Members are entitled access to or copies of records concerning their health care. All or part of the medical record may be released to the member or other "qualified persons" with written authorization from the member and in accordance with applicable state and federal law.
"Qualified persons" are appointed by members or the court to handle specific areas of concern on the member's behalf. Examples of "qualified persons" include, but are not limited to:
- Court appointed committee for an incompetent
- Parent of a minor
- Court appointed guardian of a minor
- Other legally appointed guardian
The Authorization to Use or Disclose Protected Health Information form should be completed in order to provide authorization. If this form is not used, the written consent must include the following information:
- Name of the physician from whom the information is requested
- Name and address of the institution, agency or individual that is to receive the information
- Member's full name, address, date of birth and EmblemHealth ID number
- The extent or nature of the information to be released, including dates of treatment
- Date of initiation of authorization
- Signature of the member or qualified person
Member requests should be honored within 10 days of the receive date of the written authorization.
A member or qualified person may challenge the accuracy of information in the medical record and may require that a statement describing the challenge be included in the record.
Access to member information may be denied only if the provider determines that access can reasonably be expected to cause substantial harm to the member or others, or would have a detrimental effect on the provider's professional relationship with the patient or his or her ability to provide treatment.
The physician may place reasonable limitations on the time, place and frequency of any inspections of the patient information. Personal notes or observations may be excluded from any disclosure based on the provider's reasonable judgment.
Special authorizations, forms and procedures are required for HIV-related testing (both before and after the test is performed) and for release of any HIV-related information from the medical record. In order to release confidential HIV-related information, consent forms created or approved by the New York State Department of Health (NYSDOH) must be used. All authorizations requesting the release of behavioral health records must specify that the information requested concerns behavioral health treatment.
We recommended that providers consult legal counsel with regards to records disclosure issues.
Glossary terms found on this page:
Services that have been approved for payment based on a review of EmblemHealth's policies.
Conditions that affect thinking and the ability to figure things out that affect perception, mood and behavior.
A unique number which identifies the member's enrollment with EmblemHealth. EmblemHealth's claims are processed by this number. Also known as Member ID Number.
Specific circumstances or services listed in the contract for which benefits will be limited.
Acronym for Medicare Advantage. An alternative to the traditional Medicare program in which private plans run by health insurance companies provide health care benefits that eligible beneficiaries would otherwise receive directly from the Medicare program.
An individual and each of his or her eligible dependents, including Medicare beneficiaries who are enrolled or participate in a benefit program and who are entitled to receive covered services from the practitioner pursuant to such benefit program and the terms of the practitioner's agreement.
The state regulatory agency that certifies reimbursement methods and rates to hospitals and reviews HMO activities in the state of New York. Also called NYSDOH.
The state regulatory agency that certifies reimbursement methods and rates to hospitals and reviews HMO activities in the state of New York. Also called the New York State Department of Health.
A health plan that offers benefits in-network and out-of-network. In-network services are available to enrollees at lower out-of-pocket cost than the services of non-network providers. In addition, PPO enrollees may self-refer to any network provider at any time. Also called a Preferred Provider Organization.
A medical practitioner or covered facility recognized by EmblemHealth for reimbursement purposes. A provider may be any of the following, subject to the conditions listed in this paragraph:
- Doctor of medicine
- Doctor of osteopathy
- Doctor of podiatric medicine
- Physical therapist
- Nurse midwife
- Certified and registered psychologist
- Certified and qualified social worker
- Nurse anesthetist
- Speech-language pathologist
- Clinical laboratory
- Screening center
- General hospital
- Any other type of practitioner or facility specifically listed in the member's Certificate of Insurance as a practitioner or facility recognized by EmblemHealth for reimbursement purposes
A provider must be licensed or certified to render the covered service. The covered service must be within the scope of the Provider's license or certification.
New York State Department of Health. This agency provides information for consumers, doctors, researchers and health care providers.