BOP Program Statement 6090.04 § 3

Medical reports must be exchanged freely between Federal and non-Federal health care

professionals and other organizations to contribute to a fuller understanding of the inmate’s

physical and mental status.

Except as required by law, any record that contains clinical, social, financial, or other data on a

particular inmate will be treated in a strictly confidential manner and will be protected from loss,

tampering, alteration, destruction, unauthorized duplication, and unauthorized or inadvertent

disclosure of information.

Release of medical reports and information to a routine user requires a written request stating the

reason for the information; however, the inmate’s consent is not required. Routine uses for

physical and mental health records have been published in the Federal Register, 67 FR 11712

(5/14/02).

a. Incarcerated Inmate Review of Health Record. The following procedures apply to the

release of health records to an inmate who is currently incarcerated in a Bureau institution.

An inmate seeking review and/or copies of his/her health records must complete an Inmate Request

to Staff (BP-A0148) in order to review or receive copies of the record. The BP-A0148 will be

addressed to the HSA or his/her designee.

Prior to review of records by an inmate (or copies given to an inmate), Health Services staff will

review the records to determine if a legitimate security concern exists (i.e., whether there is any

information which, if disclosed to the inmate, might reasonably be expected to harm the inmate or

another person). The r eviewer may have to consult the institution physician in evaluating records

for release.

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Currently incarcerated inmates may review their records, including laboratory results or other

HIV-related information, but may not receive a copy. H IV-related health records may be

forwarded to a third party of the inmate’s choosing outside the institution, provided that the inmate

authorizes the disclosure in writing.

The HSA/Designee will make the copies in a reasonable amount of time and give them to the

inmate. An administrative note in the EHR or paper chart will be made with the following

information:

■ Date of release.

■ Number of copies.

■ Items released (as an example, this can be accomplished by notations such as “SF-600 dates

inclusive of 01-01-93 thru 03-06-94”).

■ Items withheld.

■ Signature.

The original BP-A0148 will be filed in section 6 of the paper health record or EHR document

manager.

If information is withheld from the inmate, he/she will be provided a copy of the administrative

note denying the release and advised that he/she may send a Freedom Of Information Act (FOIA)

request for the withheld records to:

Central Office, Office of General Counsel

Freedom of Information (FOI) Section

320 First Street, NW

Washington, DC 20534

If the inmate makes a FOIA request, a copy of the records withheld and the administrative note

will be forwarded to the Regional Office. The Regional Counsel’s Office will conduct a review of

the document(s) that the institution has indicated on the administrative note were not released.

Regional Counsel staff, in coordination with the Regional Health Systems Administrator, if

necessary, will determine whether the document(s) will be released to the inmate, or exempted

from mandatory disclosure to the inmate under the provisions of the FOIA. Under all

circumstances, the Regional Counsel’s office will make any direct release of records to the inmate

and/or inform the inmate of the denial(s) and his/her appeal rights.

A system will be maintained for tracking requests for releasing medical information, including:

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■ Patient name and number.

■ Requester name.

■ Date requests received.

■ Disposition of requests (date).

■ Number of pages copied.

■ Number of pages withheld.

■ Fee, if any.

The Bureau has limited facilities to reproduce copies of x-ray, xerography, and ultrasonography

films. Therefore, when copies are requested, the HSA/designee will estimate the current costs for

reproduction from a community source. The requesting inmate will be financially responsible for

these costs and will provide a mailing address for a physician he/she chooses to receive the films.

Due to security and property restrictions, the films will not be allowed in inmate housing units.

b. Inmates Released from Federal Custody or in Residential Reentry Centers (RRCs). The

following procedures apply to the release of health records to an inmate who has been released

from Federal custody or is currently housed in a RRC.

If an inmate seeking copies of his/her health records sends his/her request directly to the

institution, the request will be returned to the inmate with instructions to make a written request to

the address in Section 3.a. The inmate will be further instructed that he/she must provide a

signature that is notarized or signed under penalty of perjury to establish his/her identity along with

the written request for records.

