Healthcare Audit Letter

HEALTHCARE AUDIT LETTER

Notice To / Audit Contact

To: Auditor Name:

Organization:    Contact Person:

Address:

Phone:    Email:

Date of Notice:

Patient Information

Insurance Information

Medical History (Summary)

Audit Scope and Records Requested

Purpose of Audit:

Records requested for the period from to .

Please produce the following records (check all that apply):

Medical progress notes, history and physical

Billing and claims records, itemized statements

Radiology images and interpretive reports

Laboratory reports and pathology

Operative and anesthesia reports

Psychotherapy notes (special authorization required)

Entire medical record for the date range specified

Confidentiality, Use, and Limitations

The auditor and its agents will use the disclosed records solely for purposes of the audit, quality review, payment verification, or legal compliance as stated in Purpose of Audit. The auditor must maintain the confidentiality of records in accordance with applicable law and not further disclose protected health information except as permitted by law. The auditor shall implement administrative, physical, and technical safeguards to protect against unauthorized use or disclosure.

The auditor shall not alter, destroy, or remove original records. If copies are requested, originals must be retained by the provider. Any discovery of unauthorized access or disclosure must be reported promptly to the provider with a description of remedial actions taken.

Authorization and Expiration

I authorize the release of the records specified above to the auditor named in this letter for the stated purpose. This authorization is limited to the records and purpose described and does not authorize any other use or disclosure.

Authorization expiration date: . Unless earlier revoked in writing, this authorization expires on that date.

Right to revoke: I understand that I may revoke this authorization in writing at any time, except to the extent that the auditor or provider has already taken action in reliance on this authorization. Revocation must be delivered to the provider's records department and will not affect disclosures made prior to receipt of the revocation.

Costs and duplication: Patient / Responsible party will bear reasonable copying and delivery costs associated with fulfilling this request. Auditor will bear reasonable copying and delivery costs.

HIPAA Acknowledgment

By signing below, I acknowledge that I have been informed of my privacy rights under applicable privacy laws with respect to the disclosure of my medical records for purposes of this audit. I understand that psychotherapy notes require specific written authorization and will be released only if expressly indicated above.

Acknowledgement: I acknowledge receipt of this authorization and my privacy rights.

Delivery Instructions

Representation and Certification

I certify under penalty of perjury under applicable law that the information provided in this form is true and correct to the best of my knowledge and that I am the patient named above (or am authorized to act on behalf of the patient). I understand that falsification of this document may subject me to civil or criminal penalties as provided by law.

If signing as an authorized representative, the representative must provide legal authority to act for the patient (e.g., power of attorney, court order, or guardianship documentation) and a copy must be attached to this authorization.

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