Medical Records

No, we cannot. This is due to the need to protect patient confidentiality. We are not able to confirm identity over the telephone so we do not supply information over the phone. Additionally, we are not clinical personnel and cannot explain the test results.

For your information: An authorization is not needed to send copies of records to the physician overseeing your care while in the hospital, your family physician of record, and/or the physician who ordered outpatient testing. You may be able to obtain this information over the phone from your physician who has a relationship with you and is comfortable confirming your identity on the telephone. This depends on the physician's policy and may not be true of all offices.

Yes, we do accept faxed authorizations as long as the quality of the fax is legible. We accept authorizations from other facilities as long as they contain the basic components we require in a valid authorization. The components are:

• Patient Name
• Patient Date of Birth
• Name of organization records requested from
• Name and address of organization or person to receive the record
• Date(s) of treatment
• Specific type of documents/reports needed
• Purpose and need for disclosure
• Dated signature of patient or patient’s representative Informational notice regarding records protected under 432 CFR Part II (Substance Abuse and Mental Health Records)
• Informational notice regarding records protected under DPH rules of 1989, Public Act 174(HIV, ARC, AIDS)

For your information: Authorization for release of protected health information (medical records) can be a letter as long as it contains these elements.

It allows a formal method of obtaining patient consent and is evidence of that consent. The authorization serves several purposes:

• It serves as documentation of what needs to be done and
• Of the patient's consent to do so as well as
• A record of what has been released in the past.

Charges are made for record copies to help pay for record retrieval and copying. Patients have full access to their medical information at all times. The use of authorization forms and the practice of charging for copies reflect the regulatory and business aspects of this function.

For your information: Exceptions can be made for authorizations only in an emergency situation or if releasing to a physician involved in the care of the patient. The Operations Manager and/or the Department Director will address all exceptions on a case-by-case basis.

For in-patient care: If your family physician is your attending physician while you are in the hospital, yes, as the attending physician usually gets copies off all reports. An attending physician is the physician primarily responsible for your care while you are in the hospital. If your attending physician is not your family physician they may not automatically get copies of your reports. The attending physician may direct that copies be sent to your family physician. This is generally addressed on a case-by-case basis.

For outpatient care or testing: Copies of reports are sent to the physician that ordered the test. If this is your family physician, he/she will get a copy. If another physician orders them, your family physician will only get copies if the ordering physician directs that a copy be sent.

For your information: Your family physician can call us for copies of reports in your medical record as needed. An authorization is not required as long as that is your physician of record. If you are seeing a new physician for the first time, we may require authorization from you to confirm that it is acceptable to send copies. This is required to protect patient confidentiality.

No. The age of the majority in Michigan is 18. Therefore, in order to make the release valid, the patient would have to sign for himself/herself

Medical records are only faxed for immediate patient care purposes to a physician’s office or healthcare facility. It is not necessary that the patient is in the office when the fax is received, only that an appointment is scheduled for some time that day or the next. Otherwise, copies of medical records will be mailed or held for pickup. Faxing is a higher-risk method of transmitting patient information and will only be used for patient care purposes. Fax copies are often of poor quality. It is best to request records far enough in advance so they can be mailed. Records more than two years old are stored at an off-site facility and will take several days for retrieval.

Generally, we do not require notarization, just a signature comparison and check of identification. We may require notarization when we are not otherwise able to confirm your signature or if there is any legal indication that a notarized signature is required.

Yes, but only if the signed authorization form specifies that they may be released to that person. If there is a chance that someone else might pick them up for you, list them as the receiving party, along with yourself, on the authorization. See the question, “How can I get a copy of my medical records?”, for more details.

For your information: If the person picking up your medical records was not listed in the original authorization, provide an addendum (letter) with the date and your signature authorizing the designated person to pick up the records. If we can confirm your signature and the identity of the receiving individual, we will release your records to that person.

No, only if they have an authorization, signed by you or your legal representative, that specifies that your medical records may be released to that particular individual. Medical records will not be released without authorization except for continued patient care directly to a physician’s office or healthcare facility or in the event of a medical emergency.

