v2 HIPAA Overview and Universal Consent Overview v2

CBEST

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HIPAA andUniversal Consent Overview

Disclaimer:This training was designed as an in-house training for the DHS CARES Clinical Staff and Administrative Team.

What IS HipAA?

https://eforms.com/

• HIPAA stands for Health Insurance Portability and Accountability Act

• A HIPAA release and authorization (also known as a Consent Form) allows an individual to authorize healthcare providers to release protected health information to third parties

WHAT IS HIPAA?

https://eforms.com/

• The purpose for which the information may be used or disclosed.
• A description of the protected health information to be used and disclosed.
• The person authorized to make the use or disclosure.
• The person to whom the covered entity may make the disclosure.
• An expiration date, or an expiration event that relates to the patient or the reason for the disclosure of the information.

Recap: An Authorization Must Specify:

A Universal Consent that has been accurately and fully completed ensures that we are in compliance with accessing and sharing PHI with appropriate entities and allows them to share information with us.Without the informed written consent (or verbal consent, in some cases) of the client, we cannot access or share their information, and may be in violation of HIPAA laws.

The Universal Consent is used by the Los Angeles County Department of Health Services to obtain permission from the client to access and share their Protected Health Information (PHI).The Universal Consent has been reviewed and approved for use by County Counsel for the purposes of our work.

How does that apply to the Universal Consent?

DO NOT DELETE EXISTING CONSENT FORMS ALREADY RECORDED/UPLOADED IN CHAMP.

• It gives us permission to upload the client’s information in CHAMP. • It allows us to communicate with other agencies (such as for housing purposes) on the client’s behalf. • Some agencies accept the Universal Consent and will honor it when requesting medical records. • Other agencies require their own consent when requesting medical records. A folder with agency-specific Authorizations has been created and can be shared with your agencies. These need to be completed on an individual basis if a client indicates they have received treatment at a specific agency such as Kaiser, Healthright or the Department of Corrections.

Purposes of the Universal Consent:

Per the Los Angeles CountyHealth Information Management (HIM) Department, Universal Consents not properly completed will be rejected.The CARES Team reviews theUniversal Consent prior to the medical review to ensure Universal Consents are completed correctly.

Important Info about the Universal Consent

Universal Consent: Wet Signature Instructions

1: Please spell out the entire first and last name.Ensure the correct spelling of the name and information provided matches CHAMP. **If client indicates they have an alias,please identify name as "AKA" and include in name field.2: Date of Birth: Please enter client's DOB. Make sure the year is accurate.**If client indicates they have an alternate DOB,please indicate this in the DOB field.

Universal Consent (Wet Signature) - Page 1

Boxes not checked and initialed cannot be accepted as our scope of work requires we are able to access and share this information when requesting and reviewing medical records and applying for benefits.

3: Boxes must be checked.4: Initials are required on both lines.

Universal Consent (Wet Signature) - Page 2

5: Optional Field:If completed, write name, telephone number, and relationship in field box.

Universal Consent (Wet Signature) - Page 3

6: Wet Signature: Client signs.7: Wet Signature Date (Cannot be typed if wet signature is obtained).*Please Note: This is NOT a witness signature. The client must sign the consent unless they are under a Conservatorship or Power of Attorney.Accompanying documentation must be uploaded in CHAMP.

Universal Consent (Wet Signature) - Page 4

Adding a Witness Signature:Add a line under the signature line.Label "Witness Signature", "Print Name" and "Date".*This is especially important when a client signs "X"or uses another "symbol" as their signature.

Universal Consent (Wet Signature) - Page 4

8: DO NOT COMPLETE unless client is opting out of the CBEST program.

Universal Consent (Wet Signature) - Page 6

Universal Consent: DOCUSIGN Signature Instructions

*DocuSign Document must have the DocuSign Verification in top left-hand corner of form

1: Please spell out the entire first and last name.Ensure the correct spelling of the name and information provided matches CHAMP. **If client indicates they have an alias,please identify name as "AKA" and include in name field.2: Date of Birth: Please enter client's DOB. Make sure the year is accurate.**If client indicates they have an alternate DOB,please indicate this in the DOB field.

