TUMG Authorization for Release of Protected Health Information Policy TUMG Authorization for Release of Protected Health Information Policy Approved- 10/29/18 Purpose This policy applies to Tulane University Medical Group, its participating physicians and clinicians, and all University employees and business units who provide management, administrative, financial, legal, and operational support to or on behalf of Tulane University Medical Group and have been designated as part of the Tulane University HIPAA Health Care Component Policy The Tulane University Health Care Component must obtain a written authorization from a patient prior to using or disclosing of protected health information (PHI) for the purposes described in the implementation section of this policy and in the Tulane University Notice of Privacy Practices (the “Notice”) or any joint notice with respect to organized healthcare arrangements in which Tulane University Medical Group participates (“Joint Notice”) Requests by Tulane University Medical Group patients relating to information maintained by a hospital should be referred to the hospital Implementation of Policy Authorization for uses and disclosures of protected health information (PHI) must be obtained for: 1) Uses and disclosures outside of treatment, payment, and health care operations, unless otherwise permitted by law or the Notice or Joint Notice as applicable; 2) Uses and disclosures created for research; 3) Psychotherapy notes with the exception: a) To carry out treatment, payment, or health care operations: i) Use by the originator of the notes for treatment; ii) Use or disclosure in training programs in which trainees, students, or practitioner in mental health learn under supervision to practice or improve their skills in group, joint, family, or individual counseling; or iii) Use or disclosure by a facility to defend a legal action or other proceeding brought on by the individual b) Use and disclosure with respect to oversight of the originator of the notes “Psychotherapy notes” means: notes recorded (in any medium) by a physician or clinician who is a mental health professional documenting or analyzing the contents of a conversation during a private counseling session or a group, joint, or family counseling session that are separated from the rest of the individual’s medical record Psychotherapy notes exclude medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items; diagnosis, functional status, the treatment plan, symptoms, prognosis and progress to date 4) Deceased patient records, unless fifty (50) years have elapsed since the individual’s death In such cases the health information is no longer subject to HIPAA and is no longer considered protected health information Accordingly, no authorization is required to use or disclose such health information 5) An individual may revoke an authorization at any time in writing See Attachment B Procedure 1) In general, all written authorization must be obtained using the authorization form However, any signed form presented by a patient or his/her representative that contains the same information as the form in Attachment A is acceptable 2) Every signed authorization must be documented and retained for a minimum of six years 3) An authorization for use of PHI may not be combined with any other document to create a compound authorization, except as follows: a) be combined with any other type of written permission for the same research study, including another authorization or a research informed consent; b) combine conditioned and unconditioned authorizations for research as a single document, so long as the authorization clearly differentiates between the conditioned and unconditioned research components and clearly allows the individual to opt in to the unconditioned research activities; and c) include future research as a purpose of the research authorization, so long as the I.R.B., in its discretion, determines that the future purposes have been described in such a way that an individual would understand that his or her PHI could be disclosed for future research d) An authorization for use or disclosure of psychotherapy notes may only be combined with authorization for use or disclosure of psychotherapy notes e) An authorization in accordance with this policy, other than an authorization for a use or disclosure of psychotherapy notes, may be combined with any other authorization except when the provision of treatment or payment has been conditioned on the provision of one of the authorizations 4) HIPAA requires reasonable protocols designed to verify the identity and authority of the requestor A covered entity may reasonably rely on documentation, statements, and representations that on their face meet the applicable requirements (examples – affidavit notarized, birth certificate, death certificate is reasonable proof According to LA R.S 40:1299.96, in the case of a deceased patient, the executor of the will, the administrator of the estate, the surviving spouse, the parents, or the children of the deceased patient all have a right to obtain a copy of the patient’s medical records after providing a signed authorization for the release of records Process Tulane University Medical Group has established a direct point of contact regarding release of information requests for medical records Such requests can be forwarded to tumgroi@wave.tulane.edu Urgent or timely requests may be submitted to tumgroi@wave.tulane.edu as well This email account will be checked consistently for updated requests for records Requests will be prioritized based on the deadlines for requested information Turnaround time expectations will be approximately business days unless later accommodations are expressed Communication with 3rd party requesters will be established should a time extension be required 1) All medical records requests pertaining to the operations of the clinic should be fulfilled by the appropriate clinic staff at no charge a Operational medical records requests include patient requests for records or outside doctor’s office requests for records; b If assistance is needed with fulfilling these requests please e-mail tumgroi@wave.tulane.edu for assistance with these requests 2) All third-party requests for medical records will not be fulfilled by clinic staff If you are to receive a third-party request Immediately forward it to tumgroi@wave.tulane.edu a Third-party requests include legal medical records requests, insurance medical records requests, disability medical records requests and subpoena medical records requests 3) In order to ensure we are capturing all information related to patient medical records, continuous contact with clinic managers/designated staff will resume for their assistance Some clinics may still have paper charts alongside documentation in eClinical Works Assistance from clinics is necessary to cross check if a paper chart exists If so, coordination with clinics will occur to provide the paper chart information If no paper chart