SYSTEM NAME:
Health Care Record System (June 16, 2003, 68 FR 35657)
SYSTEM LOCATION:
Military outpatient health (medical and dental) records of active duty individuals are retained at the member's medical or dental treatment facility. Official mailing addresses are published as an appendix to the Navy's compilation of systems of records notices.
Military outpatient health (medical and dental) records of current reservists are retained by the member's command.
Military outpatient health (medical and dental) records of retired and separated individuals are retained at the National Personnel Records Center, 9700 Page Avenue, St. Louis, MO 63132-5100; Naval Reserve Personnel Center, 4400 Dauphine Street, New Orleans, LA 70149-7800; Marine Corps Reserve Support Center, 10905 El Monte, Overland Park, KS 66211-1408; Bureau of Medicine and Surgery, 2300 E Street, Northwest, Washington, DC 20372-5300; or Commandant of the Marine Corps, Headquarters, U.S. Marine Corps, 2 Navy Annex, Washington, DC 20380-0001.
Inpatient health records are retained at the originating naval medical treatment facility (official mailing addresses are published as an appendix to the Navy's compilation of system of records notices); Department of Veterans Affairs Hospitals; other medical treatment facilities such as PRIMUS; National Personnel Records Center (Military), 9700 Page Avenue, St. Louis, MO 63132-5100; National Personnel Records Center (Civilian), 111 Winnebago Street, St. Louis, MO 63118-4199; Naval Reserve Personnel Center, 4400 Dauphine Street, New Orleans, LA 70149-7800; Marine Corps Reserve Support Center, 10950 El Monte, Overland Park, KS 66211-1408; Medical Director, American Red Cross, Washington, DC 20226; Bureau of Medicine and Surgery, 2300 E Street, Northwest, Washington, DC 20372-5300; or Commandant of the Marine Corps, Headquarters, U.S. Marine Corps, 2 Navy Annex, Washington, DC 20380-0001.
Outpatient health (medical and dental) treatment records of civilians are retained at the originating naval medical or dental treatment facility (official mailing addresses are published as an appendix to the Navy's compilation of system of records notices); Department of Veterans Affairs Hospitals; other medical treatment facilities such as PRIMUS; National Personnel Records Center, (Military Personnel Records), 9700 Page Avenue, St. Louis, MO 63132-5100; National Personnel Records Center, (Civilian Personnel Records), 111 Winnebago Street, St. Louis, MO 63118-4199; Medical Director, American Red Cross, Washington, DC 20226; Bureau of Medicine and Surgery, 2300 E Street, Northwest, Washington, DC 20372-5300; or Commandant of the Marine Corps, Headquarters, U.S. Marine Corps, 2 Navy Annex, Washington, DC 20380-0001.
CATEGORIES OF INDIVIDUALS COVERED BY THE SYSTEM:
Navy and Marine Corps personnel, other military personnel, dependents, retired and separated military personnel and dependents, civilian employees, Red Cross personnel, foreign personnel, VA beneficiaries, humanitarian patients, and all other individuals who receive treatment at a Navy medical or dental treatment facility. All commercial insurance carriers with whom the Department of the Navy has filed a claim under the Third Party Payers Act.
CATEGORIES OF RECORDS IN THE SYSTEM:
Outpatient and inpatient health (medical and dental) records contain forms documenting care and treatment. These records contain patient and sponsor demographic data.
Secondary health records contain forms documenting care and treatment at specific departments or clinics.
Subsidiary health records contain information from individual health records and supporting documentation. Examples are X-ray files; electrocephalogram tracing files; laboratory or secondary treatment record with supporting documentation or they may be based on the files; pharmacy files, social work case files; alcohol rehabilitation files; psychiatric or psychology case files, including psychology files documenting the clinical psychological evaluation of individuals for suitability for certain assignments; nursing care plans; medication and treatment cards, stat/daily orders; patient intake and output forms; ward reports; day books; nursing service reports; pathology and clinical laboratory reports; tumor registries; autopsy reports; laboratory information system (LABIS); blood transfusion reaction records; blood donor and blood donor center records; pharmacy records, surgery records, and vision records and reports; communicable disease case files, statistics, and reports; occupational health, industrial, and environmental control records, statistics, and reports, including data concerning periodic and total lifetime accumulated exposure to occupational/environmental hazards; emergency room and sick call logs; family advocacy case files, statistics, reports, and registers; psychiatric workload statistics and unit evaluations; gynecology malignancy data, etc.
