information is the patients name; grade or rate; date of
admission or disposition; age; sex; component, base,
station, or organization; and general condition.
2. Release to the Individual Concerned. Release
of healthcare information to the individual concerned
(patient) falls within the purview of the Privacy Act and
not the Freedom of Information Act. When individuals
request information from their medical record, it will be
released to them unless, in the opinion of the releasing
authority, it might prove injurious to their physical or
mental health. In such an event, the releasing authority
will request authorization from the patients to send their
medical information to their personal physician.
3. Release to Representatives of the Individual
Concerned. Upon the written request from patients,
healthcare information will be released to their
authorized representatives. If an individual is mentally
incompetent, insane, or deceased, the NOK or legal
representative must authorize the release in writing.
NOK or legal representatives must submit adequate
proof that the member or former member has been
declared mentally incompetent or insane, or furnish
adequate proof of death if such information is not on
file. Legal representatives must also provide proof of
appointment, such as a certified copy of a court order.
4. Release to Other Government Departments
and Agencies.
When requested, healthcare
information will be released to other government
departments.
These government departments and
agencies must have a legitimate need for the
information as listed in the Routine Uses section of
the Medical Treatment Records System, which is
annually set forth in SECNAVNOTE 5211, Systems of
Personal Records Authorized for Maintenance Under
the Privacy Act of 1974, 5 USC 552a (PL 93-579).
If the releasing authority is in doubt whether the
requesting department has a legitimate need for the
information, it will ask the requesting department to
specify the purpose for which the information will be
used. In some cases, the requesting department should
be advised that the information will be withheld until
the written consent of the individual concerned is
obtained.
RELEASING MEDICAL INFORMATION TO
FEDERAL AND STATE AGENCIES
In honoring proper requests, the releasing
authority should disclose only information relative to
the request.
In the following three instances, for
example, departments and agencies, both federal and
state, may have a legitimate need for the information:
1. Health care information is required to process a
governmental action involving an individual. (The
Veterans Administration and the Bureau of Employees
Compensation process claims in which the claimants
medical or dental history is relevant). If an agency
requests health care information solely for employment
purposes, a written authorization is required from the
individual concerned.
2. Health care information is required to treat an
individual in the departments custody. (Federal and
state hospitals and prisons may need the medical or
dental history of their patients and inmates.)
3. Release to federal or state courts or other
administrative bodies. The preceding limitations are
not intended to prevent compliance with lawful court
orders for health records in connection with civil
litigation or criminal proceedings, or to prevent release
of information from health records when required by
law. If you have doubts about the validity of record
requests, ask the Judge Advocate General (JAG) for
guidance.
RELEASING MEDICAL INFORMATION
FOR RESEARCH
Commanding officers of MTFs are authorized to
release information from medical records located
within the command to members of their staff who are
conducting research projects. Where possible, the
names of parties should be deleted. Other requests
from research groups should be forwarded to Bureau
of Medicine and Surgery (BUMED) for guidance.
FILING HEALTH RECORDS
LEARNING OBJECTIVE: Recall filing
procedures for health records.
The Navy Medical Department uses the Terminal
Digit Filing System (TDFS) to file health records. In
this system, health records are filed according to the
terminal digits (last two numbers) of the service
members social security number (SSN), color coding
of the health record jacket, and use of a block filing
system.
To understand the TDFS filing system, you will
need to view the SSN in a different way. As you know,
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