To make the tracking of valid releases more effective and noticeable for staff and clinicians. This process will help avoid potential risk of disclosure of PHI by marking releases accordingly if invalid or revoked.
Steps to Revoking a Release:
If client comes in and signs revocation:
A valid release is already entered into Neo under Release of Info (Active) tab and a scanned copy of valid release is in digital record. Client walks in and wants to Revoke this Release now…
Email should be sent out ASAP to any clinician open to the client Staff History at the time of revocation.
Email the Managed Care Staff group that the Payor release has been revoked so they can follow up with billing etc.
Print off the release so client (or guardian) can sign the revocation page (on back of form). A separate revocation page may be attached.
From the release of information (ROI) screen, select the expire button. An expire ROI screen will pop up. In the new expiration date field, enter the date that the release was revoked, select revoked from the status drop-down field, enter any comments, and save.
Scan in the completed revocation form (revocation on top and release behind) under document description REVOKED Authorization to Release Information and attach to the original *remember to use the original signed date as the document date and the revoked date as the expiration date and that when attaching the doc description “Authorization to release protected health information” will automatically be selected, so this will need to be changed to REVOKED Authorization to Release Information
Be sure to revoke any other releases to that organization from the release of information screen using the expire button and end date those with the revoked date. Add a comment to the effect of “see revoked release dated [date of revoked release]”
For external releases from the scanning edit screen, change the doc description to REVOKED Authorization to Release Information and change the end date to the date the release was revoked.
If the clients release is marked as Give, Get and Discuss and there is a possibility that the other facility may act on this revoked release (i.e. They have a copy of the release in their possession or have acted on this release in the past), we will call that facility to let them know this release has been revoked by the client.
If client just calls to revoke a release
A valid release is already entered into Neo under Release of Info (Active) tab and scanned copy of valid release is in digital record. Client calls in and wants to Revoke this Release now…
Email should be sent out ASAP to any clinician open to the client (Staff History) at the time of revocation.
Email the “Managed Care Staff” group that the Payor release has been revoked so they can follow up with billing etc.
Client (or guardian) will be told they need to come in to sign the revocation as soon as they can (next appt, etc) or offer to mail form to them for completion.
From the release of information screen select the expire button. An expire ROI screen will pop up. In the new expiration date field enter the date that the release was revoked, select revoked from the status drop down field. In the comment section note that the ROI was verbally revoked and the name of who revoked it or who relayed the message to you if unknown. e.g. “Per front desk staff [name] client/guardian has verbally revoked ROI”
Once a release has been verbally revoked, it MUST be signed. If the client has changed their mind by the time they get to sign the release, they still need to sign revocation page and a new release can be staged for them to sign with new dates and limitations, if necessary.
Be sure to revoke any other releases to that organization from the release of information screen using the expire button and end date those with the revoked date.
For external releases from the scanning edit screen change the doc description to “REVOKED Authorization to Release Information” and change the end date to the date the release was revoked.
When we receive the signed revocation, scan it in as above and delete the scanned original release. Before scanning in be sure to write on the revocation page that client verbally revoked on such and such a date. That will explain the end date used for the revoked form.
If the clients release is marked as “give, get and discuss” and there is a possibility that the other facility may act on this revoked release (i.e. They have a copy of the release in their possession or have acted on this release in the past), we will call that facility to let them know this release has been revoked by the client.
Steps to Invalidating a Release:
Always follow up with the clinician, client, or guardian to get a valid release as soon as it is determined invalid. There are pink forms for clinicians for this process:
Common Drive>> RecordRoom>> templates >>Invalid ROI form to clinician
When a release has been deemed Invalid, the reason it is invalid needs to be easily recognized by circling the error or noting it on the release before it is scanned in.
The invalid release should be scanned as:
(Be sure to end date using the date they were signed…this will make them show up as expired and eliminate confusion)
*Document Description: INVALID Authorization to release information
*Tag: Releases
If the release was previously scanned and later determined to be invalid, from the release of information screen:
Select the expire button
An expire ROI screen will pop up
In the new expiration date field, enter the date that the release was signed
Select Invalid from the status drop-down field
In the comments field, note why the release is invalid
Click Save.
The following criteria will cause an internal (KBH) release to be invalid:
Name is missing or incorrect. Client’s legal name must be at the top of the form. Preferred names and former names may also be included along with the legal name.
Client ID and/or date of birth is required, preferably both.
Give/Get/Discuss section is incomplete. At least one item must be checked.
Organization/Primary Contact is incomplete, illegible or names more than one organization/contact. For individuals, first and last name is required. No acronyms, organization names must be written out.
Relationship is incomplete. This is required especially for individuals where their role may not be obvious.
Phone number and/or address is required. Both along with a fax number is preferred if known.
Section A is incomplete. A complete to and from date range is required (From: mm/dd/yyyy To: mm/dd/yyyy).
Section B is incomplete. Applicable items must be checked off and if ‘other’ is checked, then something must be written on the line provided.
Section C is incomplete. Applicable items must be checked off and if ‘other’ is checked, then something must be written on the line provided.
Section D is incomplete. Either ‘Do’ or Do Not’ must be selected for each option.
Section F is not checked. This does not render the release invalid, however if the intention is to act on the release in the future, this box must be checked.
Section G is incomplete or impossible. There must be a specific expiration date (mm/dd/yyyy). If the expiration date is longer than 1 year it will automatically expire at one year. If the date is before the signature date or falls on a day that does not exist (ie Feb 29th on a year there is not a leap year) it will need to be corrected.
Signature is missing or signed by a person who is not authorized.
Signature date is missing, illegible, or impossible (ie a date in the future)
Verbal consent was provided. Verbal consent is only acceptable for Mobile Crisis clients. When possible, follow-up to obtain a valid signature is required and attempts to follow up should be documented. ***Note: verbal releases will not appear in the ‘Release of Information’ screen in Neo. They will be found under the ‘Verbal’ Tag in ‘Document Search’.
Corrections were made to the release, and those changes were not initialed by the client/guardian or their authorized representative. Changes must be initialed to show informed consent.
Steps to Reviewing a Release:
When a client checks the box (Section E) on the release form (“I wish to look at the information before it is released. This review must be documented”), the following steps need to be taken:
The information must be reviewed by the client with the clinician present.
The clinician must document this in progress note or memo to chart
Alternatively, the provider(s) may give approval for a copy of records to be provided to a client
Per the Rights of Recipients of Mental Health Services
“The recipient or the recipient's guardian has the right to review the recipient's record at any reasonable time upon request, including prior to its authorized release. Such records shall be made available within three working days of such request.”
*When a release is for ONLY ONE DAY:
On a rare occasion, a client will ask for a release that is good for only THAT day. Our digital record does not allow us to enter/expire a release on the same day. The workaround for this type of release would be to enter it as you normally would in Neo, but near the bottom of the form, select Expired from the status drop-down. In most cases, the release will already be expired by the time med records enters it, but if it is scanned on the same day and a provider questions it, you can let them know it is still okay to act on the release for that one day.
*When entering the release in Neo on the same day there will be no error. If the release is entered after it has expired, then the “Status” field will need to be changed from Active to Expired.
*When scanning the release on the same day, there will be no problem. If the release is scanned after it has expired, then the release will not appear in the Connect to Release section of the scanning module. The release can be scanned without making the connection.
