Lab Assignment 8.3 - Release of Information Correspondence Log 3 Student Name: Complete this correspondence log for cases 2-10. Case 1 is completed for you as an example. CORRESPONDENCE LOG CASE TYPE OF REQUEST IS REQUEST APPROPRIATE? (IF NO, WHY NOT?) RESPONSE FORM LETTER SENT REPORTS RELEASED AND COST 1 Physician Yes 2 Entire record $0.00 2 3 4 5 6 7 8 9 10
Lab Assignment 8.3 - Release of Information Correspondence Log 5 Case01 Request for Information Received in Health Information Department for processing on June 1, (this year). AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION (PHI) (1) I hereby authorize Alfred Medical Center to disclose/obtain information from the health records of: Marsha Dennis 02/09/YYYY (607)555-7771 Patient Name Date of Birth (mmddyyyy) Telephone (w/ area code) 344 Maple Avenue, Alfred NY 14802 Case01 Patient Address Medical Record Number (2) Covering the period(s) of healthcare: 04/27/YYYY 04/29/YYYY From (mmddyyyy) To (mmddyyyy) From (mmddyyyy) To (mmddyyyy) (3) I authorize the following information to be released by Alfred Medical Center (check applicable reports): Face Sheet Progress Notes Pathology Report Drug Abuse Care Discharge Summary Lab Results Nurses Notes Other: Entire record History & Physical Exam X-ray Reports HIV Testing Results Consultation Scan Results Mental Health Care Doctors Orders Operative Report Alcohol Abuse Care This information is to be disclosed to or obtained from: Dr. Raymond Beecher 9 Langston Dr, St. Petersburg, FL 00000 (800) 555-5698 Name of Organization Address of Organization Telephone Number for the purpose of: follow-up treatment by Dr. Beecher. Statement that information used or disclosed may be subject to re-disclosure by the recipient and may no longer be protected by this rule(4) I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing and present my written revocation to the Health Information Management Department. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. Unless otherwise revoked, this authorization will expire on the following date, event, or condition: Expiration Date Expiration Event Expiration Condition If I fail to specify an expiration date, event or condition, this authorization will expire within six (6) months. Signature of individual and date(5) I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment. I understand that I may inspect or copy the information to be used or disclosed, provided in CFR 164.534. I understand that any disclosure of information carries with it the potential for an unauthorized redisclosure and may not be protected by federal confidentiality rules. If I have questions about disclosure of my health information, I can contact the Privacy Officer at Alfred Medical Center. Signed: Marsha Dennis Signature of Patient or Legal Representative May 25, (this year) Date
Lab Assignment 8.3 - Release of Information Correspondence Log 6 Case02 Request for Information Received in Health Information Department for processing on July 30, (this year). EMPIRE BLUE CROSS AND BLUE SHIELD of Central New York 344 South Warren Street, Box 4809 Syracuse, New York 13221 315/424-3700 July 15, (this year) ATTENTION: Health Information Department Alfred State Medical Center Patient: Dilbert Hunter Service Date: 4/26/YYYY 4/20/YYYY Group #: 52656388 Claim #: 02216 Copies of the following provider records are requested for the adjudication of the above mentioned claim. Under terms of our subscriber contract, the patient has given prior authorization for the release of this information. Please send the following reports: [X] Final Diagnosis (Face Sheet) [X] History & Physical Examination [ ] Progress Notes [ ] Physician's Orders [ ] Operative Report [ ] Ancillary Reports Please return a copy of this letter with a copy of the records to: Medical Review Blue Cross Claims Department Patient #: 1104272 Thank you. Sincerely, Mary Ann Jones Mary Ann Jones, Claims Reviewer
Lab Assignment 8.3 - Release of Information Correspondence Log 7 Case 03 Request for Information Received in Health Information Department for processing on May 30, (this year). AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION (PHI) (1) I hereby authorize Alfred Medical Center to disclose/obtain information from the health records of: Erica P. Stanley 04/05/YYYY (607)555-8818 Patient Name Date of Birth (mmddyyyy) Telephone (w/ area code) 23 Langley Drive, Alfred NY 14802 Case03 Patient Address Medical Record Number (2) Covering the period(s) of healthcare: 04/28/YYYY 04/29/YYYY From (mmddyyyy) To (mmddyyyy) From (mmddyyyy) To (mmddyyyy) (3) I authorize the following information to be released by Alfred Medical Center (check applicable reports): Face Sheet Progress Notes Pathology Report Drug Abuse Care Discharge Summary Lab Results Nurses Notes Other: History & Physical Exam X-ray Reports HIV Testing Results Consultation Scan Results Mental Health Care Doctors Orders Operative Report Alcohol Abuse Care This information is to be disclosed to or obtained from: Abdul Raish, M.D. 1421 Lincoln Avenue New York, NY 10035 (800) 555-8951 Name of Organization Address of Organization Telephone Number for the purpose of: treatment by Dr. Raish. Statement that information used or disclosed may be subject to re-disclosure by the recipient and may no longer be protected by this rule(4) I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing and present my written revocation to the Health Information Management Department. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. Unless otherwise revoked, this authorization will expire on the following date, event, or condition: Expiration Date Expiration Event Expiration Condition If I fail to specify an expiration date, event or condition, this authorization will expire within six (6) months. Signature of individual and date(5) I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment. I understand that I may inspect or copy the information to be used or disclosed, provided in CFR 164.534. I understand that any disclosure of information carries with it the potential for an unauthorized redisclosure and may not be protected by federal confidentiality rules. If I have questions about disclosure of my health information, I can contact the Privacy Officer at Alfred Medical Center. Signed: Erica P. Stanley Signature of Patient or Legal Representative May 1, (this year) Date
