■ Duties and responsibilities:
Expectations of physicians in practice
Did you know? You need authorization to provide medical records to lawyers
Published: January 2018
The information in this article was correct at the time of publishing
If you receive a request from a lawyer asking for a patient’s medical records, you need to ensure you have the patient’s consent or other legal authorization to release the records.
Disclose only with authorization
In the case of a request from a lawyer, you can provide the records only once you have authorization from the patient or the patient’s substitute-decision maker, or when required by law. Ideally, the authorization should be in writing. The authorization should state whom you can release the records to and which records you are authorized to release. If the patient does not provide authorization to release the records, you generally cannot release them until there is a court order or warrant compelling you to produce the records or unless production is otherwise required by legislation or regulation.
Be alert to potentially sensitive information
If you do have authority to release a medical record, you should review it for potentially sensitive information, which may or may not be directly relevant to the request. This could include information relating to the patient’s mental health, substance use, or family history. Where the patient authorizes the disclosure of records, but your review reveals the records contain sensitive information, you should ask the patient whether he or she intended this information to be released. Redact any information the patient does not want released, as well as any personal information about other people.
When sending a redacted record, tell the lawyer that some relevant information has been redacted at the patient’s request or because it contains personal information about third parties. Where the records are being released without the patient’s consent pursuant to a statutory requirement, but there is sensitive information in the records, call the CMPA before disclosing the information.
When you provide records, send copies, not originals, unless otherwise ordered by a court. Remember that you can recover reasonable copying and administrative expenses associated with providing the material. Some medical associations and Colleges have guidelines about what amount would be considered reasonable.
If in doubt about how to respond to a request for medical records, members should contact the CMPA for advice.