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Policy No: 1-012.1


To assure that the patient/client's right to privacy is protected by specifying the protocol regarding confidentiality of the clinical record and release of information, as necessary.


MHHC, Inc. and its personnel maintain, as confidential, all clinical records and information related to patients/clients. No information shall be released without prior written authorization by the patient/client or his/her representative. (See Release of Information, Policy No: 7-006)


  1. Only personnel involved in the care or supervision of care on specific patients/clients including accrediting agency personnel and state surveyors will have access to patient/client clinical records.
  2. Patient/clients will not be discussed by clinical or non-clinical personnel outside of the context of professional conversation regarding patient/client's condition and care.
  3. Clinical records will not be released to any third-party without a written authorization from the patient/client.
  4. An agreement and Consent for Services form, will be signed by the patient/client upon admission to the agency.
  5. Any release of information for purposes other than claims processing or as required by law or regulation must have a separate clinical record release. Information may be released to another health organization when the patient/client is under their care. Appropriate information will be forwarded upon proper authorization.
  6. All requests for patient/client information will be reviewed by the appropriate agency personnel to determine whether or not this information can be made accessible. Requests for information that may not be released will be referred to the Executive Director/Administrator.
  7. Copies of clinical records or excerpts of same, cannot be removed from the agency except by subpoena, where statutory law requires it, or on written authorization of the agency. This confidential information is treated as such and is to be mailed in an envelope designated "confidential".
  8. Patient/clients will be allowed access to their clinical records at the agency during hours after giving reasonable notice to the Executive Director/Administrator or designee.
  9. All clinical records will be kept in a locked cabinet/room when not being utilized. The clinical supervisor or designee will be responsible for the key. No unauthorized individual will be allowed access to these clinical records.
  10. The following patient/client information will be secured after business hours:
    1. Clinical records
    2. Field clinical records
    3. Patient/client intake information
    4. Minutes of patient/client care meetings
    5. Performance improvement data
    6. Clinical notes prior to filing in clinical record
    7. Signed physician orders
  11. Information contained in Performance Improvement reports will not contain individual patient/client or personnel information.
  12. All agency personnel will be asked to sign a confidentiality statement during their orientation process.
  13. Any breach in confidentiality on the part of agency personnel is grounds for possible termination.
HIPPA Commitment to Compliance Privacy Practice