For your information: A spouse may request that medical records be sent to an insurance company to resolve a billing problem and we will do so, however, the spouse will not see the records and will not be provided copies.

You can do so by submitting this form "Request for Amendment of Protected Health Information."

Your blood type may or may not have been tested when you were born. The only way to know is for us to look in your birth record if you were born at Lansingor LansingSt. Lawrence. All records that are more than two years old are stored at an off-site facility so it will take several days for them to be retrieved and reviewed. If you were not born here, your blood type was probably not tested unless you have had major surgery that presented the possibility that a blood transfusion may be required. It will be necessary for you to complete the form “Individual Request for Access to Protected Health Information” available from our office. Please see the Q: “How can I get a copy of my medical records?” for more details.

For your information: Contact the hospital where you were born (if not here) and/or the physician that delivered you. They may have it on file. If not, request an order from your family physician to have it tested.

Birth Records and Paternity papers are filed with the county in which you were born and the state in which you were born. Copies of these documents may be obtained from the County Clerk's office or the State Registrar where you were born. The hospital is not allowed to release copies of birth certificates and a copy is not maintained in the medical record.

We can only make corrections to very recent birth certificates and paternity papers prepared by our staff. This is determined on a case-by-case basis. You must contact the State Registrar to make corrections to older documents.

In the State of Michigan, death certificates are obtained from the county clerks office in the county where the individual expired. You may also be able to receive a copy of a death certificate by contacting the State of Michigan Bureau of Vital Statistics if the individual expired in Michigan.

Tetanus shots are usually given when there is an open wound. It will be noted in your record if you received a tetanus shot when in the hospital. You will need to sign an authorization to receive this information.

For your information: Your family physician may have this information in their files. Also, the Public Health Department tracks routine immunizations and will have a record of it if it was done as a routine immunization.

No, only if they have an authorization, signed by you or your legal representative, that specifies that your medical records may be released to that particular individual. Medical records will not be released without authorization except for continued patient care directly to a physician’s office or healthcare facility or in the event of a medical emergency.

Yes, non-custodial parents have an equal right to a child's medical information, with certain exceptions, as required by law. They can only be denied access if they have been stripped of all parental rights. We must have knowledge of the lack of parental rights to facilitate the denial.

Under the Michigan Medical Records Access Act, Public Act No. 47 of 2004, an heir or beneficiary of a deceased patient may be entitled to obtain copies of the deceased patient’s medical records from a health care provider.

Please follow from HF-35 “Affidavit of Heir or Life Insurance Beneficiary Requesting Medical Records” for all deceased patient record requests.

If the requester is not an heir or beneficiary, please follow the steps below.

1. The Personal Representative of the estate can only authorize records of deceased patients for release.
2. The Personal Representative is appointed by the court to function in this capacity.
3. The Personal Representative must present copies of the court appointment before records are released.
4. These records cannot be released to the next of kin or to the person nominated as the Personal Representative nominated prior to death in a will, trust, power of attorney, or other document.

The Personal Representative of the Estate of the deceased individual can authorize the medical records of the deceased. The Personal Representative fills a role similar to that of the Executor and is the title now commonly used. The Personal Representative has to be appointed by the Probate Court and bring documentation proving the appointment before records will be released. Items such as Power of Attorney, Durable Power of Attorney, or designation as decision-maker in an Advance Directive are no longer valid after the death of the patient. Also, we cannot accept copies of Wills or Trust documents naming potential Personal Representatives, they must be formally appointed by the court before we can accept their authority.

For your information: There is one document, generally titled "Assignment of Personal Property" that may be acceptable for records release depending on what it specifies. It must be signed by a judge and specify medical records as property to be disbursed. Check with the Operations Manager if one of these is received.

Also, records on deceased persons can be sent directly to life insurance companies for purposes of payment of benefits.

This area of law is open to much interpretation and differing opinions. We will be glad to review any supplied documentation with UM Health-Sparrow Risk Management and/or legal counsel.

