Authorization to Release Confidential Information Forms

CONFIDENTIALITY

Way Station, Inc. respects the right to privacy of the individuals it serves and protects the confidentiality of client information received. Protected Health Information (PHI) in all forms, paper, electronic, spoken word and recorded, is released to those people requesting it only if they have the right and need to know the information. By state and federal law, in some circumstances, confidential information may be disclosed without the express consent of the client. Details of these circumstances are provided in the Sheppard Pratt Notice of Privacy Practice and the Sheppard Pratt Policy Manual. All clients receive the Notice of Privacy Practice at the time of enrollment/admission to services.

Authorization to Release Confidential Information Forms

The right to know information is granted by the individual served in writing via an Authorization to Release Confidential Information form. A client signs the authorization form in order for information to be shared in written, verbal, electronic or recorded form. The information requested is specific and understood by the client. The authorization clearly states the nature of the information requested; it should be as specific as possible and in language easily understood by the client. An authorization automatically expires at the end of one year or sooner if specified by the client at the time the authorization is signed. It is Way Station policy to update authorizations on an annual basis. Either the original or a copy is retained in the client’s record or scanned into the electronic medical record, if applicable. In special cases the right to know is granted by the client orally and is documented in the client’s record. Follow-up communication occurs within the boundaries of documented releases. If a client wishes to rescind/revoke an authorization, the client must put this in writing, date and sign and send to the medical records department for the services given permission to share PHI. See the Notice of Privacy Practices for limitations with revoking authorizations.

Guidelines for Protecting Privacy of Clients in Situations Involving Oral Communications

It is natural to talk to one’s family and friends about one’s work or daily activities. However, it is important to remember to exercise restraint in such discussions in order to respect the confidentiality of Way Station clients. Personal information and names may not be shared with persons who are not employees of Way Station.

It is sometimes difficult to maintain confidentiality in the informal and family-like setting of Way Station where it is natural to share information about each other in casual conversation and often out of genuine concern. Therefore staff and clients need to keep an awareness of this issue by using discretion, exercising restraint, and thought before sharing information.

Staff working with a client communicates with each other information regarding the client. Sharing information beyond the client’s team is done with discretion and only on a need to know basis. Only information, which is necessary and appropriate, should be shared. Staff who “need to know” are defined as those responsible for providing or overseeing services to the individual.

Staff may not agree to “keep secrets” or withhold information from other staff which is essential for providing good service to the client. Secrecy creates special privilege relationships with the client and is counter-productive and potentially dangerous.

If a staff member deems it appropriate to share with other staff outside of the team, information about or from a client, s/he informs the client that s/he feels it is necessary and appropriate to share with other staff. Staff need to recognize that staff communication may feel uncomfortable to the individual involved. Therefore it is most important to respect the dignity of the person in all staff communications, limiting this type of communication to information which is of benefit to the person and communicating the information in a respectful manner.

Confidential information regarding persons served should be discussed in privacy, out of earshot of individuals not authorized to participate in or hear the discussion.

Communication about clients is focused and goal directed for the benefit of the client. Casual offhand remarks are avoided.

Staff persons and clients discuss individuals on the phone only with people authorized to receive the information. (This includes giving out information about a client’s whereabouts or other personal business.) Training is provided to clients regarding confidentiality.

Clients’ Access to Their Medical Record

Clients have the right to access their personal records with limitations as noted in the Sheppard Pratt Notice of Privacy Practice and specific policies in the Sheppard Pratt Privacy Manual. Representatives of clients may have access to the individual’s record providing a valid Authorization to Release Confidential Information form has been received by Way Station. A client submits in writing to her/his Program Director, the request to review his/her record. The Program Director notifies the Privacy Officer of the request. The protocols are outlined in the Sheppard Pratt Privacy Manual. Review of the record occurs in the presence of the individual’s Program Director so that questions or concerns may be addressed and clarified directly. A client may request corrections of the record, however by law WSI is not required to agree to amend the record. Access to the record or any portion of the record by any individual may be limited only in such cases as it is documented that such access will have a significant adverse effect on that individual’s treatment. The decision to deny access to an individual’s record is made by the Compliance Officer and a licensed mental health professional in consultation with WSI’s General Counsel.

If access to an individual’s record is denied, the individual may request a brief summary of the record.

Requesting Information from an Outside Source

Information is requested from external sources by letter together with the original of a valid Authorization to Release Confidential Information form specifying the information requested.

Releasing Information to Outside Source

Information is requested by an outside source regarding an individual currently being served by WSI through a written consent either forwarded to WSI by that source, or obtained by WSI staff. If the consent form is WSI’s, the original of that consent form is forwarded to the outside source. Or if the client record is in the electronic medical record a copy of the scanned document is forwarded to the outside source. Requests for client record information by external sources are forwarded to the designated medical records staff. Discretion is exercised in selecting the aspects of the record to be copied to external sources. Medical Records staff consults withthe ComplianceOfficer when requests for record information by external sources are atypical. Way Station generally releases only information generated by Way Station staff. In special circumstances WSI may release externally generated documentation which is not stamped “Confidential” with a signed Authorization to Release Confidential Information from the individual giving permission to release the specific externally generated documentation. Reports, summaries, etc. from other sources which are stamped “Confidential” are not forwarded.

If Way Station is no longer serving the individual, a summary of our prior contact is forwarded, provided the necessary authorization form has been received by Way Station.

Copying/Printing Portions of Medical Records for Internal Use

Discretion is equally important in copying and/or printing portions of the medical records for internal use. This is done only when absolutely necessary and is limited to Way Station Staff whose job description authorizes them to do so.

Destroying Confidential Materials

Medical records are retained per the Document and Medical Records Retention policy. When copies are made and are no longer needed, they are deposited in shredding receptacles. Way Station Staff who have printed/copied materials are responsible for proper disposal.

Limits of Confidentiality

Appropriate records shall be open to review by representatives of funding, licensing and certification agencies.

Access to record material beyond the boundaries previously enumerated and any oral communication requested by outside sources is allowed only if Way Station’s Corporate Compliance Officer determines that an appropriate order has been issued by a court of competent jurisdiction or an authoritative agency, which meets the federal Privacy Laws (HIPAA) and/or State of Maryland Medical Record laws.

Confidentiality may be broken in cases of life threatening situations to self or others.

This policy is contained in the Client Rights policy which is made available to all applicants, clients and staff.

Special Circumstances Related to Family/Friends of Staff Receiving Services

From time to time a WSI staff person may by virtue of the scope of their job duties as an employee have access to protected health information (PHI) of friends, family members and/or acquaintances. It is the responsibility of the staff person to immediately report the potential conflict to their supervisor and the Director of Compliance and Quality Improvement.

Policies: client rights/confidentiality policy