Overview 

Clients have a right to request a record of any disclosures that have been made on their behalf throughout the course of their treatment. Here are our policies in relation to this issue.

Unemancipated Children and Dependent Adults or Adults under a Conservatorship/Guardianship

Emails. Preserve any emails that are written to any individual outside of Delve about this client in which the parent/guardian(s) is/are not the recipient. Do not ever delete these. As a part of the exiting process for any clinician leaving the practice, the clinician must archive all emails that could be considered a disclosure of protected health information. Save all of these emails as PDFs and upload them to the respective client’s folders. 

Letters. Any letters written to any individual or other entity other than the client, their guardian(s), or an individual within Delve must be uploaded to the client’s file (in PDF form) prior to sending the letter to the entity in question. 

All other correspondence. In the case of a phone conversation or other non-written communication, create an appointment in SimplePractice. Use billing code 00000. Do not charge the client for this communication. If this correspondence occurs in tandem with another meeting, set two overlapping meetings, one for the primary service (for instance, individual psychotherapy) and one for the consultation. For the consultation appointment, use the “Record of PHI disclosure” note to document the consultation. 

Emancipated Children and Adults who are not under any form of Guardianship

Emails. Preserve any emails that are written to any individual outside of Delve about this client. Do not ever delete these. As a part of the exiting process for any clinician leaving the practice, the clinician must archive all emails that could be considered a disclosure of protected health information. Save all of these emails as PDFs and upload them to the respective client’s folders. 

Letters. Any letters written to any individual other than the client or an individual within Delve must be uploaded to the client’s file (in PDF form) prior to sending the letter to the entity in question. 

All Other Correspondence. In the case of a phone conversation or other non-written communication, create an appointment in SimplePractice. Use billing code 00000. Do not charge the client for this communication. If this correspondence occurs in tandem with another meeting, set two overlapping meetings, one for the primary service (for instance, individual psychotherapy) and one for the consultation. For the consultation appointment, use the “Record of PHI disclosure” note to document the consultation. 

Guidelines for Responding to a Request for PHI disclosure

Any clinician currently in the practice that made any form of disclosure on behalf of the client must participate promptly in addressing a request for records of PHI disclosures. 

Active clinicians who interacted with the client at any point must review their emails to identify any that could be considered a PHI disclosure. Save these emails as a PDF and upload them to the client’s file. 

After all emails are collected, managers must compile all emails, letters, and a copy of all PHI disclosures into a single PDF document and save it in the admin google drive folder. Again, all files should be saved in PDF form. Email the single PDF document to the client who made the request, upload this single PDF document to the client’s file and print/mail a physical copy to the client. Make a chart note in the client’s file reflecting that all of these procedures were followed.