VA Southeast Network (VISN 7)

Report ID: SPE000000076193, U.S. Department of Veterans Affairs

Reported Entity: VISN 07 Columbia, SC

Issue:

On 05/24/12, the Release of Information Office (ROI) received a letter and subpoena from an attorney requesting a copy of Veterans medical record. The attorney requesting the records represents the defendant in the case. Upon research, the Lead ROI Technician discovered that copies of the medical records were released by a ROI clerk to the defendants attorney based on a subpoena received on 01/12/12. The ROI clerk did not have the proper authority (court order or the Veterans authorization) to release copies of the medical record to the defendants attorney. All subpoenas and court orders are routed through the Dorn VA Regional Council office for review. Medical Records are never released based on a subpoena unless the Veteran is deceased. A total number of 440 pages were released to the attorney. It was noted that in the letter there is a statement that a copy of the defendants attorneys letter and subpoena was provided to the Veterans attorney. (I.e. Veterans attorney was aware that the Veterans medical record was requested by the defendants attorney). The information that was disclosed included the Veterans full name, full social security number, address, provider names, list of medications, protected health information and 7332 information. Update: 06/04/12: Medical Records are not to be released based solely on a subpoena. The ROI office released the records prior to receiving advice from General Counsel. The Veterans attorney did receive a notice that the records were being requested, making the Veteran aware of the release of information. Regional Counsel advised that they would not have recommended the release of the records without either a signed consent from the Veteran or a court order. At this point, Regional Counsel is not recommending the return of the records. 06/07/12: The DBCT questioned who signed the subpeona. It has been attached to the ticket and is signed by an attorney. 06/12/12: The DBCT determined that there was no legal authority to release the records since the subpeona was not signed by a judge. Therefore, the disclosure was inappropriate and it would be in the best interest of the Veteran to grant credit protection services.

Outcome:

The ROI clerk retired on 05/31/12. All ROI employees have been re-educated on processing subpoenas. Medical records are not permitted to be released based solely on a subpoena unless the Veteran is deceased. Per discussion with a Dorn VAMC Regional Counsel Attorney, it is not recommended that the facility ask that the records be returned at this point. The Veteran was formally notified of the incident.