Request, Uses, and Disclosures Data Collection Form


Name: ______________________________ Department: ___________________________

Title: ________________________________ Phone extension: ______________

Requesting Patient Health Information

1. Do you ever request patient health information from individuals or businesses outside our organization?

___ Yes ___ No

1a. If yes, is the information you request for treatment?

___ Yes ___ No

1b. If yes, is the information you request for payment?

___ Yes ___ No

1c. If not treatment or payment, what is the information you request used for? ___________________________________________________________________
Accessing Patient Health Information

2. Do you have access to patient health information within the organization?

___ Yes ___ No

2a. If yes, to what patient health information do you have access? (Check all that apply)

___ Information sent or called into us by other organizations
___ Information I receive from the patient or the patient's family
___ Schedules (Please list)______________________________________________________________
___ Information on the computer (Please describe)______________________________________________________________
___ The patient's medical record
___ The patient's billing record
___ Other (Please describe)______________________________________________________________

3. How do you use the information to which you have access? (Check all that apply)

___ Obtaining pre-authorization
___ Scheduling the patient for services here
___ Registering the patient
___ Providing treatment/healthcare services
___ Arranging for services within the organization
___ Arranging for services external to the organization (Please describe)______________________________________________________________
___ Obtaining payment
___ Other (Please describe)______________________________________________________________

4. Is there any information to which you have access, but don't need the information?

___ Yes ___ No

4a. If yes, please describe the information you can access but don't need_______________

Disclosing Patient Health Information

5. Do you disclose patient health information to individuals or businesses that are not part of our organization?

___ Yes ___ No

5a. If yes, to whom and for what purpose do you disclose the information? (Check all that apply)

___ The patient's third party payer for obtaining pre-authorization
___ To contract dietary, lab, and therapy departments for securing services
___ To the patient's physicians for treatment and continuity of care
___ To the patient's family/friends as appropriate to their involvement in the patient's care or payment of the bill
___ Directory information to individuals who ask for the patient by name
___ Reporting infectious diseases to the public health authority as required by law
___ Reporting gunshot wounds to law enforcement as required by law
___ Reporting child or vulnerable adult abuse to appropriate government authority as required by law
___ Reporting births and deaths to Vital Statistics as required by law
___ To individuals identified by the patient in a valid authorization
___ To the patient
___ To third party payers to substantiate charges and facilitate payment
___ To third party payers who contract with the organization and need to audit claims
___ To the risk management insurer to audit the record as part of premium setting
___ To financial auditors to access the records to see if documentation supports claims
___ To our legal department, counsel, or malpractice insurer in anticipation of legal action
___ To attorneys on receipt of a valid subpoena or court order
___ Other (Please describe)________________________________________________________________