Our practice requires a written release of information to be documented in the client's file with a clear expiration date before we will share information. All releases automatically expire one year after the date executed if an earlier date is not specified. If there is any question when the clinician reviews the written release about whether or not specific content should be disclosed, we will err on the side of caution and our client's privacy, and we will not release information until (or if) we are able to clarify with the client.
Professional Records and HIPAA
We are required by law and by professional standards to maintain clinical records. Certain information must be documented in records, such as a description of symptoms and presenting problems and how they are impacting your life; diagnosis; health status and medical history; relevant family, social, educational, vocational, and treatment history; treatment goals; treatment plans; a record of treatment visits; progress and prognosis; any past treatment records that we receive from other providers; letters and reports; reports of any professional consultations; substantive electronic-mail and other communication; billing records; a discharge/termination summary; and any reports that have been sent to anyone, including reports to your insurance carrier (which some may request before processing claims for out of network benefits).
Pursuant to HIPAA, we may keep Protected Health Information (PHI) about you in two sets of professional records. One set constitutes your clinical record, as described above, and the second in a set of psychotherapy notes.
Except in unusual circumstances that disclosure is reasonably likely to endanger the life or physical safety of you or another person, HIPAA provides you with several rights with respect to your clinical records and disclosures of PHI. You may examine and/or receive a copy of your clinical record, if you request it in writing. To help safeguard your privacy, we only include the information necessary in your clinical record to be compliant with laws and meet the ethical standards of our profession. You have the right to request to see your record, to amend your record, to restrict what information in your record is disclosed to others, and to receive an accounting of most disclosures of Protected Health Information (PHI) that you have neither consented to nor authorized (e.g., these are usually from your insurance company). If you make any complaints about our policies and procedures, this information is also recorded in your records. Seven years from the end of treatment (or the length of time required by the standards of our profession or applicable law), it is our practice’s policy to destroy records. In some cases, your records may be maintained for longer, though this is not guaranteed. You have a right to a paper copy of this agreement, the attached notice form, and our privacy policies and procedures.
Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, should you ever wish to review your records, we recommend that you initially review them in our presence or that you have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, we are permitted to charge a copying fee (and certain other expenses). Any exceptions to this policy are contained in the HIPAA Notice Form provided with the consent forms upon intake. If we refuse your request for access to your clinical records, you have a “right of review,” which we are happy to discuss with you upon request.
Your clinician may also choose to keep a set of psychotherapy notes, which is the other set of professional records. These notes are for our use and are designed to assist us in providing you with the best treatment. While the contents of psychotherapy notes vary by clinician (in those cases where the clinician chooses to keep separate notes), they may include sensitive information that is not required to be included in your clinical record, such as the contents of therapy conversations, the analysis of those conversations, and how they impact your therapy. These psychotherapy notes are kept in a separate, secure location from your clinical record.
While insurance companies can request and receive a copy of your clinical record, they cannot receive a copy of your psychotherapy notes without your signed, written authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal. In those cases where we are out-of-network with your insurance company, should you choose to submit receipts for services to request out-of-network reimbursement, please be aware that your insurance company may contact us to request a copy of your clinical record.