Universal Consent (DocuSign Signature) - Page 1

Boxes not checked and initialed cannot be accepted as our scope of work requires we are able to access and share this information when requesting and reviewing medical records and applying for benefits.

3: Boxes must be checked.4: Initials are required on both lines.The DocuSign verification “DS” must be present.

Universal Consent (DocuSign Signature) - Page 2

*DocuSign Document must have the DocuSign Verification in top left-hand corner of form

Universal Consent (DocuSign Signature) - Page 3

5: Optional Field:If completed, write name, telephone number, and relationship in field box.

*Please Note: This is NOT a witness signature.The client must sign the consent unlessthey are under a Conservatorship orPower of Attorney.Accompanying documentation must be uploaded in CHAMP.

*DocuSign Document must have the DocuSign Verification in top left-hand corner of form

Universal Consent (DocuSign Signature) - Page 4

6: DocuSign Signature: Client types name on first line, client signs second line. The DocuSign verification must be present: “DocuSigned by:”.7: DocuSign Signature Date. (Cannot be wet date if DocuSigned)

*DocuSign Document must have the DocuSign Verification in top left-hand corner of form

Universal Consent (DocuSign Signature) - Page 6

8: DO NOT COMPLETE unless client is opting out of the CBEST program.

common Universal Consent Errors

A Universal Consent that is missing pertinent information will be rejected.

Incomplete Information:

A Universal Consent that is not legible will be rejected.

Highlighting:

A Universal Consent that is not legible will be rejected.

Highlighting/Dark Upload:

Click the "+" for additional information

A Universal Consent that has cut-off information or is not legible will be rejected.

Scanning Issues:

Ensure there are no scanning issues.The information on the Universal Consent needs to beclear and legible.

A Universal Consent that is not legible will be rejected.

Scanning Issues:

A Universal Consent that is not legible will be rejected.

Picture Copies/Blurry Upload:

*Excluding Verified DocuSigned Documents.(Refer to the example on the next slidefor necessary DocuSign Verification)

A Universal Consent that has typed signatures/initials will be rejected.

Typewritten Initials/Signature*:

*DocuSign Document must have the DocuSign Verification in top left-hand corner of form

The DocuSign verification “DS” must be present around initials.The DocuSign verification must be present: “DocuSigned by:”.DocuSign Signature Date. (Cannot be wet date if DocuSigned)

Docusign Verification:

Remember:A "wet" document must have wet information and datesA DocuSigned Document must have typed information and dates.

A Universal Consent that has mismatched DocuSign/Wet Info will be rejected.

Docusigned Document with Wet Info/Dates:

You can see these initials are identical and there is no DocuSign verification.

A Universal Consent that has copied/pasted signatures/initials will be rejected.

Copy and Paste Initials:

A Universal Consent with evidence of Correction Fluid/White out use will be rejected.

The use of Correction Fluid/White out is not allowed on any legal document.Refer to the next slide for instructions on how to make appropriate corrections.

Use of Correction Fluid/White Out:

Alternative:Start over with a new or clean copy of the form

• Cross out the error with a single line
• Write your initials and date next to the line
• Write the correct information

Making Corrections:

*Exceptions:Conservatorship and/orPower of Attorney

Please note: the space/line underneath the client's signature is not a "witness" signature.

A Universal Consent that is signed by someone other than the client will be rejected, unless that person is the conservator or has Power of Attorney and the appropriate documentation is on file.

Signed by someone other than client*:

Click the "+" for additional information

DHS CARES ADDRESS:Los Angeles County Department of Health Services CBEST/Housing For HealthLA General Medical Center 2010 Zonal Ave Bldg. B. #2P70 Los Angeles, CA 90033

Required information left blank:

What Are Some Penalties for VIOlating Hipaa?

Consider this:If this was your personal information (your address, social security number, financial information, banking information), would you leave this in plain view? Talk openly about this with co-workers or clients around? Throw this information in the trash?

• throwing away documents with PHI in the trash can
• talking to a co-worker about PHI in an open space with other people or clients around

• leaving documents with PHI on the printer for an extended period
• leaving documents with PHI on your desk in plain view

Data Breaches include but are not limited to:

Questions?

Thank you for all you do!!