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Recording visit notes for referrals and refill authorizations

I am a practitioner in a speciality clinic. When we send a copy of visit notes to a referring or primary practitioner, is that considered a disclosure of PHI that needs to be added to our "Accounting Log for PHI Disclosure" kept in patient charts? In addition, do we need to record on the log when authorizing refills of medications by fax or mail?

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Generally speaking, accounting of disclosures is not required if the disclosure is made for treatment, payment or operations purposes. Given this as it relates to your specific questions, you should be OK, but I would still recommend that you confirm this with a HIPAA consultant or attorney that is completely familiar with your business practices.

For more information on this topic, visit these other resources:
  • Ask the Expert: When to seek legal consultation for HIPAA
  • Ask the Expert: Release of medical forms under HIPAA
  • Best Web Links: Health Care/Health Services

    This was first published in February 2003

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