| Survey
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)________________________________________________________________
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