36C25819R0003-016.docx

PVAHCS Standard Operating Procedure (644)

RELEASE OF INFORMATION- 1st & 3rd Party Requests at the Community Based Outpatient Clinic (CBOC)

1. PURPOSE: To establish a standardized process for releasing 1st party patient information from the Computerized Patient Record System (CPRS).

2. SCOPE: This SOP applies to Community Based Outpatient Clinics that receive requests for medical records from a Veteran.

3. RESPONSIBILITIES:

a. Managers and staff are responsible for ensuring they are familiar with Medical Center Policy on Privacy (PO-01).

b. Health Information Management Staff will review all completed ROI requests received from the CBOC and ensure all authorizations are valid and will follow-up with staff on an as-needed basis.

4. PROCEDURES: When patients present to a CBOC requesting copies of their own medical records (1st Party), staff will follow the following procedures:

a. Provide the patient with the appropriate VA Form to release information.

(1) For medical information going to the VETERAN, use form:

VA Form 10-5345a INDIVIDUALS' REQUEST FOR A COPY OF THEIR OWN HEALTH INFORMATION (attachment A)

Forward the completed form to ROI at the Main Campus; either via inter-office mail or fax (222-6495).

b. Point of Care Release:

Clinical Providers may disclose patient information at Point of Care, without a written request, if it is for patient education purposes. If the patient is requesting information/records from prior visits (example: 6 weeks prior), they must complete a 10-5345a so the CBOC staff can forward it to Release of Information.

c. All 3rd party requests for medical information going to someone OTHER than the Veteran, use form:

VA 10-5345 REQUEST FOR AND AUTHORIZATION TO RELEASE MEDICAL RECORDS OR HEALTH INFORMATION (attachment B).

Forward the completed form to ROI at the Main Campus; either via inter-office mail or fax (222-6495).

NOTE: All information released (other than Point of Care by a Clinical Provider) must be tracked for Accounting of Disclosures, so it’s imperative that all requests be sent to Release of Information.

CBOC Staff may assist the Veteran (by explaining required fields, etc.) in completing the 10-5345 for 3rd Party Requests but staff may not complete the form for the Veteran.

d. If the patient needs Letters or Statements, they can go to ROI Department at the Phoenix Campus or request them via regular mail (not email) to the attention of the Phoenix ROI Department or the CBOC may fax the request to ROI at 222-6495.

e. When completing a 3rd Party release, the Veteran must identify if Drug/Alcohol Abuse, HIV status or Sickle Cell Anemia (7332 Sensitive Diagnosis) information is to be included in the information released.

f. DO NOT engage in the following behaviors:

(1) Email with a patient outside Secure Messaging/MyHealtheVet

(2) Put patient information on your work MS Outlook calendar; this is not secure

(3) Pre-mark the 7332 sensitive diagnosis sections on form 10-5345 (these may only be checked-off by the Veteran)

5. FOLLOWUP RESPONSIBILITY: Health Information Management

6. REVIEW DATE: 6/18/2018

7. APPROVING OFFICIAL

Chief Health Information Management or Designee

Attachments:

Distribution Community Based Outpatient Clinics image1.emf vha-10-5345a-fill_updated ver.pdf

Text

10-5345aVA FORM JUN 2017 Page 1 of 1

NOTE: If signed by someone other than the individual, indicate the authority (e.g. guardianship or power of attorney) under which request is made.

PATIENT SIGNATURE (Sign in ink)

MAIL TO ADDRESS:

IN-PERSON PICK-UP, PROVIDE CONTACT PHONE NUMBER:

COPY OF HEALTH INFORMATION IS TO BE DELIVERED TO THE INDIVIDUAL

The purpose of this form is to provide an individual the means to make a written request for a copy of their information maintained by the Department of Veteran Affairs (VA) in accordance with 38 CFR 1.577. The information on this form is requested under Title 38 U.S.C. Your disclosure of the information requested on this form is voluntary. However, if the information including the last four of your Social Security Number (SSN) and Date of Birth (used to locate records for release) is not furnished completely and accurately, VA will be unable to comply with the request. Failure to furnish the information will not have any effect on any other benefits to which you may be entitled.

