sedgwick county medical – legal code · by anyone other than the patient, such as a personal or...

Sedgwick CountyMedical – LegalCode

Developed cooperatively by theWichita Bar Associationand the Medical Society of Sedgwick County

Last amended 2005

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Sedgwick County Medical - Legal Code

2005

Preamble We, the Physicians and Attorneys practicing in Sedgwick County, acknowledge that in order to resolve disputes between parties which involve evidence of medical matters that the mutual cooperation of physicians and attorneys in Sedgwick County is essential. This cooperation is necessary in order to fulfill the obligations of treating Physicians toward their patients as set forth in the American Medical Association Principles of Medical Ethics and the obligations of attorneys to their clients as set forth in the American Bar Association Model Rules of Professional Conduct. We further acknowledge: ! that a substantial part of the practice of law and medicine is concerned with the problems

of persons who are in need of the combined services of an attorney and physician; ! that the public interest and individual problems in these circumstances are best served

only as a result of cooperative efforts of all concerned; and, ! that members of both the legal and medical professions share an obligation to the

individual and to society. Therefore, we, the members of the Wichita Bar Association and the Medical Society of Sedgwick County, do adopt and recommend the following declaration of principles as standards of conduct for attorneys and physicians in interrelated practices.

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Section 1

PRIVILEGE 1.1 GENERAL. The protection of individually identifiable health information (“PHI”)

under the Health Insurance Portability and Accountability Act of 1996, 45 C.F.R. Parts 160 & 164 (“HIPAA”) and the physician-patient privilege of confidential communications under Kansas law is a right of the patient, not the physician. This means that the physician must refuse to testify at trial and deposition in civil cases, including Worker’s Compensation, unless the patient waives the privilege or a court order directs such testimony. The physician may not refuse to testify based on privilege if the patient has waived the privilege or a court order is in effect. By statute “confidential communication between physician and patient” means such information transmitted between physician and patient – including information obtained by an examination of the patient or personal health information as defined by HIPAA – as is transmitted in confidence and by a means which, so far as the patient is aware, discloses the information to no third persons other than those reasonably necessary for the transmission of the information or the accomplishment of the purpose for which it is transmitted.

1.2 WAIVER. The protection for PHI and the physician-patient privilege is waived by the

patient or his or her personal/authorized representative by giving a written patient authorization or by operation of law or statute or on the issuance of a court order, subject to any limitations in the authorization or court order and any prohibitions by law.

1.3 CONFERENCE WITH ADVERSE COUNSEL. To the extent authorized by a patient

authorization or court order, any treating physician and any attorney in the case may confer about the patient outside the presence of the patient or other counsel if the physician is provided with written consent or court order. Sedgwick County Court Rules provide that it is the decision of the physician whether or not to consent to an interview with the attorney who does not represent the patient.

1.4 PRODUCTION OF MEDICAL RECORD. When a request, through authorization,

court order or HIPAA-compliant subpoena, is made for protected health information (PHI), medical records or a medical chart, the physician shall produce the entire file of the patient, cover to cover, which file shall include all documents relating to the patient, whether located in the medical chart or elsewhere, regardless of the nature or source of the document, unless such production is specifically restricted by the request or prohibited by court order or by law. Payment for the records will be by the requesting party unless other arrangements are made; charges are controlled by K.S.A. 69-4971 (See Appendix A). If any portion of the medical record or chart is not produced, the physician shall disclose that fact and the type of information not produced to the person making the request.

1.5 WORKERS COMPENSATION EXCEPTION. The HIPAA regulations specifically

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allow covered entities to disclose health information as authorized by, and to the extent necessary to comply with workers compensation laws (45 CFR § 164.512). Kansas workers compensation law and regulations require health care providers to provide health information to employers, insurance carriers, and the director of workers compensation without the injured worker's authorization (K.S.A. 44-515; 44-557a, K.A.R. 51-9-10; 51-9-16). Therefore, a health care provider may disclose health information related to a workers compensation claim to the parties involved in the claim, or to the division of workers compensation, without the patient's authorization, and such disclosure will not violate the HIPAA regulations.

