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Records, Confidentiality and Information Release

Categorized In: Case Services - General Case Management Policies

Approved Date: October 02, 2018

Owner: Angela Fujan

Written informed consent required

 Before a third party (such as an attorney or an organization) may view or receive information from or copies of VR records from the service record, and before a client and/or their representative can view and make copioes of their case record, or request a copy of their casefile, VR must receive a request or authorization for release that meets all four of these requirements:

  • Is written
  • Is signed by the client or applicant (or that person's parent, guardian, or designated representative)
  • Is dated
  • Specifies the records or information to be released and to whom they are to be released

Note: If the request does not specify the records or information to be released, or if the request is for the entire record, contact the requesting entity to determine what specific information is wanted. (See Service Record definition in this chapter.)

VR information release

 A completed, signed, and dated VR Information Release satisfies the requirements for informed written consent.

You may release the following information to an agency or organization to the extent it is necessary for its program:

  • Information on the person's application
  • Information about the person's job goal, services, providers, progress, and VR aid
  • Medical and psychological information about the person, unless harmful to the person
  • Drug or alcohol information about the person
  • Vocational test scores and analysis
  • Vocational assessment scores and analysis
  • Education and training information, including grade reports and transcripts
  • Other available information in the person's service record.

Limitations on release

Release is limited as follows:

  • Conditions of other agency or organization

You cannot release information VR received from another agency or organization which is designated "Do Not Release" or "Do Not Re-release. Simply being marked “confidential” does not prohibit release itself.

  • Harmful information

You cannot 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 that it will not be released to the person.

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 Nebraska VR 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 VR 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.

Release in response to a subpoena, court order, or other release without written consent

Fax copies of any subpoenas, court orders, or other releases without written consent to the NDE Legal Counsel's office (Scott Summers @ FAX 402.471.6631) for advice on how to proceed before releasing any information. If necessary, inform the requesting party the request is under review by Legal Counsel.

Service record

The service record, comprised of both the electronic record (QE2) and the supplementary paper record, means the unique record of service for each occurrence of an applicant or recipient served. All information in a service record 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 service records.

The service record includes:

All information in QE2 concerning the person and the services and supports planned or provided to the person, and

All information in the supplementary paper record supporting or verifying determinations, decisions, and service delivery activities recorded in QE2, including:

  • Official agency forms signed and dated by the person, and a responsible VR staff member when appropriate.
  • Information supporting determinations of eligibility or ineligibility, priority in the order of selection, approval of the IPE and any amendments, the nature and scope of services, progress toward the job goal, achievement of the job goal, and decisions to terminate services to the client.
  • Information supporting the authorization and expenditure of funds, including: personal and family income, financial, and budget records, price quotations, bids, invoices, bills, receipts, and verification that services were rendered or goods provided, and exceptions to Rule 72. Information supporting service delivery activities, including: copies of correspondence sent to or received from the applicant or recipient, service providers, and vendors; grade reports and school transcripts; results of professional evaluations and assessments, and progress reports from service providers.
  • Information copied from a prior service record to be included in a new service record shall be stapled together with a coversheet labeled: Information copied from service record of (Date of Termination).

Records, Confidentiality and Information Release

Process

Information release contacts

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

  • Exchange of information with entities identified on the VR Information release
  • Requests to provide VR records to a third party accompanied by a written request signed by the applicant/client
  • Requests from applicants/clients to see their own VR records or obtain copies.
  • The information release contacts will seek advice from the NDE Legal Counsel's office (Scott Summers at 402.471.7828) when necessary.

Written informed consent required

 Before a third party (such as an attorney or an organization) may view or receive information from or copies of VR records from the service record, VR must receive a request or authorization for release that meets all four of these requirements:

  • Is written
  • Is signed by the client or applicant (or that person's parent, guardian, or designated representative)
  • Is dated
  • Specifies the records or information to be released and to whom they are to be released

Note: If the request does not specify the records or information to be released, or if the request is for the entire record, contact the requesting entity to determine what specific information is wanted. (See Service Record definition in this chapter.)

VR information release

 A completed, signed, and dated VR Information Release satisfies the requirements for informed written consent.

Scope of release

You may release the following information to an agency or organization to the extent it is necessary for its program:

  • Information on the person's application
  • Information about the person's job goal, services, providers, progress, and VR aid
  • Medical and psychological information about the person, unless harmful to the person
  • Drug or alcohol information about the person
  • Vocational test scores and analysis
  • Vocational assessment scores and analysis
  • Education and training information, including grade reports and transcripts
  • Other available information in the person's service record.

