Form Com025 - Internal Tracking Of Request To Access Medical Records - Department Of Behavioral Health, County Of San Bernardino

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County of San Bernardino
Department of Behavioral Health
INTERNAL TRACKING OF REQUEST TO ACCESS MEDICAL RECORDS
[THIS FORM IS FOR INTERNAL USE ONLY]
This form must be returned to the Medical Records Office with your determination by (date)______________________
This is to inform you that we have received a request for access to the protect health information (PHI) of the consumer
named on this form.
This request was received from:
( )
Consumer
( )
Parent, guardian, or conservator
( )
Legal representative
( )
Law Enforcement
( )
Other
Specify: ____________________________________________
The type of access request is:
( )
Inspection
( )
Copies
( )
Summary
If access is approved, please complete PART II of this form, signing and dating as appropriate. In certain circumstances,
access can be denied. If access is denied, please complete PART IV, including reason for denial, your signature and date of
decision.
Inspection must be permitted within five (5) working days after receipt of the request. Copies must be
transmitted within fifteen (15) calendar days or if a summary is requested within ten (10) working days.
An extension can be made up to thirty days from the date of the request.
After making your determination, A NOTATION MUST BE ENTERED IN THE MEDICAL RECORD explaining:
•
The reason you denied the requester to review/receive copies of the medical record
•
A description of the specific adverse or detrimental consequences to the consumer or any other person if
applicable
PART I - APPROVED ACCESS (Completed by Licensed Practitioner of the Healing Arts)
Access to PHI is approved to provide: ______________________________________________
(Specify inspection, copies, or summary)
Date_____________
___________________________
____________________________
__________________
Printed name
Signature
License/Title
PART II (COMPLETED BY MEDICAL RECORDS OFFICE)
Check the box(es) below to indicate action taken on request for access to PHI.
How was the identity of the individual verified?_________________________________
Date the individual was informed of acceptance of access request and any cost to
consumer._______________________________________ $ __________________________
Date of referral to another organization/location to obtain the information because the information requested is not
part of the Designated Records Set. ____________________
COM025 (5/08)
Compliance
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