Forms
How do I complete the AOB/POA and PHI authorization forms?
Organization ApprovedSource Verified
Summary
The Assignment of Benefits/Power of Attorney directs insurance payment to the office; the PHI Authorization lets the clinic request outside records. Originals stay in the chart and only completed copies go out.
- 1AOB/POA: every patient except PC patients completes it. It directs insurance payment to the office and allows the clinic to deposit checks payable to the patient and/or clinic.
- 2The CA prints the patient's name at the top; the patient signs and dates in the middle and at the bottom; the CA signs as witness.
- 3Leave the claim number and carrier name blank on the original — fill those in only on the copy sent to each billed carrier, and return the original to the right side of the chart.
- 4If the patient objects, explain the purpose, try to overcome the objection, then continue with the rest of the paperwork.
- 5To endorse a check payable to the patient, print the patient's name and “Power of Attorney on file” on the back, then stamp with the bank deposit stamp and process normally.
- 6Authorization to Use & Disclose PHI: every patient except PC patients signs it before the clinic requests records from an outside source (ER, PCP, etc.).
- 7The CA prints the patient's name, address, and date of birth; the patient signs and dates; the CA signs as witness.
- 8Never fill in the date of request or provider information on the original — keep the original permanently in the chart and complete only photocopies for each outside request.
- 9To request records: copy the form per provider, return the original to the chart, gather facility contact info (or use the Outside Facility Log), fax the completed copy, document the request on the Travel Card Consultation page, and set a 5-business-day follow-up in the Fax File.
- 10If records have not arrived after 5 business days, confirm none were received, refax marked “2nd request” with the date, and re-file with a further 2-business-day follow-up; escalate to a director if unresolved after 7 business days.
- 11Acknowledgement of Receipt of Notice: every patient signs it documenting they were advised of the clinic's compliance with state and federal confidentiality laws. Show the posted Notice of Privacy Practices and provide a printed copy on request.
Citation
CA Manual, AOB/POA; Authorization to Use & Disclose PHI; Acknowledgement of Receipt of Notice, p. Patient Charts · Revised 2/9/26Answers source the CA Manual first; the Medisoft guide is used only where the CA Manual does not cover the task.