exists, information from eClinical Works will be released accordingly 4) Pursuant to La R.S 40:1165.1, we are allowed to charge for copying fees regarding patient records As a professional courtesy, we will not charge patients to receive a copy of their medical records Requests for records may not be available for same-day pick up A scheduled time should be arranged with the patient to pick up or mail records Third-party requests for records will incur copying fees a The charges set forth in this section shall be applied to all persons and legal entities duly authorized by the patient to obtain a copy of their medical records b The charges for providing digital copies shall not exceed $100.00 If the treatment records exist in both digital form and paper form, the maximum limit of $100.00 shall apply only to the portion of records stored in digital form 5) Pursuant to La R.S 40:1165.1, If requested, the health care provider shall provide the requestor, at no extra charge, a certification page setting forth the extent of the completeness of records on file a In the event a hospital record is not complete, the copy of the records furnished shall indicate, through a stamp, coversheet, or otherwise, the extent of completeness of the records b When requested, certification pages must accurately indicate the status of records (partial complete, incomplete records, no records available, etc.) 6) See Medical Records Copying Fees Process-Attachment C Attachment Tulane University Medical Group AUTHORIZATION FOR THE RELEASE OF CONFIDENTIAL HEALTH INFORMATION Tulane University Medical Group must obtain a written authorization from a patient or their Personal Representative prior to releasing Confidential Health Information, unless a legal exception applies This form must be fully and completely filled out to be valid A reasonable copying and handling charge may be charged for this request pursuant to La R.S 40:1165.1 PATIENT AND RECIPIENT’S INFORMATION I hereby authorize Tulane University Medical Group to release Confidential Health Information on the patient listed below THE RECORDS OF: (Patient’s Information) Name: DOB (MM-DD-YYYY): Address: Phone: DELIVER TO: (Recipient’s Information) Name: Address: Phone: Fax: PURPOSE OF DISCLOSURE Treatment Personal Legal Insurance SPECIFIC TREATMENT PERIODS Specific treatment date or time period for which the information is requested: Single treatment date of Period of treatment from Any and all treatment encounters to date to DESCRIPTION OF INFORMATION TO BE USED OR DISCLOSED Specific description of information to be used or disclosed (Check only those that apply or select All Records.) Medical Records Progress Notes Doctor’s Orders Billing Records Nurse’s Notes Lab Reports Immunization Records Other Medical Records: Mental Health Records All Records Mental Health Records Health Treatment and Billing Records Psychotherapy Notes (Please Describe) *This is the only item you may request on this authorization You must submit another authorization for other items requested I hereby consent to release my HIV test results: where release is authorized by law without my consent (Initial) I have a right to refuse to release my HIV test results, except I understand that: I may refuse to sign this authorization and that it is strictly voluntary If I not sign this form, my health care and the payment for my health care will not be affected I may revoke this authorization at any time in writing This authorization, and in copy thereof, will be deemed revoked once the requested disclosure is made Subsequent authorizations must be executed for each requested disclosure If the receiver is not a health care provider, the information may no longer be protected by federal privacy regulations I understand that I may see and obtain a copy of the information described on this form, for a reasonable copy fee I may have a copy of this form after I sign it SIGNATURES OFFICE USE ONLY I have read the above and authorize the disclosure of the Confidential Health Information as stated Signature of Patient/Personal Representative: Date: RECEIVED DATE: Print Name of Patient’s Personal Representative (Authority document must be attached): Relationship to Patient TIME: ATTEMPTED TO CONTACT PATIENT LEFT MSG: DATES: Y / N Y / N Y / N Faxed Mailed General Counsel No record found/Letter Sent INITIALS SEND DATE: Attachment B REVOKE AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION (PHI) Patient’s Name: Birth Date: Address: SS#: Telephone #: I hereby REVOKE authorization from To release the health information of To That was granted for the purpose of Type of access that was granted: Entire Medical Record Itemized bill Other Date Relationship to patient (Signature of Patient/Guardian/Patient Representative) (Printed name) *Revocation of authorization for release of information except to the extent the action has been taken in reliance upon it Attachment C Medical Records Copying Fees Process: TUMG Release of Information will be responsible for all duties as it relates to overseeing the process of preparing medical records to fulfill requests, creating invoices, and collecting and depositing funds into the appropriate account TUMG Release of Information: will prepare and process medical records requests per information requested from 3rd party requesters a This information will be logged on the detailed Release of information spreadsheet housed in Box Access to the Box Folder TUMG Medical Records Requests, can be shared as needed TUMG Release of Information: After the records are processed, an invoice is generated to capture all appropriate charges for preparation of records TUMG Release of Information: The invoice will be sent to the 3rd party requester and include pertinent information on how to comply a The invoice will include information on whom to make out the check to: “The Administrators of The Tulane Education Fund”; b And where to mail the check to: “TUMG Administration-Release of Information, 1430 Tulane Ave., Mail Code #8422 New Orleans, LA 70112-2699” i Release of Information should be included within the mailing address so that associated mail will be routed to the proper recipient, TUMG Release of Information TUMG Release of Information: Once Fees for copying medical records are received from the 3rd party requester, this information will be logged on the spreadsheet and records will be sent to the requester via FedEx, certified mail, secure fax, etc TUMG Release of Information: A deposit form will be filled out: a Access Gibson online: locate TAMS Forms, click on Deposit Forms, print and fill out form; b Include Account #: 995307 ; and the Natural Acct #: 4681 on the deposit form along with financial information from the check TUMG Release of Information: After the deposit form is filled out with all information required, deposit form and physical check will be brought to the business services specialist on the 14th floor who will ensure all information is given to the Financial Services Department in the Elk building