information is the patient’s name; grade or rate; date ofadmission or disposition; age; sex; component, base,station, or organization; and general condition.2. Release to the Individual Concerned. Releaseof healthcare information to the individual concerned(patient) falls within the purview of the Privacy Act andnot the Freedom of Information Act. When individualsrequest information from their medical record, it will bereleased to them unless, in the opinion of the releasingauthority, it might prove injurious to their physical ormental health. In such an event, the releasing authoritywill request authorization from the patients to send theirmedical information to their personal physician.3. Release to Representatives of the IndividualConcerned. Upon the written request from patients,healthcare information will be released to theirauthorized representatives. If an individual is mentallyincompetent, insane, or deceased, the NOK or legalrepresentative must authorize the release in writing.NOK or legal representatives must submit adequateproof that the member or former member has beendeclared mentally incompetent or insane, or furnishadequate proof of death if such information is not onfile. Legal representatives must also provide proof ofappointment, such as a certified copy of a court order.4. Release to Other Government Departmentsand Agencies.When requested, healthcareinformation will be released to other governmentdepartments. These government departments andagencies must have a legitimate need for theinformation as listed in the “Routine Uses” section ofthe Medical Treatment Records System, which isannually set forth in SECNAVNOTE 5211, Systems ofPersonal Records Authorized for Maintenance Underthe Privacy Act of 1974, 5 USC 552a (PL 93-579).If the releasing authority is in doubt whether therequesting department has a legitimate need for theinformation, it will ask the requesting department tospecify the purpose for which the information will beused. In some cases, the requesting department shouldbe advised that the information will be withheld untilthe written consent of the individual concerned isobtained.RELEASING MEDICAL INFORMATION TOFEDERAL AND STATE AGENCIESIn honoring proper requests, the releasingauthority should disclose only information relative tothe request. In the following three instances, forexample, departments and agencies, both federal andstate, may have a legitimate need for the information:1. Health care information is required to process agovernmental action involving an individual. (TheVeterans Administration and the Bureau of Employees’Compensation process claims in which the claimant’smedical or dental history is relevant). If an agencyrequests health care information solely for employmentpurposes, a written authorization is required from theindividual concerned.2. Health care information is required to treat anindividual in the department’s custody. (Federal andstate hospitals and prisons may need the medical ordental history of their patients and inmates.)3. Release to federal or state courts or otheradministrative bodies. The preceding limitations arenot intended to prevent compliance with lawful courtorders for health records in connection with civillitigation or criminal proceedings, or to prevent releaseof information from health records when required bylaw. If you have doubts about the validity of recordrequests, ask the Judge Advocate General (JAG) forguidance.RELEASING MEDICAL INFORMATIONFOR RESEARCHCommanding officers of MTFs are authorized torelease information from medical records locatedwithin the command to members of their staff who areconducting research projects. Where possible, thenames of parties should be deleted. Other requestsfrom research groups should be forwarded to Bureauof Medicine and Surgery (BUMED) for guidance.FILING HEALTH RECORDSLEARNING OBJECTIVE: Recall filingprocedures for health records.The Navy Medical Department uses the TerminalDigit Filing System (TDFS) to file health records. Inthis system, health records are filed according to theterminal digits (last two numbers) of the servicemember’s social security number (SSN), color codingof the health record jacket, and use of a block filingsystem.To understand the TDFS filing system, you willneed to view the SSN in a different way. As you know,12-5
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