GENERAL GUIDELINES
As noted in our generic instructions for ordering neurological records from any institution, the brain bank:
- now requires that records be at the brain bank prior to the passing of the intended brain donor
- neurological records ONLY are needed. No primary care physician records or hospice records. In the cases of Parkinson’s Disease, only the most recent 6-8 years of records are needed.
- it is always easiest to download neurological records via the online patient portal. If you don’t have access to the online patient portal, records must be ordered from the medical records office or clinic. Records can be sent from medical records offices or clinics directly to the brain bank. One advantage of this approach is that there may be no fee to the family. One disadvantage of this approach is that the family has no real way to confirm that records have been sent.
- ideally, records should be sent to the brain bank by email or posted to the cloud for the brain bank to download. Second choice is by fax. Third choice is by mail with tracking. Last choice is by mail with no tracking.
- ordering records and following up with the medical records offices or clinics is the family’s responsibility
Source: JDG/Pixabay
PACIFIC NEUROSCIENCE INSTITUTE INFORMATION
These suggestions are derived from communications with Dr. Melita Petrossian’s office.
There are two main ways to request medical records from Dr. Petrossian.
1. Download records via the Providence MyChart online patient portal.
Pacific Neuroscience Institute is affiliated with Providence Health. Dr. Petrossian uses the Providence MyChart system for patient records. This is often the fastest method to obtain medical records if you have access to the intended donor’s login credentials.
- Log in to the portal: https://mychartor.providence.org/mychart/Authentication/Login
- Navigate to records: Click on “Access MyChart,” enter the patient’s login information, and follow the onscreen instructions. Most MyChart applications offer an option to download medical records by date range or by the specialist’s name.
Downloaded records may be submitted to Mayo Clinic by:
- Secure email to Dennis Dickson, MD, ℅ the Brain Bank Coordinator, Rachel LaPaille-Harwood.
- Post to the cloud (Google Drive, Dropbox, Box, or other online file sharing service). Then email link to file(s) to the Brain Bank Coordinator, Rachel LaPaille-Harwood.
- Fax to 904-953-7117 (Attn: Dennis Dickson, MD)
- US Mail to Dennis Dickson, MD, Mayo Clinic Jacksonville, Birdsall 310, 4500 San Pablo Road, Jacksonville, FL 32224-1865 (phone 904-953-2439)
2. Complete an Authorization for Release of Medical Information Form.
Dr. Petrossian’s office handles medical records requests directly. You will need to complete Providence Health’s Authorization for Release of Medical Information (PDF).
-> Provide Details: Be sure to provide as much detail as possible when completing the form, including specific dates of service.
-> Type of Records Requested: Check the box for “E-Mail records”. This is the fastest delivery method.
-> Request Access As: Check the box for either “Patient” or “Medical Power of Attorney”. Notice that if you’re requesting records for a loved one, you must also provide documentation, such as a photo ID or a copy of your healthcare power-of-attorney document. Then, fill in the intended donor’s information.
-> Please SEND medical information TO: Neurologically-related records can be submitted directly to Mayo Clinic with the following information:
- Dennis Dickson, MD, Mayo Clinic Jacksonville
Birdsall 310, 4500 San Pablo Road
Jacksonville, FL 32224-1865
Fax: 904-953-7117 (Attn: Dennis Dickson, MD)
Phone: 904-953-2439
Email to the Brain Bank Coordinator, Rachel LaPaille-Harwood.
-> Please REQUEST medical information FROM:
- Melita Petrossian, MD, PNI-Santa Monica
1301 20th Street, Suite 150
Santa Monica, CA 90404
Phone: 310-582-7433
Email
-> Information to be Released (Page 2):
- Check the box for “General Medical Information (date range)”. Enter a broad date range to capture all visits with Dr. Petrossian.
- Check the box for “Information regarding specific injury or treatment” and write in “All neurologically-related appointment notes and clinical encounter notes.”
- Check the box for “Reports” under the X-ray/Imaging section. (Note: Mayo will want the reports from scans but does not need the actual images.)
-> Signatures: The authorization form must be completed thoroughly, dated, and signed. It is best if the intended donor signs the form.
If the intended donor is not able to sign, the medical power-of-attorney should sign his/her name. When you fax the completed authorization form, include the medical power-of-attorney document and a photograph of the medical power-of-attorney’s government-issued ID.
Important: Do NOT send the form to the contact information printed at the top of the PDF. Dr. Petrossian’s office handles medical records requests directly.
Submit the completed form directly to Dr. Petrossian’s office. Please submit the form via:
- Fax to 310-315-4069 (ATTN: Carolina)
We suggest a follow-up call to Dr. Petrossian’s office (phone 310-582-7641) a few business days after submitting the authorization form. Inquire when the records were sent (or will be sent) to Mayo Clinic and confirm the delivery method. Make a note of the date and method of delivery.