CASE 2: NON-COMPLIANCE
Case 2: A
22-year-old male who had been referred by his internist to a surgeon was
being terminated from the surgical practice because of
noncompliance. Upon receipt of the termination letter, the patient
called the surgeon, irate. He demanded that the surgeon send him a
copy of his record but release information to no one else. The
surgeon believed it might be in the patient’s best medical
interest to send a copy of the record not to the patient but to the
patient’s internist. He called ProMutual Group for
guidance.
This patient, like all patients
with the exception of some psychiatric patients who may be entitled only
to a summary of their record, has a right to a copy of his record, but
not to the original. In general, copies of a record that is needed
for treatment may be sent to another healthcare provider without the
patient’s written authorization. When, as in this case, the
patient specifically requests that the physician not release the record,
that request should be honored until or unless a request for release is
accompanied by a court order, the patient later signs an authorization
directing the surgeon to release records, or in certain emergent
situations. In the above case, the patient, but not the internist,
should be sent a copy of the patient’s record.
Next Page: Case
3: Abusive Behavior
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