Board of Censors Position Statement: Release of Medical Records

The general rule regarding the release of a patient’s medical record is that information contained in a patient’s medical record may be released to third parties only if the patient has consented to such disclosure. The patient’s express authorization is required before the health care provider can release medical records to the following parties: patient’s attorney or insurance company; patient’s employer unless a workers’ compensation claim is involved; member of the patient’s family, except where the family member has been appointed patient’s attorney under a durable power of attorney for health care, government agencies, physicians and other third parties.

Who Can Consent to the Release?

Generally, the authority to release medical information is granted to: (1) the patient, if a competent adult or emancipated minor; (2) a legal guardian or parent if the patient is incompetent or a minor child; and (3) the administrator or executor of the patient’s estate if the patient is deceased.

Who Has to Be in the Release?

Common elements of a valid general release include:

• Patient’s name and identifying information
• Addresses of the provider or institution directed to release the information.
• Description of the information to be released
• Identity of the party to be furnished the information
• Language authorizing release of information
• Signature of patient or authorized individual
• Time period for which release remains valid.

Information in release form should also be verbally communicated to the patient. Information should be translated into other languages as needed.

A physician can ultimately be responsible for unauthorized disclosure of medical information without the individual’s authorization, a written consent form should be completed by the examinee authorizing the physician to release the medical information or report to the third party.