These records may have been moved to another practice or placed into storage. Please contact UM Health-Sparrow Practice Management at 517.364.6200 for that information and assistance in obtaining copies of the records.

Usually, a physician that is retiring or leaving the area sells his/her practice to another physician. If there is a practice at the site of your former physician’s office, contact the new doctor to see if that is the case.

If there is no practice at that location now, contact the Michigan State Medical Society. They may have information on the physician’s whereabouts and/or provide assistance regarding the location of office records.

If the physician was located in a UM Health-Sparrow Office/Clinic, contact UM Health-Sparrow Practice Management for further information.

For your information: If none of these provide any results, contact the Medical Staff Office. They may have some knowledge of the physician’s whereabouts. Another possibility might be to contact the clinical department in which that physician practiced for any information about his/her whereabouts.

Yes, you can get them but it is necessary that you submit a written request for the information. You can come to the department to pick up the list or have it mailed to you. The written request must list the time frame and include your signature.

For your information: Getting a copy of your records will also supply all treatment dates.

If you can supply:

• The admission date
• The patient’s Social Security Number
• The patient’s date of birth
• Call back number (ask for a number of a switchboard or receptionist, an indirect number that will allow confirmation of location).

We will provide this information over the phone. We will not share any diagnosis information or any other details about the hospital stay.

For your information: For more information than the discharge date a request has to be issued in writing.

Because the medical record is the property of the Hospital, copies for subpoenas can only be produced when subpoenaed directly from the Health Information Management department. Any physician who receives a subpoena or request for deposition is welcome to come and review the record and may have copies of the documentation generated by him/her, but complete record copies are not supplied. We will check to see if the record has been subpoenaed from us, and if not, either Health Information Management staff or Risk Management staff will contact the party issuing the subpoena to clarify the issue. If the subpoena requests that someone appear with the record and testify as to the status of the record, that will be done by Health Information Management staff.

Medical Education will supply a request form authorizing the review of the record. Please call 24 hours to 48 hours in advance and bring the request form with you when you come to review the record. The record may not be removed from the department and copies may not be made.

All studies need to be approved by the Institutional Review Board. Contact the Institutional Research Review Committee for the application packet. This will provide all of the information you need to complete the application process. HIM will also need to sign off on the application. This allows us an opportunity to determine the resources needed to supply records in the time frame needed. In general, we will need to know:

• Number of records needed
• Period of time during which review will be conducted
• Age of records (some are located off-site which takes more time)
• Information sought (we can sometimes suggest another source for data, saving you from reviewing so many records).
• Copy of the record list when it exists; we can also provide assistance in generating lists based on the parameters you supply.

Please note that records pulled for studies may not be removed from the Department. All reviews must be done in HIM.

These requests will usually be met by reprinting the dictation from the transcription system. Extremely long lists will be done in turn but may take some time. We may ask you if there is a problem with the distribution of copies, as these should be routed automatically to your office. That will prevent the problem in the future. We need a list that includes:

• Complete patient name
• History # or Account #
• Date of Service
• Report needed

We can send you a copy of the order but only of the order. We will not divulge any other patient information or record copies.

For your information: You can also send a certification and/or ask for documentation from the physician. This will be necessary because if the patient was not in the hospital immediately prior to the order, no order will be in hospital records.

We should not under any circumstances release a physician's DEA number, even if you know how to access it. Only the physician should supply this number.

For your information: The Pharmacy can contact the physician for this information. They may also be able to get assistance from the Medical Staff office. If they cannot identify the physician, it may be necessary for them to contact the patient about this problem and obtain further information from them.

No. Although it is possible to consider that statement as an "order" of sorts, it is not recommended that this be done. We have no confirmation that the patient has requested, is expecting, or desires this information. There is no method for tracking this release or to confirm that the patient receives it once sent. Additionally, it is the responsibility of the physician to provide results to patients with an accompanying explanation if needed. It is not the function of transcription to provide this service to physicians.

For your information: Patients can request and receive a copy of the report or the physician can supply one through the physician's office.

Please contact Health Information Management at 517.364.2276 to request a machine readable EHI export.