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Release of Information

Release of Information

Release of Information

Patient Requests to Access Protected Health Information (PHI)

Thank you for your request for access to your/your child’s Protected Health Information (PHI).Below is a summary of our Policy and Procedure about the release of PHI.

You may request in writing access to PHI in the medical and/or billing records. Your request for access to the PHI will be processed as follows:

Written Requests:

Requests for access to PHI must be in writing. Please fill out the Consent for Release of Medical Information form provided by Three Rivers.

  • The request for access to the PHI will identify the particular PHI for which access is sought.
  • The request for access to the PHI will identify the manner in which you are requesting access to the PHI (i.e. a paper copy, an in-person review, or an electronic copy of the billing record).

Three Rivers will respond to requests for access to PHI within thirty (30) days after receipt of the request for the PHI if it is maintained on-site and within sixty (6) days after receipt of the request for PHI if it is maintained off-site. Three Rivers may extend its time to respond to a request for access for one additional 30-day period. In these circumstances, Three Rivers will notify the requesting individual before the initial term period expires of the reasons for the delay and the date by which a Facility will complete its action on the request.

Reviewable Grounds for Denial

Three Rivers may deny access to PHI in the following situations:

  • A licensed health care professional has determined, in the exercise of professional judgement, that the access requested is reasonably likely to endanger the life or physical safety of the patient or another person;
  • The PHI makes reference to another person (unless such other person is a health care provider) and a licensed health care professional has determined, in the exercise of professional judgment, that the access requested is reasonably likely to cause substantial harm to such other person; or
  • The request for access is made by the patient’s personal representative and a licensed health care professional has determined, in the exercise of professional judgement, that the provision of access to such personal representative is reasonably likely to cause substantial harm to the patient or another person.

If your request for review is denied you have a right to have the denial reviewed and will be provided the basis for the denial, a statement of your review rights, including a description of how you may exercise the review rights; and a description of how you may file a complaint to Three Rivers pursuant to the Facility complaint procedures or to the Secretary of HHS.

Fees for Copies or Summaries

Three Rivers will charge a reasonable, cost-based fee of which includes the cost of:

  • Copying, including the cost of supplies for and labor of copying, the PHI requested;
  • Postage, when you request the copy, or the summary or explanation, be mailed; and
  • Preparing an explanation or summary of the PHI, if agreed to by you, as required by facility policy.

The copying fee is $.65 per page for the first 30 pages and then $.50 per each page after the first 30 pages. Three Rivers may also include a postage fee and any summary fees described above if applicable.

 

  • Consent for Release of Medical Information

  • Date Format: MM slash DD slash YYYY
  • Information to be Released From:

  • Information to be Released To:

  • I understand that information to be released may include information regarding drug abuse, alcohol abuse, psychological or psychiatric impairments, HIV and/or AIDS, or physical conditions. I certify this authorization is made voluntarily. I understand that the information to be released is protected under state and federal laws and cannot be re-disclosed without further written consent unless provided for by state and federal law. I understand that treatment and payment are not conditioned upon my consent to release information. I understand I may revoke this authorization at any time, except to the extent that action has already been taken. If not previously revoked, this consent will expire in six months from date of discharge.