Lab Assignment 8.3 - Release of Information Correspondence Log 8 Case 04 Request for Information Received in Health Information Department for processing on August 30, (this year). DWYER & DWYER, P.C. ATTORNEYS AT LAW PARK PLACE PROFESSIONAL BUILDING OLEAN, NY 14760 716/373-1920 Joseph C. Dwyer & Elaine N. Dwyer Practice Limited to Civil Trial Law Barbara L. Laferty, Legal Assistant August 16, (this year) Alfred State Medical Center Alfred, NY 14802 ATTN: Records Room RE: Our Client: Mary C. Howe Date of Injury: 04/29/YYYY Gentlemen: We have been retained by the above to represent the above-named with regard to an injury which occurred on the above date, resulting in personal injuries. It is our understanding that our client was treated at your institution either as an outpatient or inpatient. We respectfully request that you forward to us copies of the hospital records, excluding only TPR, fluid, and laboratory reports. We specifically need the nurse's notes. Would you please have your billing office send us an original bill as to hospital services rendered but not indicating on it what, if anything, has been paid to date. Please enclose any statement for your customary charges in providing these records. Thank you kindly for your cooperation and assistance. Yours very truly, DWYER & DWYER, P.C. By: Joseph C. Dwyer JCD:cd
Lab Assignment 8.3 - Release of Information Correspondence Log 9 Case 05 Request for Information Received in Health Information Department for processing on August 9, (this year). HOSPITAL FOR JOINT DISEASES & MEDICAL CENTER (HJD&MC), 1919 MADISON AVENUE, NEW YORK 10035 DATE July 14, (this year) NAME GIBBON, Andrew PATIENT # Case05 TO ALFRED STATE MEDICAL CENTER, ALFRED NY DEAR SIRS: We have been informed that the above named patient was treated in your institution on or about 1/1/YYYY. May we obtain from you a resume of your findings, including the radiology reports, operations or other treatment provided? Very truly yours, MEDICAL RECORD DEPARTMENT AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION (PHI) (1) I hereby authorize Alfred Medical Center to disclose/obtain information from the health records of: Andrew Gibbon 08/19/YYYY (607)555 4500 Patient Name Date of Birth (mmddyyyy) Telephone (w/ area code) 22 Market Street,lfred NY 14802 Case05 Patient Address (2) Covering the period(s) of healthcare: January YYYY Medical Record Number From (mmddyyyy) To (mmddyyyy) From (mmddyyyy) To (mmddyyyy) (3) I authorize the following information to be released by Alfred Medical Center (check applicable reports): Face Sheet Progress Notes Pathology Report Drug Abuse Care Discharge Summary Lab Results Nurses Notes Other: History & Physical Exam X-ray Reports HIV Testing Results Consultation Scan Results Mental Health Care Doctors Orders Operative Report Alcohol Abuse Care This information is to be disclosed to or obtained from: HJD&MC 1919 Madison Avenue, New York, NY 10035 (800) 555 9567 Name of Organization Address of Organization Telephone Number for the purpose of: treatment by Dr. HJD&MC. Statement that information used or disclosed may be subject to re-disclosure by the recipient and may no longer be protected by this rule(4) I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing and present my written revocation to the Health Information Management Department. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. Unless otherwise revoked, this authorization will expire on the following date, event, or condition: Expiration Date Expiration Event Expiration Condition If I fail to specify an expiration date, event or condition, this authorization will expire within six (6) months. Signature of individual and date(5) I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment. I understand that I may inspect or copy the information to be used or disclosed, provided in CFR 164.534. I understand that any disclosure of information carries with it the potential for an unauthorized redisclosure and may not be protected by federal confidentiality rules. If I have questions about disclosure of my health information, I can contact the Privacy Officer at Alfred Medical Center. Signed: Andrew Gibbon Signature of Patient or Legal Representative May 1, (this year) Date
