Developmental Services - Case Management Manual
Release of Information
he purpose of this information is to insure the confidentiality of all written records or accounts in accordance with state and federal statutes and regulations. An effective confidentiality procedure should result in the protection of the dignity and privacy, rights and interest of the individual client and his/her family. As a general principle, the client person and his/her legal representative has the right to decide what personal information may be released, to whom and for what purpose. Generally, a person requesting information should demonstrate clearly that the requested information will serve a specific purpose associated with the needs of the client. Case managers should refer to their district office for a copy of the Maine State law on Disclosure of Client Information.
II. Obtaining Information From Another agency or Individual
There must be a release of information form, signed by the client, if legally competent, or the client's legal guardian, in order to obtain information about the client. In obtaining information from another agency or individual, inquiry should be made as to the agency/individual policy regarding release of information. The agency/individual policy should be honored insofar as possible in DHHS utilization of the information.
III. Release of Information to Another Agency or Individual
There must be a release of information form, signed by the client, if legally competent, or by the client's legal guardian, in order to release any information about the client. In releasing information, the DHHS worker must make sure that the information is stamped as being privileged and confidential. The release of information shall specify the information released. There must also be a clear notation in the case record indicating the information released and the circumstances of the release.
IV. Client/Legally Authorized Party Access
A. General: Clients, former clients, or other legally authorized parties may examine the entire client record, if the request is submitted to the district office/facility. In order to avoid misinterpretation of record content, a professional staff person should be available to answer questions at the time of the record review. The client or legally authorized party may obtain copies of any or all parts of the record and may be charged a reasonable cost for such reproduction.
B. Exceptions: There may be situations where information contained in the client's record may be deemed by a professional as harmful to the client or his/her family. Discretion shall be used in the disclosure of this type of information. Discretion must also be used in releasing information regarding an adult protective investigation, e.g., 22 MR Section 3474 subsection 2, Optional Disclosure of Records.
V. Family Relative Friends (other than legally authorized party) Acess
When a client or legally authorized party gives written consent to have specific record or type of record released to a specific person on a routine basis, such information shall be released routinely.
VI. Emergency Treatment
In emergency situations, information about the client may be released without a signed release of information in order to secure the emergency treatment needed, e.g., medical emergency, emergency placement.
VII. Transfer of Information within the Department
The transfer of client information interdepartmentally within DHHS may occur when a) there is a clear need for the information transfer; b) the case record is properly noted regarding the transfer; and c) the material is clearly marked confidential. No release is needed.
VIII. Agencies and Individuals Serving Developmental Services Clients
An individual or an agency should be permitted access to client files in the absence of either the client's informed written consent or a court order, only to the extent that disclosure of information is "necessary to carry out any of the statutory functions of the department", 34B MRSA, Section 1207, subsection 1B. If the individual or agency is, by contract or other agreement, performing a function on behalf of Developmental Services for its clients, access to whatever information is needed to carry out that function should be granted. Some statutory functions of DHHS are specified in Maine law: assessment of need to develop a prescriptive program plan, 34 B MRSA Section 5462; execution and performance of service agreements, subsection 5471; provision of protective and support services, Section 5203; provision of residential, educational training services to wards of DHHS, 18 MRSA subsection 3628. The range of services which are required to fulfill DHHS's obligations will vary from client to client and from case to case, as will the scope of disclosure which is necessary to carry out those obligations. Individuals and agencies seeking access to files in the control of DHHS, as a threshold, must be working on behalf of the at the request of DHHS.
IX. Court Order
An order of the court shall cause the institution/district office to disclose information to the extent required by the order. A copy of any such legal order shall be kept on file in the client's record. Any question regarding the validity or interpretation of the court order shall be referred to the Attorney General's Office for resolution.
Permission may be given for students or researchers to view specific types of information, based on a written request. Approval may be given by the Program Manager for Developmental Services.
XI. Assessing Ability to Give Informed Consent
There will be situations where a client's ability to give informed consent may be in question. A psychologist an advocate and interpreter, if needed; should participate in any assessment of a client's ability to give informed consent.
XII. Confidentiality with Legislators
From time to time legislators become involved with individual client situations and will ask for information. In these cases, the same release of information provisions would apply to a legislator, as to any person seeking client information. Department statutes set out these circumstances under which information can be released. These are:
- with consent of the client or legal guardian,
- as necessary to carry out the functions of the Department,
- by Court order.
As with any person, an explanation of our confidentiality statutes and the importance of protecting the privacy of clients should be given. It is also important to offer to assist the legislator in obtaining necessary releases.
You should always seek the advice of other experienced caseworkers or your supervisor whenever there is any question about confidentiality. Caseworkers and supervisors should also not hesitate to consult the Attorney General's office and ask for a legal opinion regarding confidentiality. The AAG's Office can be reached at (207-626-8800) TTY (207-626-8865).