• A specific, meaningful description of the information to be released
• The name of the person or class of persons authorized to release the information
• The name or other identification of the recipient of the information
• A description of the purpose of the release
• An expiration date or event
• The signature of the patient or personal representative and the date (if signed by a personal representative, the relationship must be indicated)
• A statement of the individual’s right to revoke the authorization and exceptions

The records that should not be released, or records that should be on an exclusion list include:

• Administrative data, which is patient-identifiable and used for administrative, regulatory, or other healthcare operations, such as audit trails, data used for quality assurance or utilization management or data prepared in anticipation of legal action.
• Derived data stored in aggregate format, which is not patient-identifiable, such as data used for accreditation reports, research data or statistical reports.
• Psychotherapy notes maintained separate from the rest of the patient’s medical record.
• Information that is subject to a legal privilege such as peer review or attorney/client privilege.

The Haugen Consulting Group has many years of experience with release of information processes and the policies which support those processes. We can help!