Lab Assignment 8.3 - Release of Information Correspondence Log 10 Case 06 Request for Information Received in Health Information Department for processing on October 15, (this year). PRUDENTIAL The Prudential Insurance Company of America August 15, (this year) AUTHORIZATION TO RELEASE INFORMATION TO: Alfred Medical Center, Alfred NY For purposes of evaluating a claim, you are authorized to permit the Prudential Insurance Company of America and its authorized representatives to view or obtain a copy of ALL EXISTING RECORDS (including those of psychiatric, drug or alcohol treatment) pertaining to the examination, medical and dental treatment, history, prescriptions, employment and insurance coverage of Charles Benson. This authorization specifically covers a period of hospitalization or medical care and treatment during 4/24/YYYY through 4/29/YYYY. This information is for the sole use of Prudential's representatives or the group policy holder or contract holder involved in processing the claim and will not be furnished in an identifiable form to any other persons without my written consent unless expressly permitted or required by law. I understand that this authorization may be revoked by written notice to Prudential, but this will not apply to information already released. If not revoked, this authorization will be valid while the claim is pending or a maximum of one year from the date it is signed. I have been furnished a copy of this authorization and acknowledge receipt. I also agree that a photographic copy shall be as valid as the original. Limitations, if any: DATE August 15, (this year) SIGNED: Charles Benson
Lab Assignment 8.3 - Release of Information Correspondence Log 11 Case 07 Request for Information Received in Health Information Department for processing on May 5, (this year). BLUE CROSS & BLUE SHIELD UTICA, NEW YORK 13502 A MEDICARE CARRIER DATE: TO: ATTN: PATIENT: DOB: ADMISSION: April 30, (this year) Alfred State Medical Center, Alfred NY Health Information Department Holley E. Hoover 01/15/YYYY 04/30/YYYY We request the following information to process the above patient's claim: 1. face sheet 2. surgical procedures performed 3. history of condition 4. discharge summary Please send a statement for clerical services with this information, and we will be glad to promptly send you a check. Thank you for your prompt cooperation. Jean Lewis Claims Examiner
Lab Assignment 8.3 - Release of Information Correspondence Log 12 Case 08 Request for Information Received in Health Information Department for processing on November 1, (this year). ADAM ATTORNEY 15 MAIN STREET ALBANY NY 00000 PHONE: (518) 555-1234 ------------------------------------------------------------------------------------------------------------ JOHN DOE, ) Petitioner, ) SUBPOENA DUCES TECUM ) vs. ) ) RICHARD ROE, M.D. ) Respondent. ) Case No. NY-895623591 ) ------------------------------------------------------------------------------------------------------------ TO: Alfred State Medical Center 100 Main St Alfred NY 14802 RE: Molly P. Mason DOB: 3/1/YYYY YOU ARE COMMANDED to produce at the County Courthouse, 15 Main Street, Room 14A, Alfred NY 14802 on November 15, (this year) at 9 A.M., a complete copy of your medical records, pertaining to the above-referenced individual who has requested the Division of Professional Licensing to conduct a prelitigation panel review of a claim of medical malpractice. Attendance is not required if records are timely forwarded to the indicated address. DATED this twenty-fifth day of October (this year). By: Petra Lyons Clerk of the Court
Lab Assignment 8.3 - Release of Information Correspondence Log 13 Case 09 Request for Information Received in Health Information Department for processing on November 15, (this year). ADAM ATTORNEY 15 MAIN STREET ALBANY NY 00000 PHONE: (518) 555-1234 ----------------------------------------------------------------------------------------------------------- DAVID LUCK, ) Petitioner, ) COURT ORDERED SUBPOENA ) DUCES TECUM vs. ) ) ALAN GHANN, M.D. ) Respondent. ) Case No. NY-895623591 ) ----------------------------------------------------------------------------------------------------------- TO: Alfred State Medical Center 100 Main St Alfred NY 14802 RE: David Luck DOB: 11/21/YYYY YOU ARE COMMANDED to produce at the County Courthouse, 15 Main Street, Room 14A, Alfred NY 14802 on November 25, (this year) at 9 A.M., a complete copy of your medical records, pertaining to the above-referenced individual who has requested the Division of Professional Licensing to conduct a prelitigation panel review of a claim of medical malpractice. Attendance is not required if records are timely forwarded to the indicated address. DATED this fifth day of November this year). By: Petra Lyons Clerk of the Court
Lab Assignment 8.3 - Release of Information Correspondence Log 14 Case 10 Request for Information Received in Health Information Department for processing on October 5, (this year). Authorization for Release of Confidential HIV-Related Information Name and address of facility/provider obtaining release: Alfred State Medical Center, 100 Main Street, Alfred NY 14802 Name of person whose HIV related information will be released: Paula P. Paulson Name(s) and address(es) of person(s) signing this form (if other than above): Relationship to person whose HIV information will be released (if other than above): Name(s) and address(es) of person(s) who will be given HIV related information: Michael Diamond, M.D., 1423 Main Street, Wellsville NY 14895 Reason for release of HIV related information: To provide historical perspective of HIV status for physician s office record. Time during which release is authorized: From: 4/26/YYYY To: 5/1/YYYY The Facility/Provider obtaining this release must complete the following: Exceptions, if any, to the right to revoke consent for disclosure: (for example cannot revoke if disclosure has already been made.) N/A Description of the consequences, if any, of failing to consent to disclosure upon treatment, payment, enrollment, or eligibility for benefits: N/A (Note: Federal privacy regulations may restrict some consequences.) My questions about this form have been answered. I know that I do not have to allow release of HIV related information, and that I can change my mind at any time and revoke my authorization by writing the facility/provider obtaining this release. Oct 1, (this year) Date Paula P. Paulson Signature