Primary Care Coding Alert

Remember: No judge’s decree, no patient info for requester.

In a past issue of the Family Practice Management Alert, we’ve provided some tips on properly responding when a patient requests access to his medical records.

Problem: What should a medical practice do if a court order or subpoena is issued for the patient’s medical records? It’s a question we put to Jim Sheldon-Dean, principal and director of compliance services for Lewis Creek Systems, LLC, in Charlotte, Vt.

Here’s what he had to say.

“First, pay no attention to subpoenas unless they are instruments of the court, with a real judge’s signature,” says Sheldon-Dean. “If that’s what you get, a valid court order, you must obey.”

It would also be good practice to inform the patient when you release his information, says Sheldon-Dean, even though the Health Insurance Portability and Accountability Act (HIPAA) does not specifically require you to contact him in most such cases.

There are exceptions, however.

In some cases, a court might subpoena information that requires patient consent, says Sheldon-Dean. This might occur “in lawsuits that involve patient information. But in those cases, the patient has a right to be notified and object to the disclosure.”

Advice: Make every effort to inform the patient if you release his information under subpoena, unless you are constricted for some legal reason. If you are unsure about your practice’s legal and/or HIPAA responsibilities when you receive patient information subpoenas, consult a healthcare attorney.