What is a medical record?

The medical record is a legal document that contains sufficient information to identify the patient, support the diagnosis, justify the treatment, document the course and results, and promote continuity of care among health care providers.

Who owns the medical record?

Healthcare facilities initiate and maintain a medical record for every individual assessed or treated. The facility collecting the information owns the record.

Is my health information kept confidential?

Releasing information is a routine and necessary activity in a health care facility to facilitate communication among caregivers and to allow the enterprise to carry on its daily operations. However, the patient’s right to privacy and confidentiality, which is protected by law, must be observed. Access to information is based on the "need to know" principle. No healthcare information (unless for a reason documented below) is released without a signed authorization form by the patient.

Slocum-Dickson Medical Group ensures that all healthcare information, whether in paper or electronic form, is kept strictly confidential.

What is the purpose of the medical record?

The purpose of the medical record is:

To facilitate patient care
Serve as a financial and legal record
Aid in clinical research
Support decision analysis
Guide professional and organizational performance improvement
How can the patient get copies of his/her medical records?

Patients have the right to inspect or receive copies of their medical records under the provisions of the New York State Public Health Law, Chapter 497, Section 18 regarding access to patient information.

  1. All patient access requests are to be directed to the Medical Record Department.
  2. All patients will be required to complete a written authorization before inspection or release of information will occur. Special release forms need to be signed for information containing AIDS/HIV related information, drug and alcohol abuse related information, and psychiatric care information.
  3. Inspection requests and inspections of medical records are limited to business hours, Monday through Friday, 8:30 a.m. to 4:30 p.m. Inspection will not take place during any other hours, holidays, or weekends.
  4. If copies of records are requested for continuity of patient care, there will be no charge for the copies. If copies of records are requested for personal use, Slocum-Dickson Medical Group is allowed, by law, to charge a fee of $.75 per page. (If a patient has proof of inability to pay, this fee will be waived.)
  5. Slocum-Dickson Medical Group shall be provided ten (10) working days to present copies of medical records.
  6. If copies of the record are being picked up by someone other than the patient, that person needs a signed permission slip from the patient, legal identification, and whatever payment that may be required.
     

How do I contact Medical Records?

To contact our Medical Records Department, call us at 315-798-1498.

Who is qualified to sign an authorization form?

The patient must personally authorize the release of his/her health information.

Exceptions:

A custodial parent may sign for a minor child under 18 years of age
A health care agent or proxy may sign for the patient
A court appointed guardian, upon presentation of documentation
In cases of divorce or separation, the parent who has legal custody of a child (it is the parent’s legal obligation to provide proof of custody)
In cases of joint custody, either parent can sign a release, unless the court ruling states otherwise (it is the parent’s legal obligation to provide proof of such ruling)
Legal guardian in the event of a patient’s incapacity (proof of guardianship required)
Emancipated minor (as defined by New York State law)
When is a patient’s authorization not required?

Patient authorization is not required for:

   

Disclosures for a medical emergency
Disclosures authorized by a court order
A court appointed guardian, upon presentation of documentation
Disclosures to report to State and Federal databases