Reason |
Description |
Authorization Missing |
An authorization signed and dated by the patient, or, in the case of a minor, by his or her parent(s) or guardian, is required. The authorization must be dated within the required number of days. |
Authorization missing TPO statement |
TPO required statement missing on authorization. |
Certification of Previously Released Records |
Unable to certify previously released records. |
Description of Disclosure Missing |
A description of the information to be disclosed was not included in the request. |
Electronic Signature |
Authorizations signed electronically may not be accepted. |
Executor's Letter Naming Executor Missing |
The patient has died. We need a copy of the Executor's Letter naming the Executor for the Estate of the patient. |
Faxed Request |
Unable to accept requests via fax. |
Forms Completion |
Records will be released in lieu of forms. |
Health Care Power of Attorney Missing |
The request was submitted by a law office / attorney, but does not include a Health Care Power of Attorney signed by the patient, patient’s parent, or guardian. |
Invalid Subpoena |
Satisfactory assurances under HIPAA not provided. |
Missing Hospital Name |
Request received does not indicate the name of the facility which treated the patient. |
No Dates of Treatment as Requested |
Dates of Service requested were not found. |
Patient Not Found |
No record of patient teated at facility. |
Person Authorized to Make Disclosure Missing |
The name of the person/company authorized to make use of the disclosure and a description of each purpose for the disclosure was not included in the request. |
Redisclosure by Recipient Missing |
The notification that disclosed information may be redisclosed by recipient was missing from the request. |
Request Expiration Date Missing |
An expiration date or event for which the request will expire was not included in the request. |
Requested documents are not permitted to be released per facility policy |
Information requested is not allowed to be released per the hospital policy. |
Right to Revoke Missing |
The notification statement pertaining to the individual's right to revoke authorization was missing from the request. |
Signature Discrepancy |
Signature on the authorization does not match signature on the consent forms. |
State Required Notice of Delay Letter |
Delay in processing is preventing the timely release of records. |
Statement of Assurance |
Statement of assurance missing. |
Written Consent Required (To Patient) Missing |
The name of the person / company authorized to make use of the disclosure and a description of each purpose for the disclosure was not be included in the request. |
Other |
You must edit the Request Refusal Letter if you select Other. |