Record Release

Releasing records sounds simple but can actually be super complicated. First off, who is requesting the records, and do they have a right to them? For minors, you must make sure we are releasing records to or receiving permission for their release from a guardian with legal custody. Has the court assigned a best interest or privilege attorney? If so, they may have to review the records first, and they will then determine who can see the records, including guardians. We must provide the entire record to a best interest/privilege attorney as they are working on behalf of the court and representing the minor's best interest. 

For all minors, per HIPAA, a provider may choose not to release records to a legal guardian when the provider reasonably believes, in their professional judgment, that the minor has been or may be subjected to domestic violence, abuse or neglect, or that the release could endanger the child.

In Maryland, if anything contained in a client's records could be injurious to the health of a client or recipient, the healthcare provider may refuse to disclose that portion of the medical record. However, upon written request, we must provide a summary of the undisclosed portion of the medical record, add the summary to the chart, or disclose the full record to a healthcare provider treating for the same diagnoses. For minor clients over age 12, it is important first to determine if the minor client has concerns about their records being released. The provider then uses their professional judgment to determine if the records should be disclosed, specifically if the disclosure could lead to harm to the minor or deter the minor from seeking care. 

In Delaware, a minor client over age 14 who has given their own consent for treatment can decide if their records are released. However, ultimately, the provider may use their professional judgment to grant or deny access.

In Pennsylvania, a minor client over age 14 who has given consent for their own treatment and understands the nature of documents to be released and the purpose of releasing them determines who can receive their records. For all other minor clients, the legal guardian has the right to determine record disclosure. When a guardian has provided consent to treatment, the guardian has the right to receive information necessary to consent to specific treatment options, including symptoms, conditions to be treated, medications, treatments, risks, benefits, and expected results. Release of records requested by a guardian who has provided consent to treatment and against the wishes of a minor client is limited to the release directly from one provider of mental health treatment to another provider of mental health treatment or from one provider of mental health treatment to the primary care provider.

Of note, when restricting the release of a minor's record, there must be a valid reason for it. We cannot restrict the release of records simply because the recipient might not like what we said in the note, absent the above-detailed exceptions, or if the note would make the provider or practice look bad. For this reason, it is so important to consider how you write your notes and what you include. When in doubt, talk to your supervisor, associate director, or compliance.