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Hospital Medical Records Process
Service providers who are completing SOAR applications and need medical records from their local hospital could approach that hospital to work out a process similar to the one outlined below that was developed with a hospital in Connecticut.
Records collection process:
- Note on the release that information is requested from the hospital using an agency or hospital release form. On all releases, put "all dates" for information requested.
- Call the Medical Records Department designee at the hospital; identify yourself as a provider who is using SOAR.
- Fax the releases to make sure that the applicant has information at the hospital
- Set up a time to come in to review the records
- When you come for your appointment, bring the agency or hospital release form as well as the SSA release of information signed by the applicant.
- Review the record and copy all the evaluative information and other information indicated on the attached list of important information. Be sure to look through the record carefully for all evaluations and copy those.
- Be sure to leave the record in the pre-determined way with medical records staff
NOTE: You may need to negotiate a waiver of the fee usually charged for copying records for SOAR applicants, if the hospital has such a fee.
Medical Information for SSI/SSDI
- Admission notes
- Physical examination reports
- Laboratory test results and reports
- Other diagnostic evaluations, such as x-rays, CT scans, MRI results, etc.
- Psychiatric evaluations
- Psychosocial history reports (usually from social workers)
- Psychological testing results and reports
- Occupational therapy reports
- Neurological evaluations
- Neuropsychological testing reports
- Any additional evaluation reports
- Progress notes for duration of each treatment episode
- Discharge summaries