Page 230 - CHHA Binder 2.3.20

4/11/2019

Authorization for Access to Patient/Member Information
Through a Health Information Exchange Organization

 Forms must be completed to be valid

 General Patient/Member Information (Header)
o Print Name
o Print Date of Birth
o Print MRN OR Case Number
o Print Address
 Capture Consent Choice
o Only one consent option is chosen (Give Consent OR Deny
Consent)
o One consent option MUST be chosen (unless the patient refuses
to sign a consent form)
 Capture Signature (Footer)
o Patient/Member or their Legal Representative MUST sign AND
date form
o Provide legal representative information, if applicable. Legal
Representative MUST print name in case signature is not legible.
 Provide the Patient/Member with the yellow NCR (No Carbon
Required) copy and return signed form to office for storage and
recording in timely manner
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Emergency Preparedness Plan

 The plan needs to be discussed with patient
and\or caregiver
 Contact information for patient caregiver or
representative should be in demographic
screen.
 Patient /CG need to be instructed on
emergency number to call depending on
emergency

 Clinician needs to assist patient/CG or patient
representative in completing the checklist of
emergency numbers and medical supplies

 Emergency Preparedness Plan include:
- Instructions on how to prepare for an
emergency and what to do during an
emergency
- Emergency numbers

 Needs to be discussed and signed by
patient/caregiver
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