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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