Healthcare Audit Request

HEALTHCARE AUDIT REQUEST

Requesting Organization:   Date of Request:

Requesting Party Contact

Patient Information

Date of Birth:   Gender:

Phone:   Email:

Insurance Information

Medical History (summary)

Audit Details and Scope

Purpose of Audit (select all that apply):

Billing audit    Utilization review    Quality assurance

Fraud investigation    Clinical review    Other (explain below)

Requested Audit Period: From to

Types of records requested (select all that apply):

Encounter / consultation notes    Operative reports    Radiology / images

Laboratory results    Medication lists / MAR    Billing records / EOBs / claims

Nursing notes    Physician progress notes    Other (describe below)

Preferred format for records:

Paper copies    Electronic copies (PDF)    Remote access or onsite review only

Authorized representatives of the auditor may include contractors or agents who will be bound by confidentiality obligations:

Auditor may disclose to designated agents/contractors for the purposes of the audit

Authorization and Legal Consent

I authorize the release of my protected health information described above to the named auditor/recipient for the limited purpose of conducting the audit described in this request. This authorization includes all information pertinent to this review, including but not limited to medical records, billing records, claims, insurance payment information, and any notes or materials related to the matters under audit. I understand that this authorization is limited in scope to the purpose identified and does not authorize use or disclosure for other purposes.

I understand that my records may include sensitive information, including behavioral health, substance use disorder treatment records, HIV/AIDS-related information, and genetic testing information, and I specifically authorize disclosure of such information to the extent it is necessary for the audit. I understand that the recipient of the information may re-disclose it and that such re-disclosure may no longer be protected by federal or state privacy laws.

Revocation: I understand that I may revoke this authorization at any time by providing a written notice of revocation to the records custodian, except to the extent that action has already been taken in reliance on this authorization. This authorization will expire on: unless earlier revoked in writing.

I certify that the information provided on this form is correct to the best of my knowledge. I understand that making false statements in this request may subject me to penalties under applicable law.

HIPAA Acknowledgment: By signing below, I acknowledge that I have received notice of privacy practices and that my protected health information may be used or disclosed pursuant to this authorization.

Patient acknowledges HIPAA/privacy notice and understands release terms

Additional Instructions / Limitations

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