1.6 AVOIDANCE OF DISCLOSURE TO PATIENT. A health care provider may

withhold copies of health care records if the health care provider reasonably believes that providing copies of the requested records will cause substantial harm to the patient or another person. K.S.A. 65-4971. In circumstances where a disclosure of medical facts to the patient may be injurious to his physical or mental welfare, the physician and attorney are each obligated to cooperate and to avoid, if possible, disclosures to the patient which may result in such injury.

1.7 MEDICAL RECORD DEFINED. For purposes of this section, the phrase “medical

record” shall include all records of treatment, including but not limited to: patient intake and registration forms; patient and insurance identification information; patient questionnaires; phone message slips; office narratives; progress notes; prescription orders; lab results; nurses or physician assistant notes; consultation reports; order sheets; correspondence with patient; handwritten notes; and radiological and laboratory reports. The phrase shall not include the following records unless specifically requested:

a. Substance abuse or mental health care; b. Copies of actual diagnostic films or fetal monitor strips; c. HIV testing or reportable infectious diseases; d. Records obtained from other health care providers or governmental agencies; e. Correspondence received from or sent to others including, but not limited to:

other health care providers; attorneys; the patient; health insurers; social security agencies; and Medicare or Medicaid agencies;

f. Billing statements; and g. Photographs and videos.

1.8 AUTHORIZATION FORM; RECORDS RELATING TO HIV, SUBSTANCE

ABUSE OR MENTAL ILLNESS. For purposes of simplifying and expediting records requests, the Wichita Bar Association and the Medical Society of Sedgwick County have approved an authorization form which is included in the Appendix to this Code. Use of this form is optional. Due to additional statutory protections afforded patients undergoing HIV or other infectious disease testing or care and treatment for substance abuse or mental illness, a separate authorization must be used for requests of those records which is not a general authorization and specifically addresses only those records.

1.9 DISABLED, DECEASED OR MENTALLY INCOMPETENT. If the patient is

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deceased, disabled or mentally incompetent, the patient’s legal or personal representative may request medical records on behalf of the patient by executing an affidavit attesting to the patient’s death or disability and identifying the nature of the relationship between the patient and the requesting person. This form may be used when no estate has been opened for a deceased patient. A suggested affidavit form is included in the Appendix to this code.

1.10 PERSONAL OR AUTHORIZED REPRESENTATIVE. If an authorization is signed

by anyone other than the patient, such as a personal or authorized representative, the Affidavit of Personal/Authorized Representative provided in the Appendix to this Code should be submitted with the authorization. As used in this Medical-Legal Code, a patient’s personal or authorized representative is defined as:

1. a duly appointed attorney in fact pursuant to a Power of Attorney; 2. the duly appointed Executor or Administrator of the Estate of the patient; 3. legal guardian of the patient; 4. custodial parent of the child-patient; 5. personal representative of the estate of the patient, who is deceased, and

where no court proceeding is necessary or has been commenced to administer an estate, the person provides documentation of status of being next of kin; or

6. anyone designated in writing by the patient to obtain the healthcare records of the patient or the person otherwise authorized by law to obtain the healthcare records of the patient. (K.S.A. 65-4970)

1.11 TIME FOR FURNISHING. Upon receiving a request for medical records, the

physician shall furnish a copy of the requested records no later than thirty (30) days after the request has been received. See K.S.A. 65-4971. If the physician does not have any records meeting the substance of the request or does not maintain the requested records because of a transfer of the records to another physician, the physician shall take reasonable steps to notify the requestor in writing of the fact and reason for the records unavailability. See K.S.A. 65-4971. If it is not possible to process the records request within the time period set forth herein due to a need for prepayment, the voluminous nature of the records or other reason, the physician shall take reasonable steps to notify the requestor of the circumstances causing the delay. See K.S.A. 65-4971.

1.12 COST OF COPYING. The cost of copying medical records is covered by K.S.A. 65-

4971 and amendments thereto and updated annually by the secretary of human resources in accordance with the all-items consumer price index published by the U.S. Department of Labor. Current charges can be found on the following website: “http://www.dol.ks.gov/home/html/medfee_all.html” *Note the underscore in this web address. The current costs as of January, 2005, are set forth in Appendix A to this Code.

