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In context Nikolai Gomez MRN-100221 · born 1972-10-13 ✦ AI Ask ✦ AI Ambient note Chart

← Release of information queue

ROI request — full review

The complete production, assembled for human review before anything is released. What follows is exactly what fulfilment would disclose — and, just as explicitly, what it would withhold and why.

AI core: ROI requirements validator v1.0 · classifier · managed in the Control panel
Nikolai Gomez MRN-100221 · DOB 1972-10-13 · UnitedHealthcare open chart
Harmon & Blake LLP
requester · attorney · purpose: legal
126
records in the production
2
records withheld — itemized below, never silent

Release requirements — jurisdiction NY

Every requirement of the applicable jurisdiction, evaluated by the validator against this request's actual authorization. The validator can block a release; it can never approve one — the decision below remains yours, and every evaluation is recorded.

RequirementAuthorityVerdictBasis
Authorization signed and dated HARD 45 CFR §164.508(c)(1)(vi) met Signed 2026-08-15.
Authorization not expired HARD 45 CFR §164.508(c)(1)(v) UNMET No expiration date or event — a required element of a valid authorization.
Description of information with specificity 45 CFR §164.508(c)(1)(i) met "Records relating to the May 2025 workplace injury"
Right-to-revoke statement present HARD 45 CFR §164.508(c)(2)(i) met Revocation statement present.
Part 2-specific consent where SUD records are in scope HARD 42 CFR §2.31 met No Part 2 records in this record set.
HIV-related information requires a HIPAA-compliant authorization that covers it NY PHL Art. 27-F §2782 met No HIV-related information in this record set.
Mental-health records released consistent with MHL §33.13 NY MHL §33.13 needs review Mental-health records present — confirm §33.13 conditions for this requester.
Release blocked. A hard requirement is unmet — pressing Fulfil will record the refusal with the requirement named, not release the records.

What fulfilment would release

Record classCountContents
Demographics1Name, MRN, DOB, sex, address, payer
Conditions6 Tooth eruption disorder; Accretion on tooth; Prediabetes (finding); …
Medications5 Furosemide 40 MG Oral Tablet; Medication; carvedilol 25 MG Oral Tablet; …
Encounters25 Visit history with dates, types, providers, facilities
Labs & vitals72 Result series with values, units and abnormal flags
Clinical notes2 Progress note · Discharge summary · full text released
Imaging studies7 Modality, body site, report status
Claims & billing8 Claims with service lines and adjudication (in scope for this requester type)

What fulfilment would withhold

WithheldCountRule
Psychotherapy notes0 Never released through ROI — separate store, separate authorization lane (45 CFR §164.508(a)(2)).
Sensitive — mental_health2 Sensitive category: excluded absent specific consent for this disclosure.

Both outcomes are audited (roi.fulfilled / roi.denied) with your name and the session's purpose.

✦ AI Second-pass leakage review

Pre-release review drafted by claude-sonnet-5 · 2026-08-29 14:30:42 · verify every quote before deciding 
=== SCOPE ===
Plausibly, yes — cardiac/CHF treatment records of this kind are commonly requested by attorneys (e.g., disability, injury, or malpractice litigation), though nothing in the set explicitly confirms the requester's purpose.

=== FINDINGS ===
- Doc #2366 — "he has resumed weekly group sessions at the Harborview recovery program and continues buprenorphine maintenance as prescribed there; he asked that this stay between us" — Category: substance-use-disorder treatment (42 CFR Part 2), including an explicit patient request for confidentiality — WITHHOLD

=== RECOMMENDATION ===
The records professional should determine whether the flagged SUD-treatment passage in doc #2366 requires segregation or a Part 2–compliant consent/authorization before release, independent of this review's suggestion.