Aviation physical examinations and evaluation case files contain medical records documenting fitness for admission or retention in aviation programs.
Marine Security Guard Battalion psychological examination, evaluation, and treatment case files contain medical records documenting suitability for assignment as Embassy Guards.
AUTHORITY FOR MAINTENANCE OF THE SYSTEM:
5 U.S.C. 301, Departmental Regulations; 10 U.S.C. 1095, Collection from Third Party Payers Act; 10 U.S.C. 5131 (as amended); 10 U.S.C. 5132; 44 U.S.C. 3101; 10 CFR part 20, Standards for Protection Against Radiation; and, E.O. 9397 (SSN).
PURPOSE(S):
This system is used by officials, employees and contractors of the Department of the Navy (and members of the National Red Cross in naval medical treatment facilities) in the performance of their official duties relating to the health and medical treatment of Navy and Marine Corps members; physical and psychological qualifications and suitability of candidates for various programs; personnel assignment; law enforcement; dental readiness; claims and appeals before the Council of Personnel Boards and the Board for Correction of Naval Records; member's physical fitness for continued naval service; litigation involving medical care; performance of research studies and compilation of statistical data; implementation of preventive medicine programs and occupational health surveillance programs; implementation of communicable disease control programs; and management of the Bureau of Medicine and Surgery's Radiation program and to report data concerning individual's exposure to radiation.
This system is also used for the initiation and processing, including litigation, of affirmative claims against potential third party payers.
This system is used by officials and employees of other components of the Department of Defense in the performance of their official duties relating to the health and medical treatment of those individuals covered by this record system; physical and psychological qualifications and suitability of candidates for various programs; and the performance of research studies and the compilation of medical data.
ROUTINE USES OF RECORDS MAINTAINED IN THE SYSTEM, INCLUDING CATEGORIES OF USERS AND THE PURPOSES OF SUCH USES:
In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act, these records or information contained therein may specifically be disclosed outside the DoD as a routine use pursuant to 5 U.S.C. 552a(b)(3) as follows
To officials and employees of the Department of Veterans Affairs in the performance of their official duties relating to the adjudication of veterans' claims and in providing medical care to Navy and Marine Corps members.
To officials and employees of other departments and agencies of the Executive Branch of Government upon request in the performance of their official duties related to review of the physical qualifications and medical history of applicants and employees who are covered by this record system and for the conduct of research studies.
To private organizations (including educational institutions) and individuals for authorized health research in the interest of the Federal Government and the public. When not considered mandatory, patient identification data shall be eliminated from records used for research studies.
To officials and employees of the National Research Council in cooperative studies of the National History of Disease.
To officials and employees of local and state governments and agencies in the performance of their official duties relating to public health and welfare, communicable disease control, preventive medicine, child and spouse abuse prevention and public safety.
To officials and employees of local and state governments and agencies in the performance of their official duties relating to professional certification, licensing and accreditation of health care providers.
To law enforcement officials to protect the life and welfare of third parties. This release will be limited to necessary information. Consultation with the hospital or regional judge advocate is advised.
To spouses of service members (including reservists) who are infected with the Human Immunodeficiency Virus. This release will be limited to HIV positivity information. Procedures for informing spouses will be published by the Director, Naval Medicine and must be used.
To military and civilian health care providers to further the medical care and treatment of the patient.
To release radiation data per 10 CFR part 20.
To third parties in those cases where the Government is seeking reimbursement under the Third Party Payers Act.
When required by federal statute, by executive order, or by treaty, medical record information will be disclosed to the individual, organization, or government agency, as necessary.
The DoD 'Blanket Routine Uses' that appear at the beginning of the Navy's compilation of system of records notices also apply to this system.
NOTE Records of identity, diagnosis, prognosis or treatment of any patient which are maintained in connection with the performance of any program or activity relating to substance abuse education, prevention, training, treatment, rehabilitation, or research, which is conducted, regulated, or directly or indirectly assisted by any department or agency of the United States, except as provided in 42 U.S.C. 290dd-2, be confidential and be disclosed only for the purposes and under the circumstances expressly authorized under 42 U.S.C. 290dd-2. The DoD 'Blanket Routine Uses' do not apply to these types of records.
