Billing Manual for Community Care Network Providers

Community Care’s senior management team. If approved, two representatives ofCommunity Care must witness the entire process of obtaining verbal authorization torelease information.Community Care considers an authorization to release information to be valid only if(HIPAA 164.508(c)) :It provides the name of the person(s) providing the information.It is in a language the member can understand.There is a purpose for the release.The specific information to be released (dates of treatment, and the exact type ofinformation to be released, i.e., mental health, drug and alcohol) is described.The member’s full name at the time of treatment and correct identifying information,e.g., date of birth and Social Security Number.The individual or entity authorized to receive the information is described.The expiration date of the authorization.The signature of the member or the member’s legally authorized representative (ifthe authorization is signed by a personal representative of the individual, adescription of such representative’s authority to act for the individual).The release is obtained in a manner that complies with applicable law andregulations.There is a statement that treatment will not be affected if the member or member’srepresentative refuses to sign the authorization.There is a witness signature.There is a date of expiration for the authorization.There is a written statement on the authorization form that once this information isreleased to the recipient, this information may be subjected to re-disclosure by therecipient and no longer protected by this rule.There is a statement on the authorization form that if this information is used ordisclosed pursuant to the authorization, it may be subject to re-disclosure by therecipient and no longer be protected by this rule.There is a statement that the individual has the right to revoke this authorization inwriting, including the exceptions to the right to revoke, and a description of theprocess for the individual to revoke the authorization.Community Care will not release the information unless the form is completed.Prior to releasing information of previously signed authorization to releaseinformation, Community Care will review all authorization forms that are still in effectto ensure that they are compliant with HIPAA regulations.If a previously signed authorization is compliant with HIPAA regulations CommunityCare will continue to release the information until the authorization expires.If the authorization is not HIPAA compliant, then Community Care will contact themember within 60 days to obtain a newly signed authorization that conforms toHIPAA regulations.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 187