Release of Patient Information Request Validation Checklist
Request Validation Checklist Completed By:
A. General Request Validation
# / Validation Items / Yes / No / N/A1 / The patient is identified by first name, last name and birth date at a minimum / q / q
2 / The requester’s first and last name is provided / q / q
3 / The requester’s complete address (street address, city, state, and zip code) is provided / q / q
4 / There is a complete address (street address, city, state, and zip code) to send the records (for postal mail delivery) / q / q / q
5 / There is a fax number to fax the records (for fax delivery) / q / q / q
6 / There is a requester contact number to arrange for in-person review/pick-up (for walk-in) / q / q / q
7 / Requester identification verified for in person pick-up/requests (for walk-in)
Ø Valid identification includes a driver’s license, passport or state issued picture identification card
Ø If no valid identification, the requester may provide a signature and the technician can attempt to match that to a document in the patient’s record. If a match can be found, identification is considered verified. / q / q / q
8 / The request is for only one patient
(Exception: court orders & subpoenas; patients typically in the same family) / q / q
9 / The request is being processed for only one requester
Ø If for more than one requester, make copies of the request for each additional requester and process each one separately
Ø highlight with yellow, the requester being processed; do not black out other requesters / q / q
10 / A specific and meaningful description of the information to be disclosed is provided (date(s) of care and record type(s) provided) / q / q
B. Authorization Validation
# / Validation Items / Yes / No / N/A /11 / An authorization is required? (if NO, skip items 12 – 22 / mark N/A)
Authorization is NOT required for uses/disclosures related to: (UWMC PP-08)
· Treatment, payment or healthcare operations (TPO)
· Medical examiners
· Department of Health
and in some cases for uses and disclosures related to:
· Public Health Activities (UWMC PP-16a)
· Care provided at the request of an Employer (UWMC PP-16b)
· Health Oversight Activities (UWMC PP-16c)
· Decedents (UWMC PP-16d)
· Averting a serious threat to health or safety (UWMC PP-16e)
· Specialized Government Functions (UWMC PP-16f)
· Judicial and Administrative Proceedings (UWMC PP-16g)
· Law Enforcement Purposes (UWMC PP-16h)
· Victims of abuse, neglect or domestic violence (UWMC PP-16i) / q / q
12 / The authorization is dated / q / q / q
13 / The authorization includes a specific expiration date or expiration event that pertains to the purpose of the disclosure / q / q / q
14 / The authorization is not expired by the date received / q / q / q
15 / The authorization is signed by the patient or the patient’s personal representative / surrogate decision maker AND if not signed by the patient, proof of legal guardianship or power of attorney and a description of the authority to act for the patient with regard to healthcare is provided / q / q / q
16 / The authorization has not been revoked by the patient
Ø Look in PowerChart for a PDS Alert or an Attorney request documenting the revoking of previous authorizations / q / q / q
17 / The authorization includes the name of the provider being asked to disclose the information / q / q / q
18 / The authorization provides a brief description of the purpose of the disclosure / q / q / q
19 / The authorization specifically covers any state and/or federally protected information if contained in the patient’s medical record / q / q / q
20 / The authorization includes a statement concerning the patient’s rights to revoke the authorization in writing. / q / q / q
21 / The authorization includes a statement regarding the exceptions to the right to revoke an authorization and a description of how to revoke or a reference to the Notice of Privacy Practices that includes this information. / q / q / q
22 / The authorization includes a statement whether the information disclosed might be redisclosed by the recipient and therefore is no longer protected. / q / q / q
23 / Any handwritten corrections are initialed either by the patient or a technician / q / q / q
24 / A statement that treatment or payment will not be conditioned based on the individual’s providing an authorization for the requested use or disclosure, except:
· When the authorization is for research-related treatment; or
· When the health care services are being provided to a patient solely for the purpose of disclosing patient information to a third party (an example of this is when a non-UW employer contracts with UW Medicine to conduct TB testing for purposes of employee health screening). / q / q
25 / The Authorization explicitly documents that the patient authorizes UW Medicine to release PHI that contains the following categories of information in order for UW Medicine to be able to disclose these types of information:
· Sexually transmitted disease,
· Acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV).
· Behavioral or mental health services and treatment for alcohol and drug abuse. / q / q / q
26 / If the authorization permits the disclosure of patient information to a financial institution or an employer of the patient for purposes other than payment, the authorization as it pertains to those disclosures shall expire ninety days after the signing of the authorization, unless the authorization is renewed by the patient. / q / q / q
27 / Where the patient is under the supervision of the department of corrections, an authorization signed for health care information related to mental health or drug or alcohol treatment expires at the end of the term of supervision, unless the patient is part of a treatment program that requires the continued exchange of information until the end of the period of treatment. / q / q / q
The request is VALID if:
· Validation items #1-10 are either Yes or N/A
AND
· Validation items #11-27 are Yes OR item #11 is No and items #12-27 are N/A
A copy of the signed authorization must accompany the records that are disclosed. The original authorization is maintained within the UW Medicine Designated Record Set.
If the request is INVALID:
· Reject the request