NOTE This system of records contains individually identifiable health information. The DoD Health Information Privacy Regulation (DoD 6025.18-R) issued pursuant to the Health Insurance Portability and Accountability Act of 1996, applies to most such health information. DoD 6025.18-R may place additional procedural requirements on the uses and disclosures of such information beyond those found in the Privacy Act of 1974 or mentioned in this system of records notice.
POLICIES AND PRACTICES FOR STORING, RETRIEVING, ACCESSING, RETAINING, AND DISPOSING OF RECORDS IN THE SYSTEM:
STORAGE:
Primary, secondary, and subsidiary medical health records are stored in file folders, microform, on magnetic tape, personal computers, machine listings, discs, and other computerized or machine readable media.
RETRIEVABILITY:
Military health (medical and dental) treatment records are filed and maintained by the last four digits of the military member's Social Security Number, the member's last name, or the member's Social Security Number. A locator case file cross-references the patient's name with the location of his/her record.
Inpatient (clinical) health records are filed and maintained by the last four digits of the sponsor's Social Security Number or a register number. A manual or automatic register of patients is kept at each Navy medical treatment facility. The location of the file can be determined by a seven-digit register number or the patient's name.
Outpatient (medical and dental) health records are filed and maintained by the sponsor's Social Security Number or date of birth, relationship to the sponsor, and name. A locator file cross-references the patient's name with the location of his/her record.
Treatment records retired to a Federal Records Center prior to 1971 are retrieved by the name and service number or file number. After that date, records are retrieved by name and Social Security Number.
Aviation medical records are filed and maintained by Social Security Number and name.
Marine Security Guard Battalion psychological examination, evaluation, and treatment case files contain medical records documenting fitness for assignment as Embassy Guards and are filed and maintained by Social Security Number and name. Subsidiary health care records may or may not be identified by patient identifier. When they are, they may be retrieved by name and Social Security Number.
SAFEGUARDS:
Records are maintained in various kinds of filing equipment in specific monitored or controlled access rooms or areas; public access is not permitted. Computer terminals are located in supervised areas. Access is controlled by password or other user code system. Utilization reviews ensure that the system is not violated. Access is restricted to personnel having a need for the record in providing further medical care or in support of administrative/clerical functions. Records are controlled by a charge-out system to clinical and other authorized personnel.
RETENTION AND DISPOSAL:
Health care records are retained, retired, and disposed of in accordance with Secretary of the Navy Instruction 5215.5 (Disposal of Navy Marine Corps Records) and Bureau of Medicine and Surgery Instruction 6150.1 (Health Care Treatment Records).
Specifics are given below
Military health (medical and dental) records, are transferred with the member upon permanent change of duty station to his/her new duty station. These records are retired to the National Personnel Records Center, (Military Personnel Records), 9700 Page Avenue, St. Louis, MO 63132-5100; Naval Reserve Personnel Center, 4400 Dauphine Street, New Orleans, LA 70149-7800; and, Marine Corps Reserve Support Center, 10950 El Monte, Overland Park, KS 66211-1408.
Inpatient health records are transferred to the National Personnel Records Center, (Military Personnel Records), 9700 Page Avenue, St. Louis, MO 63132-5100 or to the National Personnel Records Center, (Civilian Personnel Records), 111 Winnebago Street, St. Louis, MO 63118-4199, two years after the calendar year of the last date of treatment.
Outpatient health records of civilians are transferred to the National Personnel Records Center, (Military Personnel Records), 9700 Page Avenue, St. Louis, MO 63132-5100 or to the National Personnel Records Center, (Civilian Personnel Records), 111 Winnebago Street, St. Louis, MO 63118-4199, two years after the calendar year of the last date of treatment.
X-ray files are retained on-site and destroyed three years after the last x-ray in the file. Asbestos x-rays are retained on site indefinitely.
Secondary health record may be retained separate from the health record. A notation is made in the health record that these records exist and where they are being kept. When the health record is retired or the patient transfers, these records should be entered in the health record.
Aviation medical records are retained at the activity and destroyed when 30 years old.
