6/20/10: Carolyn Banks
Kane County Hospital in Kanab, Utah, will be purging and destroying medical records prior to the year 2003 with the exception of records of patients born after 1987. Both Kane County Hospital and Kane County Medical Clinic records will be purged.
Patients interested in obtaining their records prior to destruction should call the hospital at [435] 644-5811 or clinic at [435] 644-4100 and make arrangements. A written request signed by the patient must be filled out prior to obtaining the records. Requests signed by other than the patient will not be valid. If the patient is deceased, an affidavit must be completed and notarized. A form must be signed at the time the records are picked up. No records will be sent electronically or mailed. These forms will be available at the hospital and the medical clinic.
These records will be available until July 31, 2010, at which time they will be destroyed.
KANE COUNTY HOSPITAL
355 North Main
Kanab, Utah 84741
AUTHORIZATION TO RELEASE PATIENT HEALTH RECORDS
M.R.#__________________
Telephone #_____________
I, ___________________________________________, hereby authorize the Health Information
(PRINT name)
Management Department of Kane County Hospital to release the personal health record prior to
the year 2003 of ___________________________________________.
(PRINT patient’s name)
OR
(Person receiving record)
______________________________________________ __________________________ _________________________
(Patient/Patient Legal Representative Signature) (Today’s Date) (Patient Date of Birth)
______________________________________________
(Relationship if other than Patient)
PROHIBITION ON RE-DISCLOSURE: THIS INFORMATION HAS BEEN DISCLOSED TO YOU FROM RECORDS WHOSE CONFIDENTIALITY IS PROTECTED BY FEDERAL LAW. FEDERAL REGULATIONS PROHIBIT YOU FROM MAKING ANY FURTHER DISCLOSURE OF THIS INFORMATION EXCEPT WITH THE SPECIFIC WRITTEN CONSENT OF THE PERSON TO WHOM IT PERTAINS (OR HIS/HER PERSONAL REPRESENTATIVE IN THE CASE OF A MINOR OR OTHER LEGALLY DESIGNATED REPRESENTATIVE). A GENERAL AUTHORIZATION FOR THE RELEASE OF MEDICAL OR OTHER INFORMATION IF HELD BY ANOTHER PARTY IS NOT SUFFICIENT FOR THIS PURPOSE. FEDERAL REGULATIONS STATE THAT ANY PERSON WHO VIOLATES ANY PROVISION OF THIS LAW SHALL BE FINED NOT MORE THAN $500, IN THE CASE OF A FIRST OFFENSE, AND NOT MORE THAN $5,000 IN THE CASE OF EACH SUBSEQUENT OFFENSE.
KANE COUNTY HOSPITAL
355 North Main
Kanab, Utah 84741
I, ________________________________, BEING FIRST DULY SWORN STATE:
1. I am the ____________________________ of ______________________________.
(Relationship) (Patient’s Name)
2. _____________________________________ expired on ______________________.
(Patient’s Name) (Date)
3. As of today’s date, no personal representative has been appointed in the estate of
_______________________________________.
(Patient’s Name)
OR
The personal representative of the estate of ___________________________________
(Patient’s Name)
has been discharged..
OR
I have been appointed as the personal representative of ________________________’s
(Patient’s Name)
estate.
4. I believe I am entitled to act as a representative for ____________________________.
(Patient’s Name)
STATE OF UTAH )
: ss.
County of __________)
On this __________ day of ____________, 20__, before me, the undersigned, a Notary Public for the State of Utah, personally appeared ____________________________, known to me to be the person whose name is subscribed to the within instrument and acknowledged to me that he/she executed the same as his/her voluntary act and deed.
IN WITNESS WHEREOF, I have hereunto set my hand and affixed my official stamp the day and year first above written.
___________________________________
Notary Public for the State of Utah
Residing at ___________________, Utah
My commission expires ______________
I request this record be given to ___________________________________I will personally pick this record upCheck to make sure the patient signature matches the patient signature in the chart.
If patient is deceased, check to make sure a notarized affidavit is also received.
If person collecting the record is other than the patient, check to make sure the patient has authorized that person to receive the records.
Look in the active file shelves to see if there are records prior to 2003, and look in the archive files to see if there are records.
No records are to be released if the patient was born after 1987.
Remove the summary sheet(s) from the chart and attach to the records release request.
Have the patient/authorized representative sign that he/she received the charts and accepts responsibility for the information in the medical record.
File the signed release request form, affidavit and receipt form together with the summary sheet(s) from the chart and file in the designated drawer in the HIM Office.
No requests will be accepted after August 1, 2010.