PRIVACY ACT INFORMATION

INDIVIDUALS' REQUEST FOR A COPY

OF THEIR OWN HEALTH INFORMATION

PAPER CD-ROM OTHER:

DATE OF BIRTHLAST 4 SSNLAST NAME- FIRST NAME- MIDDLE INITIAL

TO: DEPARTMENT OF VETERANS AFFAIRS (Name and Address of VA Health Care Facility)

HEALTH SUMMARY (Prior 2 Years)

OTHER (Describe):

LIST OF ACTIVE MEDICATIONS

RADIOLOGY REPORTS (Name & Date):

DATE RANGE:

SPECIFIC TESTS (Name & Date):

LAB RESULTS:

OPERATIVE/CLINICAL PROCEDURES (Name & Date):

DATE RANGE:

SPECIFIC PROVIDERS (Name & Date Range):

SPECIFIC CLINICS (Name & Date Range):

PROGRESS NOTES:

INPATIENT DISCHARGE SUMMARY (Dates):

DESCRIPTION OF INFORMATION REQUESTED

Check applicable box(es) and state the extent or nature of information to be provided:

DATE (mm/dd/yyyy)

8.0.1291.1.339988.308172

INDIVIDUALS' REQUEST FOR A COPY OF THEIR OWN HEALTH INFORMATION

VA Form 10-5345a

Text

10-5345a

VA FORM

JUN 2017

NOTE: If signed by someone other than the individual, indicate the authority (e.g. guardianship or power of attorney) under which request is made.

COPY OF HEALTH INFORMATION IS TO BE DELIVERED TO THE INDIVIDUAL

The purpose of this form is to provide an individual the means to make a written request for a copy of their information maintained by the Department of Veteran Affairs (VA) in accordance with 38 CFR 1.577. The information on this form is requested under Title 38 U.S.C. Your disclosure of the information requested on this form is voluntary. However, if the information including the last four of your Social Security Number (SSN) and Date of Birth (used to locate records for release) is not furnished completely and accurately, VA will be unable to comply with the request. Failure to furnish the information will not have any effect on any other benefits to which you may be entitled.

PRIVACY ACT INFORMATION

INDIVIDUALS' REQUEST FOR A COPY

OF THEIR OWN HEALTH INFORMATION

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Department of Veterans Affairs Logo.

DESCRIPTION OF INFORMATION REQUESTED

Check applicable box(es) and state the extent or nature of information to be provided:

LIST OF ACTIVE MEDICATIONS.:

OTHER.: 0

DATE OF BIRTH. Enter 2 digit month, 2 digit day and 4 digit year.:

LAST 4 Social Security Number.:

LAST NAME- FIRST NAME- MIDDLE INITIAL.:

TO: DEPARTMENT OF VETERANS AFFAIRS (NAME AND ADDRESS OF V A. HEALTH CARE FACILITY).:

DESCRIPTION OF INFORMATION REQUESTED. Check applicable box(es) and state the extent or nature of information to be provided. HEALTH SUMMARY (PRIOR 2 YEARS).: 0

OTHER (DESCRIBE BELOW).: 0

LIST OF ACTIVE MEDICATIONS.: 0

RADIOLOGY REPORTS (NAME AND DATE).: 0

DATE RANGE.: 0

SPECIFIC TESTS (NAME AND DATE).: 0

LAB RESULTS.: 0

OPERATIVE / CLINICAL PROCEDURES (NAME AND DATE).: 0

DATE RANGE.: 0

SPECIFIC PROVIDERS (NAME AND DATE RANGE).: 0

SPECIFIC CLINICS (NAME AND DATE RANGE).: 0

PROGRESS NOTES.: 0

INPATIENT DISCHARGE SUMMARY.: 0

OTHER (DESCRIBE). Line 1 of 2.:

OTHER (DESCRIBE). Line 2 of 2.:

PATIENT SIGNATURE DATE. Enter 2 digit month, 2 digit day and 4 digit year.:

image2.emf

NEW_vha-10-5345-fill.pdf

VA Form 10-5345 Page 1 of 2

SEPT 2018

Department of Veterans Affairs REQUEST FOR AND AUTHORIZATION TO RELEASE

HEALTH INFORMATION

PRIVACY ACT AND PAPER WORK REDUCTION ACT INFORMATION: The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of section 3507 of the Act. We may not conduct or sponsor, and you are not required to respond to, a collection of information unless is displays a valid OMB number. We anticipate that the time expended by all individuals who must complete this form will average 2 minutes. This includes the time it will take to read the instructions, gather the necessary facts and fill out this form. The execution of this form does not authorize the release of information other than that specifically described below.

The information requested on this form is solicited under Title 38 U.S.C. The form authorizes release of information in accordance with the Health Insurance Portability and Accountability Act, 45 CFR Parts 160 and 164; 5 U.S.C. 552a; and 38 U.S.C. 5701 and 7332 that you specify.

