Current through Register Vol. 56, No. 18, September 16, 2024
(a) All
certificates, applications, information and records directly or indirectly
identifying persons who are receiving or have received mental health services
from a provider licensed by the Department, or for whom such services were
sought, shall be kept confidential and shall not be disclosed by any person,
except under the following circumstances:
1.
Upon authorization of the consumer:
i. For
adult consumers: Upon the written authorization of the consumer, or his or her
legal guardian or authorized representative, if any.
ii. For consumers who are minors:
(1) A minor, 14 years or older, who has
requested admission and been admitted voluntarily to a psychiatric facility,
special psychiatric hospital, or children's crisis intervention service
pursuant to R. 4:74-7A(c), may authorize the disclosure of his or her records
in the same manner as an adult;
(2)
The minor's parent or legal guardian may authorize the disclosure of the
minor's records, provided that the minor shall be given prior notice and an
opportunity to object to the disclosure. Objection by a minor, 14 years or
older, who has requested admission and been admitted voluntarily to a
psychiatric facility, special psychiatric hospital, or children's crisis
intervention service pursuant to R. 4:74-7A(c), shall render the authorization
of the parent or guardian void; or
(3) Disclosure of the clinical records of a
minor, 14 years or older, who has requested admission and been admitted
voluntarily to a psychiatric facility, special psychiatric hospital, or
children's crisis intervention service pursuant to R. 4:74-7A(c), is permitted
only upon written authorization of the minor; however, a parent or guardian,
upon proper inquiry, shall be told the minor patient's current medical
condition if the minor does not object to such disclosure;
2. Pursuant to a court order
directing disclosure, upon its determination that disclosure is necessary for
the conduct of its proceedings before it and that failure to make such
disclosure would be contrary to the public interest; or
3. To carry out any of the provisions of
Title 30 or Article 9 of Chapter 82 of Title 2A of the New Jersey Statutes
(2A:82-41) , or as required by
other Federal or State law.
(b) Consumer records may also be disclosed to
the following persons, upon presentation of appropriate credentials, under
these circumstances:
1. Employees of the
agency who are involved in the care of the consumer provided, however, that
when a consumer enters treatment(s) he or she will be informed that agency
staff will have access to his or her records.
i. Employees of the agency may disclose
information that is relevant to a consumer's current treatment to the staff of
another such agency, so long as such disclosure is in compliance with the
Health Insurance Portability and Accountability Act 45 CFR Parts 160 and
164;
2. Clinical records
audit teams, monitoring and site review staff designated by the Department, the
Office of Legislative Services, the New Jersey Department of Health and Senior
Services, and the Center for Medicaid & Medicare Services;
3. A person participating in a Professional
Standards Review Organization; and
4. Officials within the offices of the State
Medical Examiner or a County Medical Examiner making investigations and
conducting autopsies, pursuant to
52:17B-78 et seq.
(c) The records of a minor shall
be released upon request to the Department of Children and Families in
connection with investigations of whether the minor has been abused or
neglected.
(d) Whenever possible,
names of consumers shall be deleted from the records being reviewed under (b)
above and consumers shall be identified only by use of their
initials.
(e) Nothing in this
section shall preclude disclosure, upon proper inquiry and after the consumer
has had the opportunity to object and does not express an objection, of
information as to a consumer's current medical condition to any relative or
friend.
(f) Information may be
disclosed to any licensed mental health provider or medical health care
provider who has a contract with the Division of Mental Health Services or the
Department of Human Services, or to the consumer's personal physician if it
appears that the information is to be used for the benefit of the
consumer.
(g) The records of a
deceased individual who has received services or for whom services were sought
may be released to the estate's administrator or executor. If there is no
administrator or executor, records may be released to the next of kin indicated
in the consumer record. A valid written authorization for the release of
information must be obtained from next of kin:
1. Natural or adoptive parents;
2. Siblings;
3. Grandparents;
4. Family caregiver of record;
5. Spouse; or
6. Child/children.
(h) Where disclosure to third parties is
authorized pursuant to (b) above, the following conditions shall be observed:
1. The custodian of the records shall, by
written notice, advise the person receiving the records that disclosure without
the authorization of the person who is the subject of the records, or as
otherwise provided by law, is prohibited.
