RELEASE OF CLIENT RECORDS
- Strict compliance with your state statute regarding the release of records is critical.
- Usually, states require that upon receipt of a written request for records, the practitioner must respond no later than 15 days, so do not sit on the request–be responsive promptly:
- Make available for review or copy (if copies requested) during your regular business hours.
- Inform the requesting party if the information requested does not exist and document your response to include in the client file.
- You may charge a reasonable fee, but you need a written client disclosure in the client file to evidence that signed the office administration related agreement.
- You may be allowed to withhold records because of non-payment, but it is not worth it. It is better to release the documents and avoid a possible Licensing Board complaint later on.
- If your client is in an emergency situation (such as a court hearing, or some other problematic situation like hospitalization), then you cannot withhold records because of non-payment of the fee.
- You must document in writing any requested client file, or that the client was notified in writing, or by phone (document in writing in your notes as an internal memo), that the papers could be picked up by the due date.
- Train your staff to:
- Maintain a copy of an email, or create an internal memorandum documenting a phone call informing the client the records were ready for pick up; and,
- Train your staff to document in their respective files that they followed this established office procedure.
While some Licensing Boards recommend sending the records certified mail/return receipt requested with a cover letter to provide absolute evidence they mailed, we recommend you do this all the time regardless of the state that you practice.
AUTHORIZED DISCLOSURE: (EXCEPTION TO CONFIDENTIALITY)
- A Government agency, if the disclosure is required or authorized by law.
- Medical or law enforcement in cases where imminent or physical or mental harm by the client to self or others is likely.
- Persons possessing legal written consent of the client, such as parents of minors, guardians of minors, or persons deemed incompetent.
- A deceased client’s legal representative.
- If required by order of the Court
- Other situations as specified by your state’s statute.
RIGHT TO DENY ACCESS TO RECORDS / TREATMENT FILE
- The practitioner may deny access to any portion of a record if the practitioner believes that the release of that portion would be harmful to the patients’ physical, mental or emotional health.
- Depending on the state, the state Licensing Board rules may require if records intentionally withheld, the practitioner provides the client with a written statement of what and why those records are being withheld and why. Maintain a copy of the written report in your file.
- Delete all information about treatment to any other people who have not consented to the information release. Make a note in your file of what you deleted regarding your compliance with the information request.
- Charging reasonable administrative fees can be done, but only following your written office policies/disclosures that the client has been given, signed, and acknowledged at the inception of treatment therapy.