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Section 2

EXAMINATIONS, REPORTS, TESTIMONY AND COMPENSATION

2.1 GENERAL. In order to resolve disputes involving medical condition it is absolutely

essential that physicians perform examinations and give reports and testimony. Without the cooperation of both the physician and the attorney the courts cannot function to serve the public. Both the physician and the attorney must extend mutual cooperation to serve their patients and clients. The law obligates the physician to produce his records for examination, copying, and to testify as to past and present medical facts regarding a patient and the care and treatment extended. It is encouraged that attorneys enter into a fee agreement with the physician prior to his becoming involved in the review of a case as this can avoid misunderstandings regarding charges later in the case.

2.2 ATTENDING/TREATING PHYSICIAN OBLIGATION. An attending/treating

physician is obligated to his or her patient, when presented with a proper written authorization signed by the patient or personal/authorized representative or upon court order to promptly furnish a report of the medical facts, including history, findings, treatment, evaluation, diagnosis and prognosis. A reasonable charge to the patient may be made, but if the report is requested by an attorney or insurance company, the requester shall be responsible for advancing expenses to pay for the report.

2.3 REQUEST BY PATIENT FOR MEDICAL EXAMINATION FOR LEGAL

PURPOSES. In the case of examination of an individual for medical-legal purposes requested by the individual and not by the attorney, the physician should ascertain the purpose of the request and may under such circumstances, refuse to undertake the examination.

2.4 REQUEST BY ATTORNEY FOR MEDICAL EXAMINATION FOR LEGAL

PURPOSES. In the case of examination of an individual to secure an unbiased opinion for medical-legal purposes requested by an attorney, the attorney should notify the physician of such purpose in advance of the examination. The physician may refuse to examine under such circumstances but should carefully consider his usefulness to resolve litigation compared to other demands of his time. The fee for such examination should be negotiated with the requesting attorney and may be subject to court approval if one cannot be agreed upon.

2.5 MEDICAL EXAMINATION WITHOUT DISCLOSURE OF LEGAL PURPOSE;

PROTECTIVE ORDER AGAINST TESTIMONY. A physician has no ethical obligation to report or testify if an examination or treatment was obtained by subterfuge for medical-legal purposes and a physician, under such circumstances is entitled to seek

a protective order of the court if subpoenaed. 2.6 PRIOR AGREEMENT AS TO COMPENSATION. If a physician agrees to examine

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the patient and provide a report, an understanding or agreement regarding the amount and payment of fees should be established at that time.

2.7 PHYSICIANS AS WITNESSES. Physicians may be permitted to offer medical opinion

testimony if the physician possesses special knowledge, skill, experience or training in the matter to which the subject relates.

The court has the final determination of who will be permitted to give medical

opinion testimony. 2.71 ATTENDING/TREATING PHYSICIAN. An attending/treating physician

who has been or is engaged in the care and treatment of a patient who is asked questions at deposition or trial, the answers to which require the physician to testify concerning medical matters related to his patient, is entitled to be compensated for his or her time spent in conferences, preparation of reports, deposition testimony and court appearances. A reasonable charge to patients is one which is comparable to his normal charge to patients for the expenditure of similar time, skill and judgment and may be subject to court review and approval if it cannot be agreed upon. In no case should payment be contingent upon the outcome of the litigation or the amount of the recovery.

2.72 PRIOR AGREEMENT AS TO COMPENSATION. An attorney issuing a

subpoena for a medical witness has a duty not to issue such subpoena without an attempted understanding and agreement with the physician as to compensation.

2.73 RETAINED PHYSICIAN. The compensation of a retained physician (other

than an attending or treating physician) who becomes engaged in examination and/or evaluation for medical-legal purposes, either on behalf of the patient or by a party other than the patient, is a matter of contract to be mutually determined between the physician and the retaining party.

