essay

POLICY AND PROCEDURES

NUMBER: R01

SUBJECT: Access and Disclosure Policy Comment by Steve Warszawski: Identify and correct the errors in the following areas:1. Policy paragraph2. Procedure sections A, B, and J.Explain

POLICY:

PROCEDURE:

A. Confidential patient records will be released only upon receipt of consent from the patient, legal guardian, or authorized representative.

1. If the patient is a minor, the parent should sign the consent form. There should not be any exception to this rule.

2. Any authorization signed by a deceased patient's family member shall be honored.

3. If the patient is unable to sign the authorization by reason of physical or mental incapacity, the authorization should be signed by an authorized representative or legally appointed guardian.

B. CONTENT OF RELEASE OF INFORMATION AUTHORIZATION

Authorizations to release information should be completed in entirety. They must include the following information:

1. First and last name of the patient.

2. Name of person, agency, or organization that will be releasing information.

3. Name of person, agency, or organization to which the information is to be released.

4. Specific information to be released.

5. Purpose of disclosure

6. Signature and date of patient, parent/guardian or authorized representative.

7. Notice that the authorization is valid for a specified period of time.

C. VALID CONSENT

The written consent of a patient, legal guardian or authorized representative is considered valid only if the following conditions are met:

1. Patient or the representative is informed, to their understanding, of the specific type of information that has been requested and, if known, the benefits and disadvantages of releasing the information.

2. Consent is given voluntarily.

3. Services are not contingent on their decision concerning the release of information.

4. Patient’s consent is acquired in accordance with applicable law and regulation.

D. Forward any written requests or phone calls from a commercial insurance company for onsite record review to a Nurse Account Specialist at the Shared Services office.

E. PROCESSING TIME

Act upon each request no later than 30 days (or more stringent state-required time frame) after the request is received. If any challenges are encountered fulfilling an access request within the initial 30 day timeframe (i.e. the requested PHI is in off-site storage and may take some time to retrieve, etc.), notify the requester about the status and the intent to provide the requested PHI within the next 30 days.

F. COSTS - determined by state statute or regulation

1. Nonpatient-initiated requests, charge state regulated fee.

2. Charge flat rate of $6.50 for the following requests

a. All patient-initiated requests and attorney requests on behalf of the patient

b. All records released via SFTP (secure e-mail)

3. Payment received for copies of medical records must be sent to the hospital’s Shared Services Director of Finance at the address below. Note: Cash is not accepted. Check, money order or cashier’s check only made payable to the hospital. Please see Attachment A for current Record Copy Fees by state

4. Patients and other authorized representatives may be reminded that there is no charge for viewing a record onsite, and that electronic transfer of records (via secure file transfer protocol, known as SFTP or other available method) is preferable and less costly compared with paper release.

G. REQUESTS FOR INFORMATION

1. When authorization is received, hospitals will log request in Release of Information logbook and stamp request with date of receipt.

2. Review authorization for completeness. If authorization is incomplete or more information is needed, complete Release of Information Response Letter and return to requester.

3. Request prepayment on all record requests that are billable. (See letter E for handling payments received) – Cash is not accepted. Check, money order or cashier’s check only made payable to the hospital.

4. If authorization is complete and prepayment has been received, copy the requested information.

5. Hospitals will complete Release of Information log.

6. Release copies of records via the method requested to requester.

7. File original request and authorization in the correspondence section of the paper medical record if the chart is available on site. Add or scan the original request/authorization and index to the HIM ROI Authorization in the EMR.

H. TELEPHONE REQUESTS

Telephone requests for release of information will be discouraged and limited to emergency or urgent situations at the request of other health care providers. Information will be released only on a “call back” basis as a means of verifying the identification of the person making the request.

Documentation of the nature of the release of information, circumstances that led to the release of information and to whom the information was released to shall be noted in the medical record.

I. FAXING INFORMATION

Information may be faxed to other health care professionals or facilities treating the patient or for record completion. Hospital staff should verify the location and name of staff who will be receiving the faxed information.

J. REQUEST FROM INSURANCE OR QUALITY IMPROVEMENT ORGANIZATION