CONFIDENTIALITY AND DISCLOSURE OF INFORMATION

Electronic Health Records contain private and confidential information about consumers who receive services from PCS.  In order to receive the most effective care, consumers must be able to trust that information shared will be held in confidence.  Lack of trust could result in the failure to share information that would improve service planning.  All information contained in the Electronic Health Record is confidential and can be disclosed only with proper consent or as required by state and federal laws and regulations.  Any disclosure of information is documented in the consumer’s record.  Documentation must include the identity of the person to whom the information was disclosed, the reason for the disclosure, and a description of the information disclosed. 

Disclosure with Written Consent:
In most cases, when confidential information is disclosed, it is disclosed with the written consent of the consumer, the consumer’s guardian, or the consumer’s legally authorized representative.  CSB service providers sometimes need to exchange information with other service providers in order to follow best practice guidelines for treatment planning and coordination.  There are also times when consumers request disclosure of information to other parties.  Any request for the disclosure of information from the health record will be processed through the medical records department.  Medical records staff will review the request to determine the existence of a valid authorization to release confidential information.  Required elements of an acceptable written consent are:

• Name of the program or person permitted to make the disclosure.
• Name of the program or person to whom the disclosure is to be made.
• Name of the consumer.
• Confirmation of consumer identity  (Date of Birth or Social Security Number).
• Purpose of the disclosure.
• Information to be disclosed.
• A statement that the consent may be revoked at any time, except to the extent that disclosure has already been made in accordance with the consent.
• The date, event or condition upon which the consent will expire.
• The date the consent becomes effective.
• Signature of the consumer, guardian, or legally authorized representative.
• A statement prohibiting redisclosure without written consent.
• A statement advising the consumer of the risk that the recipient might redisclose the information despite the prohibition.

If a written consent does not meet minimum requirements, medical records staff will send a letter to the requester, outlining the information that must be supplied in order for PCS to release the requested records.  Upon receipt of a valid request, medical records staff will assemble the requested information and submit it to the CSB service provider/Program Manager for review.  After review, the requested information will be released.

Minor Consumers (individuals under the age of 18)
Disclosure of information from the record of a minor consumer requires the written consent of a parent, guardian, or legal representative, except:

• When the minor has presented for treatment as an adult.
• When the minor has been emancipated.
• When the minor is or has been married.

Note:  In the event that the parent of a minor consumer is also a minor, written parental consent is sufficient for the release of information concerning the child.

Deceased Consumers:
In the case of a deceased consumer, written consent to release information should be obtained in the following order or priority:

1. Executor/Administrator of the Estate
2. Spouse
3. Adult Son or Daughter
4. Either Parent
5. Adult Brother or Sister
6. Other relative in descending order of blood relationship

Revocation of Consent:
Consent to release information may be revoked at any time, except to the extent that disclosure has already been made in accordance with the consent.

Disclosure without Consent:

• Emergency Disclosure:  Disclosure may be made to any person necessary when an emergency exists.  An emergency exists when it is reasonable to believe that a delay in the disclosure of the information will result in serious bodily injury, death, or deterioration of the physical or mental condition of the consumer or other person threatened by the consumer.
  
  In responding to an emergency, the legitimacy of the request shall be verified.  Only that information required to relieve the emergency shall be released.  Documentation of the disclosure shall be recorded in the record.  It should include what was disclosed, to whom the disclosure was made, the date of the disclosure and the name of the individual releasing the information.
   

• Disclosure to Courts:  All properly executed subpoenas shall be responded to within the time frame specified on the document.  CSB staff shall accept the subpoena and route it to the appropriate CSB Service Provider or Program Manager.  If the Service Provider or Program Manager questions the merits of the subpoena, a formal request to quash the subpoena must be made to the court.  All requests for quashing subpoenas must be handled through the PCS Privacy Officer.  In civil matters, privilege exists for licensed counselors, psychologist, social workers and physicians with the following exceptions:

  • Where the physical or mental condition of the consumer is at issue in the action

  • In matters related to child/adult abuse and neglect

  • When the court deems disclosure is necessary to the proper administration of justice
     

• Subpoenas Regarding Consumers in SA Programs:  Substance Abuse records may only be released with a subpoena accompanied by a Subpart E Court Order. (Ref. 42 CFR, Part 2, Subpart E)  If a routine subpoena is received, the CSB must move to have the subpoena quashed.  If the consumer's attorney issues the subpoena, requests that his/her attorney provide an authorization signed by the consumer.  An authorization would alleviate having to take steps toward quashing the subpoena.
   