2.74 PARTIES RESPONSIBLE FOR COMPENSATION RELATING TO

DEPOSITION OF AN EXPERT OR TREATING PHYSICIAN. K.S.A. 60-226(b)(5)(C) requires the attorney requesting the deposition to “pay the expert a reasonable fee for time spent in responding to discovery” and to pay the other attorney “a fair portion of the fees and expenses reasonably incurred” by the non-requesting attorney in obtaining facts and opinions from the expert pursuant to discovery requests. Often, this statute has been applied in Sedgwick County as the requesting party pays reasonable preparation time for the expert or treating physician to prepare for the deposition, but does not pay for the expert’s time in meeting with the non-requesting attorney to prepare for the deposition. If any other arrangement is contemplated, counsel should agree in writing prior to the deposition.

2.75 FACTORS GUIDING CHARGES BY RETAINED/EXPERT PHYSICIANS.

There is no fee schedule limiting charges for expert physicians. Fees for

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deposition testimony must be reasonably related to the charges for review and preparation. Attorneys may wish to agree at the outset of a case setting a maximum fee for deposition testimony and enter into an agreed order for court approval. Factors to be considered when retained expert charges are being negotiated or when review of the charges will be submitted to the court:

A. The area of expertise of the witness; B. The education and training required to provide the expert insight

which is being offered (relationship between area of expertise and the subject matter upon which he is to testify);

C. The prevailing rates of other comparably respected available experts;

D. The fee traditionally being charged by the expert on related matters (review of records, attorney conferences, medical research, preparation of reports, deposition review, etc.);

E. The fees being charged to the party who retained the expert; F. The cost of living in the geographic area in which the expert

practices; G. Relative availability of experts in the field; H. Charges of similar local treating experts; I. The amount of materials required to review to prepare opinions,

for depositions, reports and trial (depositions, medical records, etc.)

2.76 FACTORS GUIDING CHARGES BY TREATING PHYSICIANS. Fees for

review of records, preparation for deposition, deposition testimony or trial testimony must be reasonably commensurate and related to clinical practice time charged to patients. Fees for deposition testimony must be reasonably related to the charges for review and preparation. Other factors to consider:

A. The direct charges made to patients by the health care provider for

their services at the facility; B. The size of the health care provider’s practice; C. The relative inconvenience caused by the request made (attorney

consult, deposition, trial testimony); D. The amount of standby time required to satisfy the request (waiting

time for trial testimony); E. The existence of any internal policies of the healthcare provider’s

group or employer on fees for various medical legal services; F. The nature of the healthcare provider’s practice G. The healthcare provider’s patient load and existence of a patient

waiting list 2.77 OBLIGATION OF RETAINED PHYSICIAN TO PROVIDE REPORT AND

TESTIMONY. A physician who makes an examination and evaluation of a person for medical-legal purposes is obligated to produce his records for

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examination and copying and to furnish a report, if requested, which report includes the physician’s findings, including results of all tests made, diagnoses and conclusions, or to testify as to his findings, diagnoses and conclusions.

2.78 CRIMINAL CASE. A physician who becomes engaged in the care and

treatment of a patient involved in circumstances relating to an alleged felony criminal act is obligated when presented or served with a court order or subpoena directed to him, to produce his records for examination and copying, and to testify. Compensation for testimony in criminal cases in which the physician has been involved in care or treatment is set by law (K.S.A. 28-125).

2.79 AGENCIES: Some governmental agencies have the right to issue subpoenas for

the appearance of attending/treating physicians at proceedings other than civil or criminal cases. These agencies may be obligated to pay only statutory mileage and witness fees.

2.8 OBLIGATION FOR PAYMENT. When a physician testifies or examines a client, the

attorney may advance payment to the physician but the ultimate obligation for payment is generally that of the client. The physician is entitled to have payment for his or her fees advanced by the attorney calling the physician as a witness. The physician is entitled to be paid if the client does not keep the appointment.

2.9 REFUSAL TO STATE OPINIONS. If a physician is called as a witness concerning

medical matters and only the statutory fee has been tendered, the physician may refuse to testify to medical opinions unless so ordered by the judge.