2. Information and records disclosed for any
purpose shall be limited to that information which is relevant and necessary
for the purpose of the disclosure, except as authorized by the consumer or his
or her representative or required by law. Where the disclosure is between
agencies for the purpose of treatment and is not limited by the consumer's
authorization, the agency releasing the information shall rely upon the
recipient's assertion of need for the information.
3. A request for information regarding a
consumer and the action taken upon the request shall be recorded in the
consumer's clinical records and accounted for if requested by the consumer for
up to six years from the date of the disclosure.
4. Consumers or other persons consenting to
the disclosure of records shall be informed of their right subject to (j) below
to inspect the material to be disclosed.
5. Information disclosed shall be limited to
information generated at the provider agency. However, the agency shall list
the sources of nondisclosed information contained in the consumer's
records.
(i) Consent to
disclosure of records shall be evidenced by a signed authorization from the
consumer or his or her legally authorized representative.
1. The authorization shall contain the
following:
i. The name of the agency
disclosing the information;
ii. The
name or title of the person or organization to which disclosure is to be
made;
iii. The name of the
consumer;
iv. The purpose of the
disclosure and predictable outcome;
v. The information to be disclosed;
vi. The date on which the authorization is
signed; and
vii. The signature of
the consumer or of a person authorized by law to sign for the consumer,
following a statement that the undersigned understands the nature of the
authorization and has been informed that he or she has the right to revoke
consent at any time by written communication to the custodian of the
records.
2. Unless the
time limit of, or the event that will trigger, expiration has been determined
with the consumer and noted on the release form, consumer permission to release
information automatically expires four months from the date the authorization
is signed by the consumer.
(j) Consumer access to records:
1. In case of Family Therapy, if the records
for all participants have been integrated, no single family member shall have
access to those records unless all adult participants and the guardians of any
minor participants agree through a signed authorization form.
2. A consumer currently receiving services
from an agency is entitled to inspect and/or receive a copy of his or her own
clinical records unless the consumer's treating clinician certifies to the
Director of the agency that such disclosure would be seriously harmful to the
consumer's treatment or health. A denial of access to records shall be limited
only to the extent necessary to protect the consumer. Denial shall be
accompanied by a verbal explanation to the consumer. Denial shall be documented
in the consumer's records, as to the clinical data, findings, etc., that led to
the denial of access.
3. A consumer
is entitled to inspect or receive a copy of his or her financial
records.
4. A consumer who formerly
received services from an agency is entitled to inspect and/or receive a copy
of his or her records. However, if a particular consumer has been inactive for
brief periods of time in the past and repeatedly requests and obtains service
re-admission, the same criteria for access to records outlined in (j)2 above
shall apply.
(k)
Modification of records:
1. A consumer may
submit in writing to the Director of the agency a statement for the purpose of
clarifying or correcting his or her clinical record. Such a statement shall
become part of the consumer's clinical records.
2. A consumer may request in writing to the
Director of the agency an amendment or clarification of a clinical record and,
not later than 30 days after the date of receipt of such request, the agency
shall acknowledge in writing such request and, within 10 days thereafter:
i. Make each correction, in accordance with
the consumer's request, of any or all portions of a record which the consumer
believes is not accurate or complete; or
ii. Inform the consumer of its refusal to
amend the record or portions thereof, in accordance with such consumer's
request; the reason for the refusal should be explained to the consumer and
documented in the consumer's record.
(l) At the time that a
formal consumer record is going to be initiated for ongoing service purposes,
each consumer shall receive notice:
1. Of the
specific conditions under which information may be disclosed without his or her
authorization;
2. That he or she
may request access to his or her records;
3. That he or she may supplement or request a
modification of his or her clinical records; and
4. Of the name of the agency's privacy
officer and the avenues for redress of any complaints the consumer may have
that his or her privacy was violated.
(m) Agency records directly or indirectly
identifying a consumer shall be retained for six years.
