Smith Family Medicine LLC

1785 United Dr.

Cincinnati, Ohio 45215
513-758-4574 Office
513-758-4747 - Fax

Policies and Procedures for Release of Information

The following policies and procedures have been created for the HIM Department in regards to
release of information.
1. Have the requestor completely fill out a Consent for Release of Information form. The
form can be picked up in person from the office or the form can be sent through USPS, email, or
fax. (see pages 3-4 for the form)
2. The completed Consent for Release of Information can be brought into the office or
returned to the office through USPS. An original (not a copy) is required.
3. When a consent form is returned, it should immediately be date/time stamped for further
processing.
4. Each morning, the consent forms need to be reviewed and the processing order decided.
Continuity of care requests are processed first, followed by the remaining forms in order that
they were date/time stamped.
5. The forms will need to be scanned into each of the patients electronic health record.
6. Each requestor should then be contacted in the order the forms were processed. Set up a
date and time for them to return to the office to discuss the forms and the information needed.
7. When the requestor arrives for their appointment, collect their drivers license or other
identification containing their picture and signature.
8. Present the requestor with a Signature Verification card and have them sign it in the
presence of a HIM employee. The HIM employee will then sign their name on the witness
line to verify the signature was in fact completed by the requestor. (See page 5 for the card)
9. The requestor will be asked to remain in the waiting room while verification is completed.
10. The HIM employee will need to verify the signature originally obtained by the patient at
their initial visit to the signature on the Consent for Release of Information form and also the
Signature Verification card.
** In the case of a subpoena, the HIM department must verify that the subpoena is valid
and the requested information can be released in compliance with state or federal law
or regulations

11. If the signatures differ in anyway, the HIM employee will need to contact their supervisor to
see how to proceed further. If the signatures match, the process can move forward.
12. The HIM employee will retrieve the patient record and make copies of only the forms that
were authorized to be released.
13. The requestor will meet with the HIM employee. The HIM employee will explain the
information that is being released and take any questions from the requestor.
14. Once all explanations have been made and all questions answered, the requestor will sign
the Requestor Responsibility Statement, stating they are receiving the medical record
information and they are responsible for the safe keeping of these documents. (see page 6 for
form)

AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION

Patient Name:_________________________________________________
Date of birth:________________
MM/DD/YYYY

The above named person must indicate when this authorization is to expire:
When the information is received:_____

In six months:_____

In one year:_____

In three years:_____

On date:_____________________________________

The person names above is or has been a patient of:

Name of Person, Provider, or Facility:_________________________________________
Address:_________________________________________________________________
Phone Number: (

)_______-__________

Fax Number: (

)_______-_________

The person named above hereby authorizes:

________________________________________________________________ to:
Name of person, Provider, or Facility

Request health information from:______

Send health information to:______

Discuss health information with:______

The person named above authorizes information to be requested or released by

representatives of:
Name of Person, Provider, or Facility:_______________________________________________
Address:_________________________________________________________________
Phone Number: (

)_______-__________

Fax Number: (

)_______-_________

All information regarding assessment, diagnosis, and treatment of patients condition, concern,
or disease (specify):
______________________________________________________________________________
All information regarding care received by patient between the dates of:
______________________________________ and ___________________________________
Starting Date (MM/DD/YYYY)

Ending Date (MM/DD/YYYY)

Other information (specify):

______________________________________________________________________________

Authorization
___________________________________________________________________
Printed name of Patient or Authorized Representative
______________________________________________
Signature of Patient

__________________________
Date (MM/DD/YYYY)

______________________________________________
Signature of Witness

__________________________
Date (MM/DD/YYYY)

If not signed by the patient, indicate relationship of authorizing person to patient:

Parent or guardian of minor child:_____
Guardian or conservator of conserved patient:_____
Beneficiary or personal Representative of a deceased individual:______
Certain information is covered by additional protection and requires specific authorization. To
authorize release or discussion of the following type of information, the person named above
must initial and date each item. If an item is not initialed and dated, the information, if such
information exists, cannot be released or discussed.
Initial

Date

From

To

______

______

Alcohol or drug use/abuse treatment

______

______

______

______

Mental health treatment

______

______

______

______

HIV status or treatment

______

______

Signature Verification for Release of Information

______________________________________________________________________________
Requestor Signature
______________________________________________________________________________
Requestor Printed Name
______________________________
Date (MM/DD/YYYY)
______________________________________________________________________________
Witness Signature
______________________________________________________________________________
Witness Printed Name
______________________________
Date (MM/DD/YYYY)

Requestor Responsibility Statement

Patient Name:_________________________________________________
Date of birth:________________
MM/DD/YYYY

I, ________________________________________________, have received the medical record

Printed Name of Requestor

for the above named person. I agree that it is my responsibility to keep the information private
and to only share with authorized personnel.
___________________________
Date (MM/DD/YYYY)