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Section 3

CONFERENCES AND SCHEDULING

3.1 MUTUAL COOPERATION. Physicians and attorneys have a mutual obligation to cooperate in scheduling examinations, conferences, including those in preparation for testimony, depositions and court appearances in order to minimize interference with the physician’s other obligations and to meet the mandatory schedules of the courts and attorney commitments in the judicial process.

3.2 CANCELLATION OF TESTIMONY WITHOUT REASONABLE NOTICE. If

testimony by deposition or court appearance is canceled or postponed without reasonable advance notice preceding the scheduled appearance, the physician is entitled to make a charge. This will not affect the physician’s right to make further charges for future court appearances or depositions.

3.21 WORKERS COMPENSATION. In a workers compensation case, if notice of

cancellation or a request to reschedule a deposition, testimony, or IME is less than two working days, a maximum charge of $150.00 is allowable.

3.3 DUTY OF ATTORNEY. It is the duty of the attorney to communicate with the

physician in advance of any subpoena for depositions and, if possible, for appearances in court.

3.31 RECORDS IDENTIFICATION. When a subpoena duces tecum, i.e., to bring

with him books, documents, office records and other evidence, is served, the attorney should explain to the physician what he is expected to bring.

3.4 DUTY OF PHYSICIAN. It is the duty of the physician and his office staff to

cooperate upon receipt of such communication to the end that the best possible adjustment of scheduled appearances may be arranged.

3.5 CONFERENCE PRIOR TO APPEARANCE. No physician should be called as a

witness to testify in any case by deposition or trial on behalf of his patient without prior conference with the scheduling attorney concerning the matters about which he is to be interrogated if the physician so requests. If the physician will be called as a witness by an attorney whose interests are adverse to those of the patient, Section 1.3 of this Code is applicable. Such conference should be set at a mutually convenient time for the attorney and the physician. No conference is necessary if the attorney and the physician agree that such conference is not necessary. At or prior to such conference, the physician’s records should be made available to the attorney on proper request. Whenever possible, such a conference should be arranged so it does not interfere with the scheduled commencement of the deposition and resultant inconvenience to other counsel and the court reporter.

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Section 4

HOSPITAL RECORDS

4.1 PRODUCTION BY HOSPITAL. Under the law, the hospital records are the property of the hospital, and the availability and presentation as legal evidence of the records for proper use for medical-legal purposes is an obligation recognized by the hospital, subject to Kansas statutes and HIPAA.

4.2 PHYSICIAN’S CONSENT. If the medical records procedures of the hospital require

that the patient’s attending or treating physician consent before examination of the records is permitted or copies furnished, this consent shall be given by the physician upon presentation to him of the patient’s written request that such consent be given.

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Section 5

MEDICAL TESTIMONY

5.1 PHYSICIAN’S AND ATTORNEY’S DUTY. The physician and the attorney mutually recognize the respective duty of each to the patient and client to whom services are rendered. The attorney recognizes and accepts the physician’s primary duty to render care and treatment, and the attorney should refrain from giving medical advice. The physician recognizes and accepts the attorney’s primary duty to render legal advice concerning circumstances surrounding medical condition, its causes and to conduct negotiation and litigation seeking to establish responsibility therefore; the physician should refrain from giving legal advice. Both parties recognize that direct and cross-examination of a physician-witness is a necessary part of the judicial process.

5.2 DEPOSITION. A deposition is an official proceeding authorized by law whereby a

person, such as a physician, patient or client, may be required to give testimony and may be cross-examined under oath outside of a court before an official court reporter and in the presence of attorneys representing the parties. Unless restricted by the physician-patient privilege in accordance with Section 1 of this Code, the physician/witness is required to produce pertinent medical records and also required to release the records to the court reporter for duplication and immediate return. Unless restricted by privilege, a physician may be required to testify as to any medical opinion held on the basis of his special knowledge, skill, experience, training and education, as well as to his knowledge as to the facts of his patient’s history and condition.