• Court Orders:  Upon receipt of a properly executed court order, you should respond to the order as directed.  All disclosures should follow normal documentation procedures in the consumer's record.
   

• Third Party Payers:  When a consumer requests that a claim be submitted to a third party payer for payment, only the following information shall be released relating to the claim:

  • The consumer's name and the contract/policy number

  • The date the consumer was admitted to the CSB

  • The date of onset of the consumer's illness

  • The date the consumer was discharged from the CSB or the date services were terminated

  • The diagnosis, with brief information substantiating the diagnosis

  • A brief description of the services provided, including type of therapy, medications ordered and administered, and number of hours spent in individual, group or family treatment, recreational therapy or rehabilitative activities

  • Status of the consumer, whether inpatient or outpatient

  • The consumer's relationship to the contract subscriber or policyholder

  In the event the third party payer is unable to settle the claim based on the information provided above, a physician employed by the third party may request additional information stating the reasons for the request.  The additional information may then be forwarded to the third party payer.
   

Consumer Access to Record:

The Electronic Health Record is the property of the community services board, but state and federal laws and regulations and professional codes of ethics support consumers’ right to access information contained in their records.   Requests for information need to be made in writing, signed and dated by the requester, and reviewed by the CSB Service Provider/Program Manager.  Response to the request must be made within 15 days of the date it was received.  There are some conditions under which access may be denied.

• Consumer Access:    If the reviewers determine that, in their professional judgment, no harm will result from the disclosure of the information, either to the consumer or a third party, the consumer may have access to the health record.  The CSB service provider or another professional staff member will be present when the consumer reviews the record to explain and/or interpret its contents.  The disclosure will be documented in the record.
• Denial/Limitation of Consumer Access:  Direct consumer access to the record may be denied if (a) allowing access would be likely to endanger the life of physical safety of the individual or another person; or, (b) the record refers to another individual (other than a health care provider), and access would be likely to cause harm to that individual.  If the initial reviewer(s) recommend that the consumer should not have direct access to the record, the request will be forwarded to a physician or a clinical psychologist for review.  If the physician/clinical psychologist concurs with the opinion of the initial reviewer(s), the physician/clinical psychologist will document in the health record that, in the exercise of his/her professional judgment, allowing the consumer direct access to the record would endanger or cause harm to the consumer or another person.  If access is denied, the consumer, the consumer’s attorney, or the consumer’s authorized insurer may ask to have the records furnished, within 15 days, to the consumer’s attorney or authorized insurer. 

If direct consumer access is denied, the consumer must also be informed in writing of the right to request an independent review, at the consumer’s expense.  The reviewer chosen by the consumer must be a physician or clinical psychologist whose licensure, training and experience relative to the consumer’s condition are at least equivalent to that of the physician/clinical psychologist who made the initial recommendation for denial.  If consumer access is denied, the consumer must also be informed in writing of the right to request that the CSB designate such a provider to provide a second professional opinion.  Any health record furnished for such a review, whether at the expense of the consumer or the CSB, must be accompanied by a statement from the CSB that the consumer’s treating physician or clinical psychologist determined that the consumer’s direct access to the health care record would endanger the life or physical safety of the consumer or another person, or that the record makes reference to a person other than a health care provider, and that consumer access to the record would be likely to cause substantial harm to that third party.  If the physician/clinical psychologist determines that the consumer should be allowed direct access, the consumer will be given access to the record.  Procedures described above for consumer access will be followed.

Parental access to the records of minor consumers: