Welcome to the MEDICAL RECORDS department
at The Children's Mercy Hospital.
ESPANÓL
We are located on the ground floor of The Children's Mercy Hospital at this address:
2401 Gillham Road
Kansas City, Missouri 64108
Office Hours: 8:00 AM to 5:30 PM Monday through Friday
Phone: (816) 234-3455
Fax: (816) 234-3458
INSTRUCTIONS FOR OBTAINING RELEASE OF INFORMATION
On this page, you may do the following:
INSTRUCTIONS FOR REQUESTING COPIES OF MEDICAL RECORDS
Patient, parent, or legal guardian may request copies of medical records by filling out this release of information authorization:
Authorization for Use or Disclosure of Medical Information
(English)
Autorización para el uso o revelación de información médica
(Spanish)
By law, a specific authorization must be signed to release copies of records from Developmental and Behavioral Sciences and/or the Child Psychiatry Clinic:
Authorization for Use or Disclosure of Psychological/Psychiatric Information
(English)
Autorización para el uso o revelación de información psicológica o psiquiátrica
(Spanish)
An authorization to release a copy of a patient’s medical record must be completed with the patient’s name and date of birth. The authorization must be signed by the patient (if the patient is 18 years or older) or the patient’s legal guardian, and must be dated within one (1) year of receipt. Authorizations are good for up to one year. Once a valid authorization is received, we will respond to your request within 30 days.
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INFORMATION DESCRIPTIONS
COMPLETE RECORD*
Includes EVERY piece of medical record documentation in chart and EVERY electronic medical record document. Charges are explained below.
PERTINENT INFORMATION
Includes all documentation pertaining to doctors’ diagnoses, test results, and treatment for the last two (2) years. There is no charge for this service.
VISIT HISTORY
Includes list of visits to The Children’s Mercy Hospital or one of its clinics from 1987 to present. There is no charge for this service.
SPECIFIC INFORMATION
Includes specific clinic visits, inpatient stays, specific treatments, and test results. There is no charge for this service.
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*COPY CHARGES FOR COMPLETE RECORD
In Missouri, there is a $20.02 supply and labor fee, plus $0.47 per page. Missouri charges are based on Missouri House Bill 1427 and Missouri Law 191.227 and 191.233, RSMo. (Effective 2/1/09)
In Kansas, there is a $18.18 labor fee, plus $0.60 per page for the first 250 pages, and $0.43 per page for additional pages. Kansas charges are based on Kansas Statute No. 65-4971. (Effective 1/1/09)
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PAYMENT
We will mail you a fee letter before copying the medical record for you. Payment may be made with cash or by credit card at the Cashier’s Office. The Medical Records department accepts checks and money orders.
If copies are to be mailed to a doctor, hospital, or school, there is no charge.
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INSTRUCTIONS FOR REQUESTING CHANGES TO HEALTH INFORMATION
Patient, parent, or legal guardian may request an amendment (change or correction) to a patient’s health information by using this form:
Request for Amendment of Health Information
(bilingual English/Spanish)
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INSTRUCTIONS FOR LIMITING ACCESS TO HEALTH INFORMATION
Patient, parent, or legal guardian may request to limit the access, use, or disclosure of a patient’s protected health information for treatment, payment, or health care operations by using this form:
Request for Restrictions to the Use and Disclosure of Protected Health Information - PRINTER FRIENDLY
(bilingual English/Spanish)
Request for Restrictions to the Use and Disclosure of Protected Health Information - FILL-IN-THE-BLANK**
(bilingual English/Spanish)
**FILL-IN-THE-BLANK form can be used only if you have Microsoft Word. You can type your information into the form, then print it.
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INSTRUCTIONS FOR AUTHORIZING VERBAL EXCHANGE OF INFORMATION
A written authorization for us to exchange information verbally (by phone or in person) with another facility or individual must be completed and signed by the patient, parent, or legal guardian. The authorization must be signed by the patient (if the patient is 18 years or older) or the patient’s legal guardian, and must be dated within one (1) year of receipt. The authorization is good for one year, unless it is revoked sooner.
Authorization to Exchange Medical Information
(English)
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