Client Information Hub

Medical records contain personal health information and are used to diagnose, treat and bill for medical services.

To request a copy of medical records, you must first complete an authorization to release records form, and then submit it to our medical records department. It will then be processed and subjected to medical records release fees.

To authorize the release of medical records, please download and fill out our Release of Information Authorization Form. After completing and signing, please submit by emailing or faxing the form to our medical records department.

Email: medicalrecordsrelease@hopenetwork.org Fax: 616.389.2745 Phone: 616.301.8000 ext. 12343

Clients:

• No charges for copies of medical records

Workers’ Compensation:

$0.45 per page, plus:

• First 0-15 minutes of document retrieval: $2.50
• Each 15-minute increment after: $2.50/increment (i.e. 30 minutes would be $5 for document retrieval)
• Postage and/or supplies: Actual cost

3rd Party:

Electronic Copy of Medical Records:

Initial Fee of $30.60, plus:

• 0 - 300 pages: $12.00
• 301 – 600 pages: $19.00
• 601 – 900 pages: $26.00
• 901 – 1200 pages: $33.00
• 1201 – 1500 pages: $40.00
• 1500+ pages: $7.00 increase per 200 pages

Paper Copy of Medical Records:

Initial Fee of $30.60, plus:

• Pages 1 - 20: $1.53 per page
• Pages 21-50: $0.77 per page
• Pages over 51: $0.31 per page

Rates will be adjusted annually according to the Medical Records Access Act Fees.

Read more about our privacy and HIPPA practices with our PDF booklet.

Under this new federal law, uninsured patients (those who do not have insurance) and self-pay patients (those who are not using their insurance) have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost at any of our programs within Hope Network.

• You have the right to receive a Good Faith Estimate for the total expected costs of any non-emergency items or services.
• Good Faith Estimate must be provided within 3 business days upon request. Ensure your health care provider gives you a Good Faith Estimate in writing at least 1 business day prior to your medical service.
• If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
• Make sure to save a copy of your Good Faith Estimate for your records.

For questions or more information about your rights to a Good Faith Estimate, visit www.cms.gov/nosurprises/consumers or call the help desk at 800-985-3059.

If you have any questions or concerns regarding your privacy or confidentiality, you may call our Compliance Hotline at 866.835.6854 or contact the Corporate Healthcare Compliance & Privacy Officer below:

Hope Network – Healthcare Compliance & Privacy Officer

3075 Orchard Vista Drive SE Grand Rapids, MI 49546

Email: privacy@hopenetwork.org

Office Landline: 616.301.8000 ext. 12115

Mobile Phone: 616.260.8205