Release Of Medical Records And Consent To Disclose: Fill & Download for Free

UPFRONT DISCLAIMER: KNOW THE LAWS IN YOUR JURISDICTION!The American Psychological Association's (APA) Ethics Code for Psychotherapy requires that all psychologists discuss the limits of confidentiality with their clients during in an informed consent agreement at the start of treatment (Standard 4.02, Title 10.36.05.08A). Further, the informed consent information must be given to the client in understandable language (Standard 3.10a). If you're in therapy, look back to the informed consent document that you agreed to at the start of treatment.There are several instances where psychologists are allowed to break confidentiality without the client's consent. For typical psychotherapy (e.g., individual therapy, not court-ordered, not a forensic or corporate evaluation) it is my understanding that, currently, the most common cases are as follows:The client is at significant risk of harming themselves or others. Psychologists are allowed to break confidentiality if they believe that a client is in imminent danger of harming themselves (Knapp & VandeCreek, 2006). Psychologists have a duty to break confidentiality if they believe that their client is at risk of harming/killing someone and there is no reasonable alternative (e.g., hospitalizing the client; Knapp & VandeCreek, 2006). Some states have very specific laws regarding the psychologist's duty to commit, treat, or warn.There is evidence of child abuse. In many states, such as Maryland, practitioners and educators are mandated to report the reasonable suspicion of abuse or neglect of a minor (a child under 18; Family Law Article § 5-701). How abuse and neglect are defined differs from state to state. Often abuse includes physical, sexual, and emotional abuse. However, not all states include emotional abuse in their reporting laws (Twaite & Rodriguez-Srednicki, 2004). In some states, mandated reporters must report past abuse/neglect of an adult if it occurred when the client was a minor.There is evidence of abuse to a vulnerable adult. (The definition of a “vulnerable adult” is typically an adult who lacks the physical and mental capacity to provide for their daily needs.) Some states, such as Maryland, require that health practitioners make a report if they have reason to believe their vulnerable adult client has been subject to abuse, neglect, self-neglect, or exploitation (Family Law Article § 14-101). Other states, such as Colorado, North Dakota, Pennsylvania, South Dakota, and Wisconsin, encourage but do not require reporting (Welfel, Danzinger, & Santoro, 2000).Treatment of minors. In some states, clinicians may disclose any treatment information of a minor to their parent/guardian without the minor's consent, unless an agreement is signed by all parties that specifies otherwise.There is a court order to release the information. In most states, psychologists must comply with a judge's court order for the release of an individual's medical records. However, each state has its own laws about client-therapist privilege (DeBell & Jones, 1997).The client initiates litigation against the psychologist. If a clinician is being investigated, they may be required to disclose medical records to health and licensing boards for investigations for licensure, certification, or disciplinary action. They may also be required to disclose medical records for criminal investigations.The client is involved in litigation and introduces his relationship with the psychologist into evidence. It's my understanding that in some states, this is an exception to confidentiality.The client is impaired and requires involuntary treatment. Depending on the state, a patient can be involuntary committed by court order or by the provider if deemed necessary. When a client is transferred to new treatment facility, medical records are often allowed to be disclosed to the center or another health care provider without the client's authorization.Now, there are also special cases. For example, can a couple's therapist break confidentiality and tell the wife something she [the therapist] was told by the husband in private? How does confidentiality work for a "mature" or "emancipated" minor? If military personnel see a military doctor, is their session confidential? Etc. There are too many corner cases to get into in a simple answer here.The bottom line: Laws related to confidentiality are complex. The above is an overview, in very broad strokes, of common principles related to exceptions to confidentiality for psychologists. It is not intended to be a comprehensive list or to provide definitive answers for all readers. Know the laws in your jurisdiction! If you are a client and are unfamiliar with the laws that govern your treatment, speak with your clinician. They have an obligation to explain the informed consent you both agreed to at the start of treatment in an understandable way. If you are a treatment provider and are interested in staying up to date on the latest changes to state and federal law, contact your state psychological association.Further reading:Barnett, J.E., & Johnson, W.B. (2008). Ethics Desk Reference for Psychologists. Washington, DC: American Psychological Association.

Request the records in writing. I would suggest you include some of the requirements in your written for medical requests outlined in 42 CFR § 2.31 - Consent requirements, specifically include the following:Full name of the patient/former inmate; andWhat kind of information you want them to disclose; andHow much information you want them to give you (i.e., all records that is legally permitted to be released in the medical record during the period of incarceration); andBe specific to whom you are requesting the information disclosed to (if they are your records, state it; andState why you want or need them (e.g., continuum of care or to ensure historical medical services reflected in current medical records outside of the Department of Corrections); andSign and date the written request.I don’t care if you have a drug problem or not, just follow the suggestion.Make a copy of the signed and dated letter that you send to the Department. They have 30 days (per HIPAA) to approve or deny your request via a formal declination notice or letter. Do not confuse the declination letter with the delivery of a copy of the medical record. Also, note, as a patient, you don’t own the medical record, you have an interest in the medical record, and that is why (in most cases) it is important to include a purpose in your medical record (point #5 above).If they don’t comply, ask a new question of what you should do to compel compliance after the declination letter. Note — you have to include the reason for the declination in the new question.I hope this helps.

Thanks for the A2A, Phillip.Yikes, man! That’s a great question. So, let us throw out the morality of it all and just stick with the question itself shall we?Hypothetically, if one were to find themselves in this situation, and I’m sure there have been hundreds who have, I suppose they would simply join the service.Now as far as the military pulling civilian medical records of their own accord that’s not ever going to happen. There is a release of medical information form you have to fill out for them to access your medical records. And there is the matter of cause to pull those records. If there is no symptoms to provide cause there is no requirement to fill out the form for them to gain access. Make sense?Throwing in the scenario of a background check for security clearance doesn’t change that at all. In fact, all Soldiers nowadays have to get a S clearance and if you go to Group you’ll have to get a TS - and they never accessed civilian med records for any reason.So the answer is - No, they will never access your civilian med records for no reason without your expressed written consent.