• A case file is all parts of the client record of service (including task notes) created, uploaded, entered, and/or stored in an electronic case management system (QE2) or maintained in a paper file.
• All information in the case file will be maintained as a distinct record until disposed of. See the Records Retention Policy on VRIS for the approved disposal dates of closed FY year case files.
• Except for the email containing the results of the client background check, written communication from NDE Legal Counsel are attorney/client work product and should never be made a part of the client’s file. A summary of the email can be added in a task note.
• VR has permission to release case file information only with the organizations or individuals listed on the Release of Information form;
• A Case File Request of Information form must be completed when –
  • A client and/or their representative requests copies of case file information
  • A client and/or their representative requests to view the case file in QE2; 
  • The requestor does not specify the records or information to be released; OR
  • The request is for the entire record
• Copies of case file information are provided at no cost. If payment is sent along with a request for release/copies, return to the sender.

CONFIDENTIALITY

All information in a client's case file is confidential (including the name of the client and their current status as an applicant or recipient of services). This information cannot be released to or accessed by anyone not directly connected with VR except with the informed written consent of the client on the Release of Information form.

Protection of confidential information 

A client’s case file is accessed by VR staff who are providing, supervising, or monitoring the person's services. Activities to safeguard confidential information include, but are not limited to:

• Accompanying clients or guests with a VR staff member in any office areas;
• Assuring paper records, letters, posted lists of client names, and other materials with personal identifiable information are not in plain view in office areas when clients are in the area;
• Assuring open QE2 is not in plain view in any office areas when VR staff are not present;
• Not responding to verbal or telephone requests for names, program status, services being provided, or other identifiable personal information without a written release signed by the client;
• Limiting e-mail communication of names and other identifiable personal information to what is absolutely essential to coordinate services or resolve problems;
• Retaining personal possession of all documents (such as flowsheets) containing identifiable personal information taken out of the VR office;
• Shredding any documents, including notes or messages, containing identifiable personal information.

LIMITATIONS ON RELEASE OF CASE FILE

1. Conditions of other agency or organization - Do not release information received from another agency or organization designated "Do Not Release" or "Do Not Re-release. Simply being marked “confidential” does not prohibit release itself.

2. Harmful information -Do not release medical or psychological information VR determines will be harmful if released directly to the client unless the receiving agency or organization assures it will use the information only for the purpose for which it is being provided and it will not be released to the person.

3. Releasing Drug and Alcohol Treatment Records - Federal regulations (42 CFR Part 2) that restrict disclosure of drug or alcohol treatment records apply to alcohol or drug abuse programs that receive federal assistance. They do not apply to VR directly. However, these regulatory restrictions on disclosure do apply to others that receive such records directly from such programs if such program notifies the entity receiving such records by way of the language below, or something substantially equivalent:

“This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR part 2). The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.”

The Release of Information form specifically mentions “Drug or alcohol treatment records (including AIDS/HIV)” and provides the individual signing the release the option to cross out any types of information the individual does not want released by VR. Therefore, alcohol and drug abuse treatment records can be re-disclosed with that standard written client authorization. VR staff need to consult the Release of Information form in the case file to make sure the “drug or alcohol treatment records” line has not been crossed off by the client before releasing any such records.

4. Release in response to a subpoena, court order, or other release without written consent - Staff must obtain advice from the NDE Legal Counsel's office before releasing information in response to:

• A subpoena or court order (i.e., an order issued by a judge, magistrate, or other authorized judicial officer), or
• A law, the need to protect the person or others, or an investigation for law enforcement, fraud, or abuse requiring release.

Scan copies of any subpoenas, court orders, or other releases without written consent to the NDE Legal Counsel's office (Juan Roman for advice on how to proceed before releasing any information). If necessary, inform the requesting party the request is under review by Legal Counsel.

5. Release to Governor's office, State Ombudsman, Senators, and Representatives - The same release requirements specified in this chapter apply to inquiries, investigations, and requests for information from the Governor's office, State Ombudsman, Federal and State Senators, and Representatives.

Duty to report abuse

There is a limited duty under state law to report or cause a report to be made of abuse or neglect of a minor (Neb. Rev. Stat. § 28-711) or neglect of a vulnerable adult (Neb. Rev. Stat. § 28-372). If staff have reasonable cause to believe there is a need to release personal information to protect the individual or to protect the safety of others, the staff member should contact Juan Roman. He will advise the staff member how to proceed.

Duty to report suicide threat

If staff have reasonable cause to believe there is a need to release personal information without a written release in order to prevent a suicide from occurring, the staff member should consult with their supervisor or the VR Director/Assistant Directors, take appropriate action and contact the local Emergency Intervention Resources. Staff will document in a Task Entry in QE2 the action taken. The supervisor will review and approve documentation.

 INFORMATION RELEASE CONTACTS

A staff member in each local office has been identified and trained to handle release of information requests. These requests include:

• Exchange of information with entities identified on the Release of Information;
• Requests to provide VR case file records to a third party accompanied by a Case File Request for Information form;
• Requests from applicants/clients to see their own case file or obtain copies accompanied by a Case File Request for Information form.

The information release contacts will seek advice from the NDE Legal Counsel's office (Juan Roman) when necessary.

 

1. Obtain a Case File Request for Information form;
2. Once a Case File Request of Information form is received, the requested information must be provided to the applicant/client within 5 working days. Unnecessary delay may harm the applicant/client by delaying eligibility determination for other benefits, impeding litigation or settlement of worker's compensation claims, or resulting in termination of existing services or benefits.
   1. From the File Uploads screen, select Zip and Export Files. This exports all uploads into a zip file;
   2. From the Case Home screen, select Print Task Notes. This creates a pdf of all task notes;
   3. Information requested denoted with an asterisk (*) on the Case File Request of Information form should be provided via a screen shot from QE2.
3. If a client or applicant (or their representative) requests to view their case file the following restrictions apply: 

• Presence of VR staff member - A VR staff member must be physically present at all times when the client or their representative has access to the case file;

• Access to harmful information - If the case file contains medical, psychological, or other information VR determines may be harmful to the client, the information cannot be viewed by the client. The information must be released to a court appointed representative, if a court has appointed one. In the absence of a court appointed representative, the information must be provided to a third party chosen by the client. The third party may be an advocate, a family member, or a qualified medical or mental health professional.

• Access to information provided by other agencies and organizations - If personal information has been obtained from another agency or organization, it may be released only by, or under the conditions established by, the other agency or organization.

• Notification of withheld information -  Any time information is withheld from the client or representative, they must be notified what documents are being withheld and the reason.

Amendment of inaccurate or misleading information

• If an applicant or client believes information in their case file is inaccurate or misleading they may request VR amend the information.
• The request must be in writing and specify the inaccurate or misleading information and how they would like it amended.
• The written request for an amendment must be made a part of the case file and the reason the information was amended/not amended documented in a task note.

Case File Request for Information