5.21 RIGHT TO READ AND SIGN DEPOSITIONS. A physician has a

right to read and sign a deposition for the purpose of making corrections to his testimony. Any attorney has a right to require the physician to read and sign his deposition. If any attorney requires the physician to read and sign his deposition, the attorney will be responsible for compensating the physician for the time spent in reading his deposition. If no attorney requests that the physician read and sign his deposition, but the physician exercises his right to read and sign his deposition, the physician will not be entitled to compensation for the time spent in reading his deposition.

5.3 TRIAL. Testimony in court is taken in similar manner before a judge who presides and

supervises the entire proceedings. Objection to questions may be made by attorneys, and the judge decides such objections based upon rules of evidence. Testimony may be given to the judge only or to both judge and jury in certain cases.

5.4 PHYSICIAN’S CONDUCT. The physician, while testifying in court or at deposition,

should: 5.41 At all times maintain the dignity of his profession.

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5.42 Answer questions as concisely and objectively as possible, using terminology, when permissible, which is understandable to a jury or layman.

5.43 If he does not know the answer to any question, to so state and make no attempt to

conjecture or theorize, or give answers not responsive to questions not propounded or volunteer testimony.

5.44 Under no circumstances permit any bias, prejudice, favoritism or personal interest

to influence his testimony. 5.5 ATTORNEY’S CONDUCT. The attorney, in examining or cross-examining a

physician, should: 5.51 At all times maintain the dignity of his profession. 5.52 Prepare and propound all questions to the witness in such a form and manner as

will permit clear understanding and a forthright answer. Questioning should respect admitted and accepted medical fact without attempting to change or misrepresent such facts by the use of terminology or phrases which could distort the understanding or interpretation of medical fact by the layman.

5.53 Avoid questions which browbeat or badger the physician. 5.54 Cooperate with the physician by minimizing, as far as practicable, the time

required for the physician to remain in court. 5.6 Attorneys and physicians are encouraged to obtain or offer medical opinion testimony

only when the physician is qualified by education, formal training, certification, or substantial experience in the medical area, to state a particular medical opinion.

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Section 6

JOINT COMMITTEES & DISPUTE RESOLUTION The Wichita Bar Association and the Medical Society of Sedgwick County have established a joint Medical-Legal Committee composed of members from each profession, to meet quarterly or at such intervals deemed necessary. It should consist of the President of the Wichita Bar Association, the President of the Medical Society of Sedgwick County, the Chair of the WBA Medical Legal Committee, the Chair of the MSSC Medical Legal Committee, and the Executive Director of the MSSC. It shall have as its basic functions, among other things, the following: 6.1 Improved Relations. Work for continuing improved professional relationships between

the two groups in Wichita and Sedgwick County, including the establishment of such joint meetings for education purposes and social functions as, in the committee’s judgment, may be desirable.

6.2 Mediation. To attempt to evaluate and mediate any disputes arising between individual

physicians and individual attorneys, or between the two professional groups in the areas covered by this Code or with related problems.

6.3 Reporting. Report annually or as needed to each professional organization upon the

committee’s work during the year and to make such recommendations as the committee deems desirable.

6.4 Interpretation. Any request for interpretation of any provision of this Code may be

submitted in writing to the secretary of the joint Medical-Legal Committee. Interpretations of the Committee shall be considered as substantial recommendations which may be referred to the respective professional organization of the physician and attorney for further consideration and action.

6.5 Binding Effect. When approved by the Board of Governors of the Wichita Bar

Association and by the Board of Directors of the Medical Society of Sedgwick County, this Code shall be followed by both organizations and the members thereof and their respective clients and patients.

6.6 Dispute Resolution. Any disputes concerning the interpretation of this code, amount or

payment of compensation, or obligations of physicians or attorneys may be referred to the joint committee for evaluation and mediation. The members of the Wichita Bar Association and the Medical Society of Sedgwick County agree to make reasonable efforts to attempt resolution through the joint Medical-Legal Committee prior to seeking court intervention.

6.61 The secretary of the joint committee shall be the Executive Director of the

Medical Society of Sedgwick County.