Limitations on release

Release is limited as follows:

  • Conditions of other agency or organization

You cannot release information VR received from another agency or organization which is designated "Do Not Release" or "Do Not Re-release. Simply being marked “confidential” does not prohibit release itself.

  • Harmful information

You cannot 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 that it will not be released to the person.

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 Nebraska VR 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 VR 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.

Release in response to a subpoena, court order, or other release without written consent

Fax copies of any subpoenas, court orders, or other releases without written consent to the NDE Legal Counsel's office (Scott Summers @ FAX 402.471.6631) for advice on how to proceed before releasing any information. If necessary, inform the requesting party the request is under review by Legal Counsel.

Service record

The service record, comprised of both the electronic record (QE2) and the supplementary paper record, means the unique record of service for each occurrence of an applicant or recipient served. All information in a service record 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 service records.

The service record includes:

All information in QE2 concerning the person and the services and supports planned or provided to the person, and

All information in the supplementary paper record supporting or verifying determinations, decisions, and service delivery activities recorded in QE2, including:

  • Official agency forms signed and dated by the person, and a responsible VR staff member when appropriate.
  • Information supporting determinations of eligibility or ineligibility, priority in the order of selection, approval of the IPE and any amendments, the nature and scope of services, progress toward the job goal, achievement of the job goal, and decisions to terminate services to the client.
  • Information supporting the authorization and expenditure of funds, including: personal and family income, financial, and budget records, price quotations, bids, invoices, bills, receipts, and verification that services were rendered or goods provided, and exceptions to Rule 72. Information supporting service delivery activities, including: copies of correspondence sent to or received from the applicant or recipient, service providers, and vendors; grade reports and school transcripts; results of professional evaluations and assessments, and progress reports from service providers.
  • Information copied from a prior service record to be included in a new service record shall be stapled together with a coversheet labeled: Information copied from service record of (Date of Termination).

 Applicant/client reviewing and copying own service record

Before information may be reviewed or copied from the service record, VR must receive a request or authorization for release that meets all four requirements:

  • Is written
  • Is signed by the client or applicant (or that person's parent, guardian, or designated representative)
  • Is dated
  • Specifies the records or information to be released.

Note: If the request does not specify the records or information to be released, or if the request is for the entire record, contact the requesting entity to determine what specific information is wanted. (See Service Record definition in this chapter.)

If an applicant or client provides a written, signed request, you must make available for timely review and copying by the client (or their representative) a printout of the QE2 file and the paper record containing the requested information.

A client or applicant (or their representative) may also receive a copy of requested documents from their VR service record if they request in writing. This is to be supplied as soon as practicable, but need not be while the client is in the office.

These 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 original record.

  • Access to harmful information

If the service record contains medical, psychological, or other information that VR determines may be harmful to the client, the information cannot be released directly to 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, he or she must be notified what documents are being withheld and the reason.

Confidentiality of internal communications with NDE legal counsel

Written and verbal communication between staff and NDE Legal Counsel regarding clients is confidential and is not to be made a part of the client's records except for background checks and summaries of decisions.

Charges

Copies of records are provided at no cost. If a check is sent along with a request for release/copies of records, return the check to the sender.

Confidentiality of service record

 All information in a client's service record is confidential (including the name of the client and his or her 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.

  • Only personal information that is essential to determinations and the provision of vocational rehabilitation services should be documented in the service record.
  • All documentation by staff members should treat the person with dignity and respect.

Protection of confidential information

A client’s QE2 and paper record is accessible only to 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 with access to QE2 or paper records.
  • Assuring that 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 that open QE2 is not in plain view in any office areas when VR staff are not present.
  • Storing paper records in locked files or locked secure areas when not in use.
  • 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 person.
  • Limiting e-mail communication of names and other identifiable personal information to that which 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.

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.

Prompt access and release. Promptly respond to all requests for access to or release of information. Unnecessary delay may harm the person 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.

Subpoenas, court orders, and other releases without written consent

 Staff must obtain advice from the NDE Legal Counsel's office (Scott Summers at 402.471.7828) 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.
  • Fax the request to Scott Summers at 402.471.6631. After receiving the fax, he will advise the staff member how to proceed.

Amendment of inaccurate or misleading information

If an applicant or recipient believes that information in their record of services is inaccurate or misleading, he or she may request that VR amend the information.

  • If the information is not amended, the request for an amendment and the reason the information was not amended must be documented in the QE2 task notes.

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 (28-711 RRS) or neglect of a vulnerable adult (28-372 RRS). 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 Scott Summers at 402.471.7828. 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 office director if available or senior staff person, take appropriate action and contact the local Emergency Intervention Resources. Staff will document in a Task Entry in QE2 the action taken. The office director will review and approve documentation.

 




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