The Health Information Management Department at Jackson Madison County General Hospital is dedicated to maintaining your medical records and keeping your health information private and secure in accordance with federal and state regulations. Normal business hours are, Monday through Friday, 8:00 a.m. – 4:30 p. m. If you have any further questions, please contact us at 731-541-7800.
Your medical record in the property of Jackson Madison County General Hospital and is kept by the hospital for patient care purposes. Although these records are maintained for your benefit, the physical records (paper or electronic) are the property of the hospital.
You may request copies of your own medical records, the medical records of a minor child, or the medical records of someone for whom you are the legal guardian or hold a Durable Power of Attorney for Healthcare. Proof of legal guardianship or a Durable Power of Attorney for Healthcare must be provided. A Durable Power of Attorney for Healthcare is only effective in the event a patient is unable to act on their own behalf and that has been determined by a physician. A spouse or child of a deceased patient can request the medical records of the deceased if he/she is the executor or administrator of the deceased patient’s estate. Probate Court documents naming the requestor as the executor or administrator must be provided. Where there is no estate or an estate will not be probated, Probate Court documents releasing the estate from probate and naming the requestor as the personal representative must be provided.
Simply follow these steps:
1. Download the Authorization for Use and Disclosure of Health Information and Patient Access form.
2. Complete the authorization form (must be a patient of patient’s guardian/legal representative) and mail or deliver to:
Once your records are processed, you may pick them up in person at the location above or they can be mailed to your home address. If you pick up your records in person, you will be required to present photo identification. You may send a representative to obtain your records only if they are listed on the authorization from under information to be used or disclosed by. It is required for your representative to provide a copy of your photo identification and provide their photo identification as well.
I need my medical records sent to a healthcare provider: Pertinent medical record information* is provided to your physician at no charge for continuum of care. You will need to complete a written authorization form to have your medical records faxed or mailed to your provider. You will need to include the name, address and/or fax number of the healthcare provider in the appropriate section of the authorization form. You may fax your request to 731-541-6768. We only accept faxed requests for this purpose only.
I need to have my medical records sent to Social Security: There is a $20.00 flat fee for providing your records to Social Security Administration for disability claims. You will need to complete a written authorization form and provide the social security disability claims letter from Social Security Administration indication you are applying for benefits. However, if the SSA requests your records, there is no charge.
I need to obtain a copy of my medical records for personal use: You will need to complete a written authorization form to have your medical records mailed to your home or you may pick them up from our department. The fees for entire record requests are as follows:
| RECORDS STORED ELECTRONICALLY|
OR ON HARD COPY
|Pages 1 – 5||$18.00|
|Pages 6 – 50||$0.85 per page|
|Pages 51 – 250||$0.60 per page|
|Remaining copies||$0.35 per page|
|RECORDS REQUESTED ON ELECTRONIC MEDIA (CD)||Same as Above|
*Pertinent medical record information provided will include, as applicable: Face Sheet, Discharge Summary, History and Physical, Consultation(s), Operative Report(s), Pathology Report(s), and Diagnostic Test Results.
Fees are set by the State of Tennessee and are revised annually. If you have any questions, please contact the Tennessee Department of Health Services at 615-741-7308, or for additional information click here.
Your record will only contain the radiology report. The actual radiology images are not part of your medical record. You will need to contact Jackson Madison County General Hospital Radiology Services at 731-541-7850 for the images.
Your medical records do not contain billing statements. However, upon request we can provide them along with your medical record. If all you need is a copy of your Detail Bill please contact the Business Office at 731-541-6468.
To protect our patient’s privacy, we do not fax or email records to patients.
Our quality standard is to process your request for copies with 5 to 15 business days.
The only information the Health Information Management Department released verbally is the patient’s date of admission and/or date of discharge to the patient only.
You will need to request the birth certificate from the State of Tennessee Office of Vital Records. The document you received after the birth of your baby named Verification of Birth Facts is used to send to the Office of Vital Records to complete the official birth certificate. You can reach the Office of Vital Records at 615-741-1763.
You will need to request the death certificate for the Office of Vital Records. The funeral home works in conjunction with the physician to complete the death certificate. The funeral home then submits the death certificate information to the Office of Vital Records. You can reach the Office of Vital Records at 615-741-1763.
Medical records at Jackson Madison County General Hospital are maintained for 10 years. You will be contacted if your medical record request cannot be fulfilled due to expiration of the retention period.
Yes. There is no charge for you to review your records. To view your medical records:
1. Contact the Health Information Management Department at 731-541-7800 to schedule an appointment to view your records.
2. Complete a valid authorization for release of information is required.
3. Provide photo identification.
NONDISCRIMINATION NOTICE STATEMENT
West Tennessee Healthcare (WTH) does not exclude, deny benefits to, or otherwise discriminate against any person on the grounds of race, color, national origin, age, religion, disability, Limited English Proficiency or sex, including discrimination based on gender identity, sexual orientation, sex stereotyping or pregnancy in admission to, participation in, or receipt of the services and benefits under any of its programs and activities, whether carried out by WTH directly or through a contractor or any other entity with which WTH arranges to carry out its programs and activities.
For further information about this policy, contact Amy Garner (731) 660-1188.