Marine Security Guard Battalion psychological examination, evaluation, and treatment case files containing medical records documenting fitness for assignment as Embassy Guards are retained at the activity and destroyed after 50 years.
Clinical psychology case files documenting suitability for special assignment will be retained at the originating medical treatment facility and destroyed when 50 years old.
Radiation exposure records for personnel are maintained indefinitely in the health record, and in a centralized exposure registry held by the Navy Environmental Health Center Detachment, Naval Dosimetry Center, Bethesda, MD 20889-5614.
SYSTEM MANAGER(S) AND ADDRESS:
Service medical (health and dental) records for active and reserve, Navy and Marine Corps Chief, Bureau of Medicine and Surgery, 2300 E Street, Northwest, Washington, DC 20372-5300; Commanding Officers, Naval Activities, Ships and Stations; and, Director, National Personnel Records Center, Military Personnel Records, 9700 Page Avenue, St. Louis, MO 63132-5100. Official mailing addresses are published as an appendix to the Navy's compilation of system of record notices.
Inpatient and outpatient treatment records Chief, Bureau of Medicine and Surgery, 2300 E Street, Northwest, Washington, DC 20372-5300; Commanding Officers and Officers-in-Charge of naval medical treatment facilities; and, Director, National Personnel Records Center, Military Personnel Records, 9700 Page Avenue, St. Louis, MO 63132-5100. Official mailing addresses are published as an appendix to the Navy's compilation of system of record notices.
NOTIFICATION PROCEDURE:
Active duty Navy and Marine Corps personnel and drilling members of the Navy and Marine Corps Reserves seeking to determine whether this system of records contains information about themselves should address written inquiries to the originating medical or dental treatment facility. Official mailing addresses are published as an appendix to the Navy's compilation of system of record notices.
Inactive Naval Reservists should address requests for information to the Naval Reserve Personnel Center, 4400 Dauphine Street, New Orleans, LA 70149-7800. Marine Reservists should address requests for information to Marine Corps Reserve Support Center, 10950 El Monte, Overland Park, KS 66211-1408.
Former members who have no further reserve or active duty obligations should address requests for information to the Director, National Personnel Records Center, (Military Personnel Records), 9700 Page Avenue, St. Louis, MO 63132-5100.
All written requests should contain the full name and Social Security Number of the individual, his/her signature, and in those cases where his/her period of service ended before 1971, his/her service or file number. In requesting records for personnel who served before 1964, information provided to the National Personnel Records Center should also include date and place of birth and dates of periods of active Naval service.
Records may be requested in person. Proof of identification will consist of the Armed Forces Identification Card or by other types of identification bearing picture and signature.
Requests for inpatient records within two years of inpatient stay should be addressed to the Commanding Officer of the hospital where the individual was treated.
Requests for inpatient records after two years after inpatient stay should be addressed to the Director, National Personnel Records Center, (Civilian Personnel Records), 111 Winnebago Street, St. Louis, MO 63118-4199 or to the Director, National Personnel Records Center, (Military Personnel Records), 9700 Page Avenue, St. Louis, MO 63132-5100.
Requests for subsidiary medical records should be addressed to the Commanding Officer of medical or dental center where treatment was received.
The following data should be provided Full name, Social Security Number, status, date(s) of treatment or period of hospitalization, address at time of medical treatment, and service number.
Full name, date, and place of birth, I.D. card or driver's license, or other identification to sufficiently identify the individual with the medical records held by the treatment facility must be presented.
RECORD ACCESS PROCEDURES:
Individuals seeking access to record about themselves contained in this system of records should address written inquiries to the medical or dental treatment facility where treatment was received or to the officials listed under 'Notification procedure'.
CONTESTING RECORD PROCEDURES:
The Navy's rules for accessing records, and for contesting contents and appealing initial agency determinations are published in Secretary of the Navy Instruction 5211.5; 32 CFR part 701; or may be obtained from the system manager.
RECORD SOURCE CATEGORIES:
Reports from attending and previous physicians and other medical personnel regarding the results of physical, dental, and mental examinations, treatment, evaluation, consultation, laboratory, x-rays, and special studies conducted to provide health care to the individual or to determine the individual's physical and dental qualification.
EXEMPTIONS CLAIMED FOR THE SYSTEM:
None.
FEDERAL REGISTER HISTORY: