Current through Register No. 40, October 3, 2024
(a) Area agencies, service coordinators, and
other provider agencies, or their designees shall maintain a separate record
for each individual who receives services and ensure the confidentiality of
information pertaining to the individual, including:
(1) Maintaining the confidentiality of any
personal data in the records;
(2)
Storing and disposing of records in a manner that preserves confidentiality;
and
(3) Obtaining a release of
information pursuant to
He-M
503.04(h) prior to release of any
part of a record to a third party.
(b) An individual's record shall include, as
applicable:
(1) Personal and identifying
information including the individual's:
a.
Name;
b. Address;
c. Date of birth; and
d. Telephone number;
(2) All information used to determine
eligibility for services pursuant to
He-M
503.05 and
He-M
503.06;
(3) Information about the individual that
would be essential in case of an emergency, including:
a. Name, address, and telephone number of
legal guardian, representative, or next of kin or other person to be
notified;
b. Name, address, and
telephone number of current providers; and
c. Medical information as applicable,
including:
1. Diagnosis(es);
2. Health history;
3. Allergies;
4. Do not resuscitate (DNR) orders, as
appropriate;
5. Advance directives,
as determined by the individual;
6.
Current medications; and
7. Any
correspondence related to medical information relevant to the
individual;
(4)
A copy of the individual's current service agreement;
(5) Copies of all service agreement
amendments;
(6) Progress notes on
goals and support services provided as identified in the service
agreement;
(7) All service
coordination contact notes and quarterly assessments pursuant to
He-M
503.10(i)(2)-(4);
(8) Copies of evaluations and reviews by
providers and professionals;
(9)
Copies of correspondence within the past year with the individual and guardian,
area agency, provider agencies, providers, physicians, attorneys, state and
federal agencies, family members, and others in the individual's
life;
(10) Other correspondence or
memoranda concerning any significant events in the individual's life;
(11) Information about transfer or
termination of services, as appropriate; and
(12) Proof that the individual was given
choice of provider agencies.
(c) All entries made into an individual
record shall be legible and dated and have the author identified by name and
position.
(d) In addition to the
documentation requirements identified in He-M 503, each area agency, service
coordinator, provider agency, and provider shall comply with all applicable
documentation requirements of other department rules.
(e) Each billing entity shall:
(1) Retain records supporting each Medicaid
bill for a period of not less than 6 years; and
(2) Retain an individual's social history,
medical history, evaluations, and any court-related documentation for a period
of not less than 6 years after termination of services.
#1969, eff 2-25-82; ss by #2615, eff 2-6-84; ss by
#2962, eff 1-22-85; ss by #5211, eff 8-28-91; EXPIRED: 8-28-97
New. #6581, INTERIM, eff
9-19-97, EXPIRED: 1-17-98
New. #6932, eff 1-27-99; ss by
#8805, eff 1-27-07
