sample letter patient treatment information release

SAMPLE LETTER PATIENT TREATMENT INFORMATION RELEASE UPDATE

The consequences to the individual of a refusal to sign the Authorization.

The covered entity may not condition treatment or payment, on whether the individual signs the Authorization.

The ability or inability to condition treatment or payment, for care, by stating either: The individual's right to revoke the Authorization in writing, and any exceptions to that right, and a description of how the individual may revoke the Authorization.Ĩ. If the Authorization is signed by a personal representative of the individual, a description of such representative's authority to act for the individual must also be provided. The statement 'end of research study,' 'none,' or similar language is sufficient if the Authorization is for a use or disclosure of protected health information for research including for the creation and maintenance of a research database or research repository. An expiration date or an expiration event that relates to the individual or the purpose stated of the use or disclosure.

The above statement or some other description must be included.ĥ. The statement 'at the request of the individual' is a sufficient description of the purpose when a patient initiates the Authorization and does not, or elects not to, provide a statement of the purpose. A description of each purpose of the requested use or disclosure. A cover sheet stating who should receive the information is NOT sufficient.Ĥ. The specific entity(ies) to receive the information must be identified on the form. The name or other specific identification of the person(s), or class of persons, to whom you may make the requested disclosure. For instance, the signed form should list either your department or someone in your department by name.ģ. The name or other specific identification of the person(s), or class of persons, who can make the requested use or disclosure. A separate from is required for Psychotherapy Notes.Ģ. Note: A single Authorization form may not be used to authorize the release of Psychotherapy Notes and other medical records. The form may request the entire health record, all records between specific dates, or other specific items. A description of the protected health information to be used or disclosed that identifies it in a specific and meaningful fashion. Send the Authorization and letter or documentation to the Office of Legal Counsel for assistance.ĬHECK LIST FOR HIPAA AUTHORIZATION MEDICAL RECORDS REQUEST (12 Item Check list)ġ. If the compliant Authorization is accompanied by a cover letter that is more specific than the Authorization, you may be able to rely on the more specific request. If it is not compliant, forward the requestor OU's HIPAA-compliant Authorization and ask that they complete and return it so that we may consider their request. If the Authorizations you receive do not contain all 12 items, then the Authorization is not compliant for release of Protected Health Information. I have also attached the University's HIPAA compliant Authorization ( ) to correspond with the numbers described on the checklist, and a copy of the HIPAA Privacy Policy #23-Authorization. Any Authorization form that you receive requesting health information must contain all12 items.

SAMPLE LETTER PATIENT TREATMENT INFORMATION RELEASE UPDATE

HIPAA Update - Check List for HIPAA AuthorizationsĪttached is a 12- item checklist for HIPAA Authorization to Release/Request for an Individual's Health Information.

Sample letter patient treatment information release