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
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.