Running head: POLICIES AND PROCEDURES 1

Policies and Procedures

Amanda Hall

University of Cincinnati
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Running head: POLICIES AND PROCEDURES

Policies and Procedures

The policies and procedures being implemented for the release of information at Troy

Family Physician Network are as follows: The medical record is property of the Troy Family

Physician Network and the information contained within belongs to the patient. Confidential

information is not to be released to individuals without written authorization from the patient or

legally authorized entity (i.e. legal guardian, POA, or authorized HIPAA contact appointed by

patient at time of registration and documented in their medical record). Patients have the right to

control the release of their personal information and therefore these policies are set regarding the

release of medical, social, personal, or financial information on Troy Family Physician

Network’s patients.

All authorizations for release of patient information must be signed and dated by the

patient or legally authorized representative. Individuals requiring more sensitive information

including mental health records, alcohol or drug treatment records, and records pertaining to HIV

related diagnosis must be requested in writing and addressed to the Troy Family Physician

Network. This form must include that organization or individual’s name; patient’s full name,

address, last four of their social security number, and date of birth; specific dates of treatment

being requested as well as specific information being requested and reason for release; date the

consent is signed, and signature of the patient or legal representative. This authorization will be

valid for 90 days from date of signature.

A competent adult aged 18 or older may sign their own release. A minor under the age of

18 that is emancipated, has been married, has a child, is pregnant, or is being treated for a sex

related condition (i.e. abortion, birth control, STD treatment) may authorize the release of their
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Running head: POLICIES AND PROCEDURES

own personal health information and sign their own release. Parents of minors in these situations

may not obtain release of related information without the signature of the minor. In the case of

minors not covered above and in adults over 18 who are legally incompetent, release of

information must be signed by a legally appointed representative or legal guardian. If there is no

legally authorized representative authorization must be obtained by the court.

In the case of deceased patients, a legal representative must sign the authorization for

release and provide a copy of the death certificate, advanced directives, or letters of

administration. If no legal representative has been appointed, authorization can be obtained from

the next of kin with notarized next of kin affidavit in the following order of priority: Spouse,

adult son or daughter, adult grandchild, either parent, adult sibling, nephew or niece, any other

person authorized to dispose of the body of the deceased. Individuals requiring more sensitive

information including mental health records, alcohol or drug treatment records, and records

pertaining to HIV related diagnosis must be requested with a court order, except if requested by a

life insurance company for purpose of payment to a beneficiary.

Authorization is not needed when requested by Troy Family Physician Network’s legal

representative or liability insurers to protect the interests of the company in cases involving

liability, requests made by members of the medical staff necessary for the care and treatment of a

patient (though release of a record in its entirety can not be made without a release), the Medical

Records supervisor who must have access in order to complete his/her duties, the Financial

Director for the purpose of billing and processing insurance claims, the review of records

authorized by the Medical Records supervisor for use of quality assurance, and committees of

the medical staff as obligated for review of quality and appropriateness of patient care.
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Running head: POLICIES AND PROCEDURES

Resources

AHCA. (n.d.). HIPAA Policy and Procedure Manual. Retrieved from

https://www.ahcancal.org/facility_operations/privacysecurity/Pages/HIPAAPolicyProcManual.aspx