Your disclosure of the information requested on this form is voluntary. However, if the information including the last four of your Social Security Number (SSN) and Date of Birth (used to locate records for release) is not furnished completely and accurately, VA will be unable to comply with the request. The Veterans Health Administration may not condition treatment, payment, enrollment or eligibility on signing the authorization.

VA may disclose the information that you put on the form as permitted by law. VA may make a “routine use” disclosure of the information as outlined in the Privacy Act system of records notices identified as 24VA10P2 “Patient Medical Record – VA”, 08VA05 “Employee Medical File System Records (Title 38)-VA” and in accordance with the Notice of Privacy Practices. VA may also use this information to identify veterans and person claiming or receiving VA benefits and their records, and for other purposes authorized or required by law.

TO: DEPARTMENT OF VETERANS AFFAIRS (Name and address of VA health care facility):

LAST NAME-FIRST NAME-MIDDLE INITIAL

LAST 4 SSN DATE OF BIRTH

NAME AND ADDRESS OF ORGANIZATION, INDIVIDUAL, OR TITLE OF INDIVIDUAL TO WHOM

INFORMATION IS TO BE RELEASED

PURPOSE(S) OR NEED: Information is to be used by the organization or individual for

� Treatment � Benefits � Legal � Employment � Other – Please specify.______________________

INFORMATION REQUESTED: Check applicable box(es) and state the extent or nature of information to be provided:

� Health Summary (prior 2 years) � Inpatient Discharge Summary (dates): ________________________________________________ � Progress Notes:

� Specific clinics (name & date range): ____________________________________________ � Specific providers (name & date range): __________________________________________ � Date range: ________________________ � Operative/Clinical Procedures (name &date): __________________________________________ � Lab results:

� Specific tests (name & date): __________________________________________________ � Date range: ____________________________ � Radiology Reports (name & date): ___________________________________________________ � List of Active Medications � Flu Vaccination (dose, lot number, date & location) � Other (describe below):

VA Form 10-5345 Page 2 of 2

SEPT 2018

LAST NAME-FIRST NAME-MIDDLE INITIAL

LAST 4 SSN DATE OF BIRTH

SENSITIVE DIAGNOSES: REVIEW AND, IF APPROPRIATE, COMPLETE WHEN RELEASE IS FOR ANY PURPOSE

OTHER THAN TREATMENT.

I request and authorize the Department of Veterans Affairs to release the information pertaining to the condition(s) below for the non-treatment purpose(s) listed in this authorization:

� Drug Abuse � Alcoholism or Alcohol Abuse � Sickle Cell Anemia � Human Immunodeficiency Virus (HIV)

I understand that information on these sensitive diagnoses may be released for treatment purposes without me checking the above boxes, and will be released even if the boxes are unchecked unless I indicate by checking the box below that I do not want this information released for this specific disclosure.

� I do not want sensitive diagnoses released for treatment purposes under this specific authorization. I realize this does not impact other future requests unrelated to this authorization.

AUTHORIZATION: I certify that this request has been made freely, voluntarily and without coercion, or because a condition of VA employment mandates the signing of this authorization. The information given above is accurate and complete to the best of my knowledge. I understand that I will receive a copy of this form after I sign it. I may revoke this authorization in writing, at any time except to the extent that action has already been taken to comply with it.

Written revocation is effective upon receipt by the Release of Information Unit at the facility housing records. Any information disclosed per this authorization may no longer be protected by Federal confidentiality laws or regulations and may be subject to re-disclosure by the recipient.

I understand that the VA health care provider’s opinions and statements are not official VA decisions regarding whether I will receive other VA benefits or, if I receive VA benefits, their amount. They may, however, be considered with other evidence when these decisions are made at a VA Regional Office that specializes in benefit decisions.

EXPIRATION: Without my express revocation, the authorization will automatically expire � After one-time disclosure, if all needs are satisfied � On __________________ (enter a future date other than date signed by patient) � Under the following condition(s):_________________________________________________________________

PATIENT SIGNATURE DATE (mm/dd/yyyy)

LEGAL REPRESENTATIVE SIGNATURE (if applicable) DATE (mm/dd/yyyy)

PRINT NAME OF LEGAL REPRESENTATIVE

RELATIONSHIP TO PATIENT

FOR VA USE ONLY

Type and Extent of Material Released:

Date Released: Released by: