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Release of Records Authorization

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Medical Records Release Policy

The purpose of this policy is to ensure that our patients' medical records are not released to any unauthorized individuals. We have developed a tracking system to document an accounting of disclosures to remain compliant with HIPAA.

  • Medical records may be released to healthcare providers who are participating in your care under continuity of care regulations. If we have referred you to another doctor, we will send your records prior to your appointment.
  • You may request a copy of your own medical record. A medical release form must be completed. No email, telephone, or verbal requests will be accepted. Your signature is required for your protection.
  • Patients are the only individuals who may authorize the release of their medical records—not spouses, adult children, or friends—unless they have legal power of attorney or are the legal guardian of a minor.
  • West Bend Family Medicine recognizes that HIPAA does not require written consent for all disclosures of medical information; however, we have chosen to implement this policy to further protect the confidentiality and privacy of our patients.
  • Due to the transition to a new electronic medical record (EMR) system, West Bend Family Medicine will make reasonable efforts to ensure that a complete medical record is disclosed. Despite these efforts, there may be instances in which certain documents are unavailable or omitted.
  • Requests for medical records may take up to 30 days to process.
  • We may charge a reasonable fee to offset the costs associated with specific categories of requests. Fees are based on factors including equipment and supplies, employee labor, administrative overhead, and postage, including express mail when requested by the authorizing party. The State of Oregon has established a fee schedule for medical records, and our charges are determined according to that schedule. We reserve the right to waive these fees under certain circumstances.
  • The HIPAA Omnibus Rule, effective September 23, 2013, allows for the identification of labor costs associated with copying protected health information (PHI), whether in paper or electronic form. This may include a reasonable, cost-based fee for the time required to create and copy the requested records. Labor costs for copying medical records vary by state according to applicable legislation. The current fees for the State of Oregon are listed below.

Pages 1–10: $30 Flat Fee
Pages 11–50: $0.50 per Page
Pages 51+: $0.25 per Page

Bonus Fee: $5.00 if processed within 7 days
Postage: Actual cost of mailing

Release of Records:
Authorization to Use and Disclose Protected Health Information

This authorization must be signed and dated by the patient or by a person authorized by law to release this information.

I hereby Authorize:*
WEST BEND FAMILY MEDICINE
633 NW York Dr. Ste. #110
Bend, OR 97703
Phone#: (541)383-8066
Fax#: (541)383-3066
Patient Full Name*
MM slash DD slash YYYY
Facility/Provider Name*

By initialing the space below, I specifically authorize the release of the following medical records, if such records exist:

for the continuity of health care. If the information to be disclosed contains any of the types of records or information listed below, additional laws relating to the use of the highly confidential information may apply. I understand and agree that this highly confidential information will be disclosed if I place my initials in the applicable space.

**INITALS REQUIRED (even if you feel they may not apply, unless you do NOT want disclosure _____Initials)

This authoriza3on may be revoked at any 3me, except when the ac3on has been taken in reliance on the authoriza3on. Unless revoked earlier, this consent will expire 1 year from the date of signing. I understand that the informa3on used or disclosed pursuant to this authoriza3on may be subject to re-disclosure and no longer can be protected under federal law. This authoriza3on must be wriEen, dated, and signed by the pa3ent or by the person authorized by law to give authoriza3on. If the individual comple3ng this form is the legal guardian, has legal custody of, or has power of aEorney for the pa3ent, the legal document indica3ng authoriza3on must accompany this request. Comple3on of this form is voluntary. However, refusal to release necessary medical informa3on may affect eligibility for services.

By Signing Below, I acknowledge that this document was given to me in a language I understand either in wri3ng or as read to me in its entirety.

Patient Name*
MM slash DD slash YYYY
MM slash DD slash YYYY

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