Medical Records Requests

Getting your Medical Records

Healthcare providers:

Fax a request for records at no cost to 406-293-7770. Request must include:
• Office/provider name
• Contact info
• Patient name
• Date of Birth
• Specific information needed

Patient/Patient Representative Request for Access:

Patient/Patient Representative Request for Access Form(PDF)

To be completed by the patient or the patient healthcare representative as defined by HIPAA - A person with legal authority to make health care decisions on behalf of the individual

Lifetime requests for access are permitted only if the "complete record" selection is marked and expiration date (never, specific future date, etc.) is completed.
Minors: Parents/Guardians may request records for their minor child. Montana Code 41-1-403. Release of information by health professional does apply restrictions to parental/guardian access to certain information.
Visit the Medical Records Office on the 2nd floor of Cabinet Peaks Medical Center between 7:30am and 4pm M-F.
Use the patient portal

To ensure quick response and identity verification please include the following information:
Full name (including previous names)
Date of birth
Address
Phone number
Email address you wish to use
Last 4 of you SS#

Complete the appropriate medical record request form and submit via:
Fax: 406-293-7770
Email: Click here to submit forms via email
To ensure quick response and identity
Mail:
Cabinet Peaks Medical Center Health Information Management
209 Health Park Drive
Libby, MT 59923

Patient Authorization to Disclose to Other Entity/Individual:

Patient Authorization to Disclose Form (PDF)
You may authorize a copy of your protected health information be given to a third party. This authorization must be signed by the patient or personal representative.

Fees

Patients:

Electronic copies will be charged $6.50
Paper copies 25 pages or less no charge
Paper copies over 26 or more will be charged $6.50

Attorneys/Other Entities (Except for Insurance/Continuation of care):

All requests will be charged $15.00 clerical/administrative processing fee plus $10 per CD/thumb drive.

Right to Request Amendment to Record:

Request for Amendment of Medical Records Form(PDF)
If you feel that your information is incorrect you may request that the protected health information be amended. You must provide a detailed explanation with the reason for your request in writing. We may deny your request if we did not create the record unless the originator is no longer available; if you do not have a right to access the record; or if we determine that the record is accurate and complete. If we deny your request, you have the right to submit a statement disagreeing with our decision and to have the statement attached to the record.

Request for Restrictions:

Request Restrictions Form (PDF)
You may request additional restrictions on the use or disclosure of your protected health information for treatment, payment, or health care operations.
We are required to review the restriction; however, we are not required to agree to a requested restriction except for a request to restrict disclosure of information to your insurance carrier or health plan, if the services that you do not want billed are paid for in full at the time of service.

If we agree to a restriction, we will comply with the restriction unless an emergency situation or the law prevents us from complying with the restriction, or until the restriction is terminated by you.

Alternative Communication Request:

Alternative Communication Request Form (PDF)
This form will allow you to receive communication from providers via alternative methods, allow detailed messages or allow providers to discuss your care with others on your behalf.

If you have any other questions pertaining to your medical records, please feel free to call us @ 406-283-7150. We have the time to help!

Government Regulations Information:

Personal Representative 45 CFR 164.502(g)
Individual's Rights to Access Health Information

Cabinet Peaks Medical Center
Health Information Management
209 Health Park Drive
Libby, MT 59923
Office: (406)283-7150
Fax: (406)293-7770