Medical Records Requests – Cerebral

Overview

ℹ️ A medical record is defined as any item, collection, or grouping of information that acts as a history of an individual's health, includes PHI, and is maintained, collected, used, or disseminated by or for a covered entity.

Medical records can be requested via:

The client themselves
A legal agency
A state or federal government agency
Other medical facilities or providers

Medical Records can be sent to:

The client
A 3rd party

Right of access

ℹ️ Clients are always entitled to their own medical records. This includes notes, medication information, and billing documents. It does NOT matter what the client intends to do with their records once they receive them.

🗒️ Cancelled or lead clients have the same rights to their records as active clients.

3rd party requested medical records

🗒️ All 3rd party requests must be completed in writing, either via our support email or fax in RingCentral.

Chart review/retrieval requests

Occasionally we will receive requests for something called a ‘Chart Review’ or a ‘Chart Retrieval’. These requests will look similar to a regular medical record request from a 3rd party, but are handled differently.

ℹ️ Chart review/retrieval requests are routine checks performed by insurance companies as a risk management process to ensure clients’ medical records are being documented accurately. These chart reviews are required under the federal Department of Health and Human Services Risk Adjustment Program guidelines.

⚠️ Chart review/retrieval requests do NOT require a HIPAA authorization or Release of Information to complete.

Please note that even though a HIPAA authorization form is not needed, the client’s information and PHI is still protected, completely confidential, and follows HIPAA guidelines.

Chart review/retrieval requests often come from companies called ‘Ciox Health’ or ‘Datavant’, but are not limited to only these companies. Be sure to look for the key words of ‘Chart Review’ or ‘Chart Retrieval’. These requests will have language to indicate that it is a chart review/retrieval request.

Changes to medical record requests: Exclusions & Amendments

There are 2 types of requests we may receive for changes to a medical record:

Exclusions
1. An exclusion is when a client wants temporary changes to their medical record by removing existing information.
2. These are the options in our HIPAA Authorization regarding exclusions:

Example: A client requesting a temporary exclusion of removing mentions of alcohol from their medical record being sent to a third party.
Note: If a client requests the exclusion of ‘Mental Health’ from their records, advise them that we will not be able to produce their records. Since we are a mental health platform, all records we contain will be related to the client’s mental health and therefore cannot be excluded. This applies to billing records and medication records as well.

Amendments
1. An amendment request is when a client wants information in their record permanently altered due to them considering the information incorrect or inaccurate.
2. Examples:
  1. Incorrect client info, such as a date of birth.
  2. An incorrect name, like switching a brother's name with a father’s name.
  3. Incorrect medication or dosage.
3. Note: The timeline for the Privacy team to review and approve or deny amendment requests is 60 days.

Legal request WITH a subpoena

⚠️ If a client is requesting their records be sent to them and states that they plan to use them in a legal proceeding or will be giving them to a lawyer, probation officer, social worker, etc., this is NOT a legal request.

🗒️ Subpoenas can come from law offices, parties to a lawsuit, or be requests from state or Federal Courts (Superior Court or U.S. District Court) as well as State Departments and/or U.S. Attorney/Attorney General Office.

Legal requests MUST be made in writing via our support email or RingCentral fax. If a law office calls in requesting records, advise them to submit their request in writing.

Emergency medical records request

ℹ️ In emergency situations, hospitals or federal/local law enforcement may contact Cerebral via phone to request a mutual client’s medical records. Records may be released to hospitals or federal/local law enforcement for emergency purposes without a HIPAA release form/client authorization. This also applies if the client is currently incapacitated/incarcerated.

ℹ️ Client medical records are protected under HIPAA for 50 years beyond the date of death.

How to send a medical record

🗒️ We cannot send medical records via physical mail at this time.

✅ DO: Always send the requester the medical record in the format it has been requested to be received.

There are 3 ways to send a medical record:

Email sent via PandaDoc
Fax sent via RingCentral [common for 3rd party requests]
Email sent via ZenDesk

🗒️ If the client is subject to incur an additional fee for requesting their records from their previous provider(s), we can offer a 30% credit off of the next month’s subscription. If we are reaching out to request records on the client's behalf and a third party asks us to pay the fee directly, we should inform them that it is the client’s responsibility to pay the fee.

Requests for financial/billing invoices

If a clients request financial/billing invoices, we can download all receipts for the dates requested.

If a client requests itemized invoices, we can provide a superbill.

ℹ️ If a client requests a copy of their invoice to be sent to a different email than the one associated with their account:

We can change the client’s email in the EMR over the phone, then send the invoice via ZenDesk to the new email associated with their account.
If the client does not want their email address to be permanently updated, they must complete a HIPAA authorization in order for us to send the invoice to a different email than the one associated with their account.