Contact the HIM department 

UW Health Release of Information, (608) 263-6030, Option 3

I need to release copies of a patient’s medical records to another doctor but don’t feel comfortable or don’t know how to do this. What should I do?

HIM can do this for you. Simply go out to the main menu of Health Link. You will notice the columns labeled MF Epic and HC Epic. Within those columns is a link to request the HIS department (working for your organization) to release those records for you. 

You need to complete all required fields for the request to be submitted. Also, please note that this process may not be used for any releases that require an authorization signed by the patient/legally authorized representative (examples of appropriate usage = release for continuity of care, work comp).

I need to speak with someone in Release of Information ASAP – how do I do that?

The Release of Information section of Health Information Management can be reached by calling (608) 263-6030, Option 3. Or page 265-7000, pager ID 5757 (during normal business hours) and the ROI staff will call you back immediately.

I would like to view my child's electronic medical record, which authorization form should I complete?

Employees are NOT permitted to access the medical records of family members (including their children of any age) or other individuals through Health Link, even if authorization for such access is provided by the family member or other individual. Effective January 1, 2014, UW School of Medicine and Public Health, UW Medical Foundation and UW Hospital and Clinics put in place a UW Health-wide policy which permits employees to use their Health Link login ID only for work-related purposes and to access their own personal medical records. All patients, including employees, are encouraged to access medical records via MyChart and may also obtain electronic (DVD) or paper copies of their medical records by submitting appropriate authorizations to the Health Information Management Department.

I've received a request for release of information. What should I do with it?

The quickest way is to fax it to (608) 262-6663. If faxing, there is no need to send the hard copy. Another way (for non-urgent requests) is to send the request to Release of Information via interdepartmental mail with mail code 2427. Please make sure the form is fully completed and contains contact information for the patient should questions arise. Call (608) 263-6030, Option 3 if you have questions or need assistance with this.

I've received a request from an insurance company (DVR, Work Comp, etc.) that includes a form that a physician needs to complete along with a request for copies of records. How should I handle this?

Have the physician complete the requested paperwork. Fax completed form and request to HIM ROI department at (608) 203-4580. HIM will process the paperwork together.

The physician I work with just received a subpoena for a deposition. Can the physician take the UW Health medical record to the deposition?

Absolutely NOT. By doing this, it allows the attorney to label the medical record as an exhibit, which means that the medical record must remain exactly as it was when it entered the deposition. This means that we may no longer use that specific record for patient care and may not add or alter the content of the record until after the trial/court case has been closed. 

Contact the Assistant Director of HIM at (608) 203-4572 for assistance in preparing copies for your reference during the deposition.

What are the documentation requirements if I release copies of medical records as requested using a signed authorization?

WI § 146.82 requires that the following elements be documented when releasing PHI: The date (mmddyyyy) the disclosure was made, name of person/organization making the disclosure, name of person/organization receiving the information, identification of specific PHI that was disclosed (including dates) and the purpose of the disclosure. 

Documentation of the disclosure can be done using Quick Disclosure via the More Activities button in Health Link (when an authorization is not required). Otherwise, staff should document on the authorization in the lower right cornerthat the disclosure was made so that HIM does not perform the release a second time. Information documented should include the date of disclosure, person making the disclosure and exactly what was disclosed (including dates).

What do I do if I get a subpoena for medical records either served to me or in the mail?

Never address the subpoena yourself - contact the Assistant Director of Health Information Management, (608) 203-4572, for assistance.

What form should I use to document a release when an authorization is not required?

Quick Disclosure should be used to document a release of PHI when an authorization is not required. There is no longer the option of documenting this on a paper form. If you have questions regarding documenting the disclosure, please call (608) 263-6030, Option 3, for assistance.

What if I want to do the releasing myself?

Staff not employed in the Release of Information section of HIM do not have the education/training in State and Federal laws that govern confidentiality and security of medical records. Release should not be done by anybody other HIM unless there is a thorough understanding of these laws. It is highly recommended that all release is performed by HIM. 

The quickest way is to get the request to HIM is to fax it to (608) 262-6663. Faxing, there is no need to send the hard copy. Another way (for non-urgent requests) is to send the request to Release of Information via interdepartmental mail with mail code 2427. Call (608) 263-6030, Option 3 if you have questions or need assistance with this. 

If releasing outside of HIM, know that the disclosure must be accounted for using Quick Disclosure. Contact HIM at 263-6030 Option 3 for guidance.

What should I do when a Work Comp insurance company calls and wants medical records or appointment dates?

UWHC - refer the caller to Health Information Management at 263-6030, Option 3.
UWMF – Callers will fax in request for appointment dates to the clinical site who will validate identity and provide information. Requests for copies are submitted to HIM for processing.

What should I do with the completed authorizations after I've released medical records?

Send the authorizations to Health Information Management (mail code 2427) to be scanned into the medical record. Remember, you must document that you released information on the authorization to avoid having HIM release again. 

Documentation requirements include: The date (mmddyyyy) the disclosure was made, name of person/organization making the disclosure, name of person/organization receiving the information, identification of specific PHI that was disclosed (including dates) and the purpose of the disclosure.

When can I release information without a signed authorization?

UWHC policy 4.13 identifies those situations where PHI may be released without a signed authorization - primarily for treatment, payment or health care operations. Please review the policy for those specific circumstances.

When should I use the Authorization for Verbal Communication?

This authorization should be used when the patient has authorized the healthcare provider to talk with somebody as requested by the patient. Hospital Policy 4.13 allows for the communication between the provider and the spouse, close family member or directly involved in the patient’s. The Authorization for Verbal Communication and/or to Leave Voice Mail Messages ( UWH #1280490V-DT) is available on U-Connect – print this out each time it is used to ensure the most current version is used.

When should I use the Authorization to Leave Voice Mail Messages?

This form should be used when the patient has authorized the health care provider to leave PHI on the patient’s voice mail - this includes such information as results. The Authorization for Verbal Communication and/or to Leave Voice Mail Messages (UWH #1280490V-DT) is available on U-Connect – print this out each time it is used to ensure the most current version is used.

Who do I contact with questions regarding release of information?

You may contact one of the following:

Dawn Paulson, RHIA
Assistant Director of Health Information Management
(608) 203-4572 or dpaulson@uwhealth.org 

Howie Heilprin
HIM-ROI Supervisor
(608) 203-4641 or hheilprin@uwhealth.org