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6.62 All disputes, whether initiated directly through the Wichita Bar Association or

through the Medical Society of Sedgwick County, shall be submitted to the secretary who shall notify the chairperson of the Medical-Legal Committees of the WBA and the MSSC respectively who shall jointly resolve the dispute or refer it to the joint committee for evaluation and mediation.

6.63 The joint committee may conduct such evaluation and mediation in any

reasonable manner that will expeditiously resolve the dispute. 6.64 In some cases, the final resolution of the dispute may be made by the court

pursuant to applicable law.

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APPENDICES

Appendix A............................................................................... Charges for Reproduction of Medical Records

Workers Compensation Medical Records

Appendix B ...................................................................................................Authorization for Medical Records

Appendix C................................................................................................ Affidavit of Personal Representative

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APPENDIX A

CHARGES FOR REPRODUCTION OF PHYSICIAN MEDICAL RECORDS K.S.A. 65-4971 (as of January, 2005)

Charges for reproduction of medical records: Basic Service Charge for Supplies and Labor ..........$15.75 Plus: Per Page Copy ............52 cents/page for the first 250 pages ........................36 cents/page for additional pages Plus:

A reasonable charge may be made for all duplication of health care record information which cannot be routinely duplicated on a standard photocopy machine.

Plus: Postage may be charged if the records are requested to be mailed. Plus: An organized copy service may charge sales tax for copying the records. A healthcare provider may make arrangements directly with an outside firm with whom he or she has a HIPAA compliant Business Associate Agreement to reproduce the record. In such instance the above statutory charges still apply.

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APPENDIX A

WORKERS COMPENSATION MEDICAL RECORDS

Charges for reproduction of medical records in Workers Compensation cases (As of December 1, 2003. Schedule revised biannually):

Up to 10 pages: $16.00 11-50 pages: $28.00 ($16.00 for the 1st 10 pages plus $12.00 for 11-50 pages) Above 50 pages $28.00, plus $0.35 per page above 50 ! The maximum allowable payment for the copying of medical records is applicable to any health care

provider, business or other entity providing any forms of copying services. Any additional charges submitted by/for copying services are prohibited. Any payments made in advance for copying medical records, that exceed the allowable payments of this fee schedule, must be refunded.

! An “access fee” or “administrative fee” for providing specific and limited information is inappropriate

as an additional charge. However, when records are stored off-site, any expense involved in the retrieval of such records will be reimbursed upon receipt of the necessary documentation substantiating the expense incurred for retrieving said medical records.

! Reimbursement for the reproduction of medical records also applies to copies of microfiche or any other

types of storage systems such as electronic media, etc. Health care providers may also charge up to $5.00 a film for the copying of X-rays.

AFFIDAVIT OF PERSONAL/AUTHORIZED REPRESENTATIVE [To be used only in conjunction with an Authorization for Protected Health Information which is signed by a personal representative.]

STATE OF KANSAS ) ) SS: ______________ COUNTY ) I, _______________________, being first duly sworn, on my oath depose and state as follows: 1. I am over the age of 18 years.

2. My legal address is _________________________________________________ 3. I am seeking protected health information regarding the following individual:

_____________________________________regarding whom I have completed an Authorization for Protected Health Information and attached hereto.

4. I am requesting this information based on my status as (check one):

G a duly appointed attorney in fact pursuant to a Power of Attorney, a copy of which is attached, authorizing me to obtain copies of medical records.

G the duly appointed Executor or Administrator of the Estate of the above individual and a copy of the Letters Testamentary or Order Appointing Administrator is attached.

G guardian of the estate of the above named individual and the Letters of Guardianship are attached.

G custodial parent of the above named child and a copy of the custody agreement is attached.

G personal representative of the estate of the above named individual, who is deceased, and because no court proceeding is necessary or has been commenced to administer an estate, I provide proof that I am next of kin by attaching documentation supporting such status.

5. I am requesting records of the above named individual and affirm that I shall not

disclose said records to any third party other than those authorized to receive said records as a matter of law or as the individual I am representing may so direct.

_______________________________________ Personal/Authorized Representative SUBSCRIBED AND SWORN TO before me this ______ day of _____________, 20___ _______________________________________ Notary Public My Appointment Expires:

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