1. Maintain the patientâ??s privacy and confidentiality.

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  • In general, maintain confidentiality unless the patient gives consent to a specific communication.

  • Under specific clinical circumstances, confidentiality may be attenuated to address the safety of the patient and others.

  • According to the Health Insurance Portability and Accountability Act (HIPAA), information from medical records may be released without a specific consent form for purposes of "treatment, payment, and health care operations." Otherwise, patients must sign an authorization form.

  • When releasing information to third-party payers (e.g., for utilization review or preauthorization decision), it may be important to request specific rather than blanket consent from the patient.

  • Psychotherapy notes have special protection under HIPAA.

  • Release of information about individuals evaluated or treated for substance use disorders is governed by the provisions of 42 CFR §2.11


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