A physician has a duty to ensure that information is released only to properly authorized individuals. Assume, for example, that a patient has signed an authorization to release information to an employer. The medical care practitioner can legally release information to the employer, but he or she must ensure that the person requesting the information is the one authorized to have it. This might require that the information be sent to the personnel department rather than be given to a caller on the telephone.

If someone presents an authorization that the patient has signed, the medical care practitioner should endeavor to determine if the release is valid. If the release is over a few months old or appears irregular, the medical care practitioner should attempt to contact the patient before releasing the information. If the patient cannot be located, the medical care practitioner should contact the person seeking the information and try to verify the authenticity of the release. If the medical care practitioner is still suspicious, he or she should request that the person seeking the information have the patient contact the office. Medical care practitioners should also be wary of subpoenas. In many states, these can be issued without supervision by a judge, and they are very easy to forge. The medical care practitioner should insist on a signed release from the patient, and should call the law office listed on the subpoena to assure that the subpoena is valid. The best policy is to have the office staff contact the patient and tell them about the subpoena before turning over the records.

A physician has a right to charge a nominal fee for a copy of the patient’s medical record. This fee should reflect the actual charge for copying the chart. If the patient is indigent, the physician should provide the chart or an appropriate summary at no cost. Under no circumstances should the physician attempt to hold the chart hostage for an unpaid medical fee or to prevent the patient from seeking care elsewhere. This is bad public relations and may cause the patient to sue to obtain the record.