Free Download: PHI Records Release Template

Document, document, document. 

If every move you make feels like it needs to be documented - you’re kind of right.  Of course we have our progress notes that document what occurred in session, however there are all kinds of other activities, according to HIPAA, that need to be documented in the client’s chart. ​

A voicemail a parent left you that included information about symptoms? A coordination of care call you had with a school counselor (that you absolutely had an ROI for)? The most recent Diagnostic Assessment that was requested for testing? 

Yes to all of the above. 

According to the HIPAA Privacy Rule 45 CFR § 164.528 clients have a right to know what information went where and why.  Specifically, The Privacy Rule requires that covered entities maintain documentation of “disclosures of protected health information (PHI)” in order to comply with the rule’s accounting of disclosures requirement.

So what’s a disclosure?

Any time you are disclosing PHI (hopefully with all the relevant releases and paperwork signed!) outside of a therapy session.  I have a separate form for verbal/email exchanges (within my HIPAA secure email platform) but today I wanted to share with you the extra steps I take to ensure I am ensuring compliance with the Privacy Rule for documents that were released via fax, mail, paper copy, or HIPAA secure email. 

First off after I send a documents via faxI always upload the fax confirmation sheet to the clients file as proof of what was faxed where.  Next, I fill out a PHI Records Release Template where I make sure to detail what specifically was sent, where it was sent, and why. 

It would be different if “entire record set from DATE to DATE” was sent vs. Diagnostic Assessment from DATE and Treatment Plan from DATE.  That way both my Fax Cover Sheet and extra document on what was sent and why serve as a clear record of why a client’s PHI was released. 

Typically you would also have documentation such as a Release of Information for in the file the client signed allowing you to release records or a court order or legal document stating what documents need to be released (in certain cases).

Grab your absolutely FREE PHI Records Release Template that you can input directly into your medical record to make sure you have all your documentation bases covered for records releases!
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Get your copy HERE! 

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