As care and services are provided to you at Millcreek Comunity Hospital it is the Medical Records Department’s responsibility to ensure this information is documented appropriately, timely and kept private in your medical record. In order to achieve this, the Medical Records Department performs a multitude of tasks. We collect the records from the various care areas and assemble it in a standardized order, analyze it for completeness, code it for reimbursement and release information from it to provide follow-up healthcare services. Additional tasks performed in Medical Records are the transcription of dictated documents to paper, completion of birth certificate information and abstraction of data for state and federal quality of care requirements.

Since Millcreek Comunity Hospital is dedicated to being a teaching hospital the Medical Records Department works closely with students, interns, residents and attendings on chart documentation guidelines and research projects to improve the quality of care they provide. We also provide local colleges with the opportunity for their medical record students to perform an internship in the Medical Records Department.

From the publics perspective perhaps the most important services we provide are the release of information services. Often patients need to obtain a copy of the services they have received at Millcreek Comunity Hospital in order to receive follow-up care by their physicians or specialists. Other patients just believe it is important to maintain copies of their records for their own personal use. Regardless of the reason it is easy to obtain these copies by adhering to the following guidelines:

• The Medical Records Department is open for release of information services from 7:30 am to 4:30 pm Monday through Friday except on holidays.

• An authorization form must be completed by the patient and sent to the Medical Records Department. Please provide at least 24 hours notice prior to when you need the copies. You may also call the Medical Records Department at 814-868-8399, request your records and complete the authorization form when picking up the copies. Release of Information Form

• When arriving to pick up the copies a picture ID will be required for verification purposes.

Here are some frequently asked questions regarding the release of information process.

Q. Why is an authorization form needed to release my information?

A. We are required by law to protect your information. In order to accomplish this the law requires that we obtain an authorization signed by the patient when releasing information to anyone, even the patient.

Q. Who is allowed to sign this authorization form?

A. It depends on the situation.

- You, the patient (not your spouse or relative)

- Your parent (if you are younger than 14 years of age for behavioral services or 18 years of age for all other services)

- Your legal guardian (documentation will be required to support this)

- Your Power of Attorney, if you are unable to sign (documentation will be required to support this). Please also note just because you have a Power of Attorney does not mean they can request your information. If you are able to sign for the information yourself then your signature is required, not the Power of Attorney’s. Also, the Power of Attorney must be specified to be able to make healthcare related decisions.

- If the patient is deceased the following people are allowed to sign the authorization form provided the appropriate documentation is provided: executor of deceased’s estate or the legal representative of deceased.

Q. What information is released?

A. Experience has shown that the information people need is contained in the discharge summary, operative reports and history and physical therefore this is the information routinely released. When another healthcare provider is requesting information they may receive copies of laboratory and radiology results as well.

Q. What information is not released?

A. Unless specifically requested behavioral health, drug and alcohol information and documents missing physician signatures are not released. Also, copies of radiology films and billing statements are not included. To request a copy of these please contact the Radiology Department or Patient Accounts Department.

Q. Are there fees I must pay to obtain copies of my information?

A. If the information is being sent directly to another healthcare provider there will not be a fee. If the information is being released to the patient there is a per page fee that is charged and required at time of picking up the copies.

Q. Is there any time that I might be told I cannot have a copy of my information?

A. Yes there are situations where this might occur. For example if you are not authorized to request the information or if your healthcare provider believes obtaining a copy of the information could bring harm to yourself or others you will be denied access to the records.

If you have further questions regarding the release of information process please do not hesitate to call the Medical Records Department at 814-868-8399.