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Psychiatric Practice & Managed Care
Published Online: 17 September 2004

What Can You Release?

Under the Health Insurance Portability and Accountability Act (HIPAA), psychotherapy notes that are kept separate from the rest of the patient's medical record are held to a higher level of confidentiality and cannot be released to insurers, including Medicare, without written patient authorization.
Psychotherapy notes are defined by law as not including the following information (which are considered to be part of the patient's medical record):
Medication prescription and monitoring
Counseling session start and stop times
Modalities and frequencies of the treatment furnished
Results of clinical tests
Any summary of the following items:
Diagnosis
Functional status
Treatment plan
Symptoms
Prognosis and progress to date
These bulleted items can be released without a separate written authorization from the patient.

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Published online: 17 September 2004
Published in print: September 17, 2004

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