The Office of General Counsel’s (OGC) FOIA/Privacy Act Section will log all proper inmate

requests, as indicated above, to review and/or copy health records. Upon receiving such a

request, staff members will determine that the inmate is currently housed in a RRC or released

from Federal custody and where the inmate was last designated.

The request will then be forwarded to the appropriate Regional Office, which will contact the

institution where the inmate was last housed and coordinate the release of records to the inmate.

When the Regional Office contacts the institution, the Regional Office will have determined from

the requesting inmate what medical information he/she is seeking.

A copy of laboratory results showing HIV status may be released to an inmate released from

Federal custody. How ever, a copy of laboratory results or other health records showing HIV

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status will not be given to an inmate housed in a RRC; he/she will be orally advised of, and may

review, the results while still housed in a Federal institution.

HIV-related health records may be forwarded to a third party the inmate chooses, provided the

inmate authorizes the disclosure in writing.

The HSA/Designee will make the copies and forward them to the Regional Office. The Regional

Office will release the records directly to the inmate.

c. Fees. Under 28 CFR 16.11, an inmate may be charged $.10 per page for duplication. An

inmate may never be charged for a review of his/her records. A ch arge for fees may not be levied

if the total to be collected is $14.00 or less.

The first 100 pages are free with no subsequent charge until a fee in excess of $14.00 is reached:

Pages 1-240 = No charge.

Pages 241 and above = charged $.10 per page for each page after the first 100.

Example: 241 pages = 241-100 = 141 pages x $.10 = $14.10

335 pages = 335-100 = 235 pages x $.10 = $23.50

Inmates will be informed of estimated fees. Fees will not be collected until copies have been

made. Copies will not be provided to the inmate until associated fees are paid.

Consult the institution’s Trust Fund Manager regarding processing of fees.

d. “Third Party” Requests. The first party is the patient-inmate, the second party is the

custodial agency holding the health records and providing care. All third party requests for

medical information will be processed under direction of OGC’s FOIA/Privacy Act Section in the

Central Office. A d ated authorization form that has been notarized or signed under penalty of

perjury must accompany any request. The authorization is valid for three months from the date of

patient’s signature. Requests from the Social Security Administration (SSA) will not be

forwarded to the OGC’s FOIA section. SSA requests will be processed at the institution level.

e. Copying of Health Records. The Bureau monitors the copying of health records because it

is time-consuming for HIM staff and may not be relevant to the recipient. When a copy of a

voluminous health record is requested, the requestor will be contacted to ask which specific

portion of the health record is required.

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f. Obtaining Records From Outside Sources. On occasion, the HSA/designee will have to

request health records from hospitals and physicians of inmates formerly treated by them. When

an inmate was treated elsewhere, such as a hospital, ambulatory surgical facility, nursing home, or

physician’s or consultant’s office, clinical summaries or other pertinent documents are obtained

when necessary for continuity of care.

Usually, a simple request for the health record giving the dates of hospitalization is sufficient. A

request for health records will be accompanied by an authorization signed by the inmate giving

permission for the health care record’s release.

g. Facsimile of Health Records. The quality of healthcare is enhanced when patient clinical

information is readily available to healthcare providers using a facsimile (fax) machine. When

HIM staff are transmitting a facsimile of the health record or health-related data, the following

notice will appear on the cover sheet:

CONFIDENTIALITY NOTICE

The documents accompanying this transmission contain confidential health information that is

legally privileged. This information is intended only for the use of the individual or entity

named above. The authorized recipient of this information is prohibited from disclosing this

information to any other party unless required to do so by law or regulation.

If you are not the intended recipient, you are hereby notified that any disclosure, copying,

distribution, or action taken in reliance on the contents of these documents is strictly

prohibited. If you have received this information in error, please notify the sender

immediately and arrange for the return or destruction of these documents.