Medicaid Release Of Information Form

Option 3 Administrator Of An Estate

An administrator, personal representative, executor, or another authorized person with the authority to act on the deceased persons estate. Suppose, for any reason, the medical records of the deceased are requested. In that case, the administrator appointed in theLast Will and Testament or a court-appointed authority may be able to obtain the records.

Release Of Information Step By Step

1. Medical record requests are delivered to our secure, confidential platform.

2. Requests are entered into our system.

3. Our ROI processing centers access record requests using our digital dashboards.

4. Authorizations are validated for HIPAA compliance.

5. Our certified HIPAA security professionals process the records.

6. Records are checked for accuracy by our quality control team.

7. Requestors are notified and required to enter security credentials before downloading records.

Instructions For Completing Section 2c Of The Authorization Form:

Please select one of the following options.

• Option 1 To include all information, check the box: “All information, including information about alcohol and drug abuse, mental health treatment, and HIV”. Proceed with the rest of the form.

• Option 2 To exclude the information listed above, check the box “Exclude information about alcohol and drug abuse, mental health treatment, and HIV”. Then proceed with the rest of the form.

If you have any questions or need additional assistance, please feel free to call us at 1-800- MEDICARE . TTY users should call 1-877-486-2048.

Sincerely,

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Types Of Information Requests

Customarily, information requests fall into one of two categories:

Either type of inquiry should be submitted by email or in writing. However, questions that can be easily answered by information that is readily available , or are received directly by program areas specific to daily operations, will be accommodated by appropriate DOM staff. Inquiries requiring dedicated staff time, processing and agency resources to provide accurate answers will be handled as an official Request for Information .

Information To Help You Fill Out The1

If you want 1-800-MEDICARE to give your personal health information to someone other than you, you need to let Medicare know in writing.

If you are requesting personal health information for a deceased beneficiary, please include a copy of the legal documentation which indicates your authority to make a request for information. Also, please explain your relationship to the beneficiary.

Please use this step by step instruction sheet when completing your 1-800-MEDICARE Authorization to Disclose Personal Health Information Form. Be sure to complete all sections of the form to ensure timely processing.

You should make a copy of your signed authorization for your records before mailing it to Medicare.

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Official Requests For Information

Requests should be submitted by email or in writing , addressed to the DOM Public Records Officer, and indicating the specific information, coverage or records/documentation desired. No more than two requests per company or organization will be assisted at a time. Please refrain from submitting duplicate requests to DOM staff, bureaus or the fiscal agent.

Time FrameAs specified by the Mississippi Public Records Act and DOMs policy, DOM will produce the requested information no later than seven working days from the date of request receipt.

If DOM is unable to produce the information requested within seven working days, DOM will notify the requestor of the delay by written notification specifying with particularity why the records cannot be produced within seven working days and will obtain a mutually agreed upon delivery date for the records/information to be released. Requests for medical records or information related to third party casualty recovery cases are not considered public records requests and are not processed within the time line described above.

Fees and ChargesCharges may apply for requests including the processing or retrieval of information or records not readily available . Information or records not readily available will be invoiced for the following applicable charges incurred due to DOM processing the records/information requested:

Option 1 Personal Representative

An individual, such as an attorney-in-fact mentioned in a Medical Power of Attorney, commonly has powers to obtain medical records. In addition, for any person that has been appointed by a court to act as a caregiver or guardian, the judgment, order, or decree must be attached to the HIPAA release form.

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Request The Medical Records

To legally request medical records, under 45 CFR 164.524, the entity holding the records may require that the request is made in writing. Therefore, use the Standard Form and use the How to Write section of this page to enter the specific fields required to complete.

The 4 sections are:

• Releasor and Recipient Who has the medical records, and to who will they be sending them?
• TimePeriod What dates are authorized for release?
• Record Types Should only specific records be released about certain medical conditions, or should all the patients records be released?
• Expiration Date Usually, a date is listed at which it expires for legal purposes.

Vi Acknowledgement Of Rights

Signature Of Patient. The signature of the Patient will be required to execute this instrument. Therefore once the Patient has completed documenting his or her desired authorization, he or she should review the content of this release, sign his or her name on the Signature Of Patient line, then print his or her name on line bearing the Print Name label. If a Representative of the Patient will be signing this document on his or her behalf, then this first signature area line may not be completed.

Date. Upon signing, the Patient should record the current calendar date on the line labeled Date.

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Major In The United States Army And A Maryland Doctor Facing Federal Indictment For Allegedly Providing Confidential Health Information To A Purported Russian Representative To Assist Russia Related To The Conflict In Ukraine

Baltimore, Maryland A federal grand jury has returned an indictment charging Anna Gabrielian, age 36, and her husband, Jamie Lee Henry, age 39, both of Rockville, Maryland, with conspiracy and for the disclosure of individually identifiable health information , related to their efforts to assist Russia in connection with the conflict in Ukraine. The indictment was returned on September 28, 2022 and unsealed today upon the arrest of the defendants.

Gabrielian is scheduled to have initial appearance at 11:30 a.m. today, in U.S. District Court in Baltimore before U.S. Magistrate Judge Brendan A. Hurson. Henry is also expected to have an initial appearance today, although a time has not yet been set.

The indictment was announced by United States Attorney for the District of Maryland Erek L. Barron and Special Agent in Charge Thomas J. Sobocinski of the Federal Bureau of Investigation, Baltimore Field Office.

As stated in the indictment, Gabrielian is an anesthesiologist and worked at Medical Institution 1, located in Baltimore, Maryland. Henry, a Major in the United States Army, who held a Secret-level security clearance, is Gabrielians husband and a doctor. During the time of the alleged conspiracy, Henry worked as a staff internist stationed at Fort Bragg, the home of the Armys XVIII Airborne Corps, headquarters of the United States Army Special Operations Command, and the Womack Army Medical Center.

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Receiving The Medical Records

Modern medical facilities are typically aware that time is of the essence in regards to the records of an individual. Therefore, if the requested information is not received within 5 to 7 business days the requestor should call or ask to know the status of the transfer.

The medical facility has 30 days to release the requested medical records. If the initial 30-day period is not met they may extend for an additional 30 days only if they send a letter to the requestor stating why the transfer is delayed. Only one extension period is allowed by law.

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Streamline Roi Processing While Maintaining Compliance

Even before you consider the continually changing regulations, handling medical records and patient information might be a daunting and time consuming task at your practice. VRCs Release of Information services can help you efficiently manage your workload while protecting your patients healthcare data.

Compliance and Certification

VRC processes over one millions pages of medical records each month for thousands of medical providers across the country. For each and every one of these clients, we provide HIPAA compliant ROI services while maintaining a HITRUST certification.

Our Integrated Approach

Weve designed our ROI services to seamlessly integrate with your own workflow. Advanced technology and security measures help you automate parts of your workflow, while built-in checkpoints ensure that all requests are released with control. Altogether, youll be able to reduce unnecessary costs and risks to your program.

Scale Up Your Operations

Secure File Requests

Our system maintains your files on secure servers to protect your practices data. Any requests and authorizations are validated per HIPAA regulations and require security credentials before records are delivered.

For New York Medicare Beneficiaries Only

• For question 2A, check the box for Limited Information, even if you want to authorize Medicare to release any and all of your personal health information.

• Then proceed to question 2B. You may also check any of the remaining boxes and include any additional limitations in the space provided. For example, you could write “payment information”.

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