Section 24. Confidentiality of Client Records
Effective August 31, 2021
(a) A program must have written policies and procedures conforming to applicable state and federal laws that ensure the confidentiality and security of client records. The policies and procedures shall at a minimum:
(1) comply with all federal and state laws, including federal rules pertaining to the confidentiality of alcohol and drug abuse patient records (42 CFR Part 2);
(2) address any conflicts between federal and state law;
(3) address disclosure of information about minor clients and incompetent or deceased clients;
(4) address disclosure of information to the following:
(A) client's family or other contact person designated by the client; third party payers;
(B) legal counsel;
(C) employers;
(D) judicial officer;
(E) probation department;
(F) prosecutor;
(G) addiction treatment services provider; and
(H) community corrections;
(5) address disclosure without client consent including but not limited to the following:
(A) medical emergencies;
(B) research, audit, and evaluation;
(C) legal orders and subpoenas; and
(D) investigation and prosecution of clients for alleged violations, including child abuse and neglect;
(6) address the use of a valid written consent for disclosure of client information and forms used for making disclosure;
(7) address storage and disposal of case records in compliance with Indiana Supreme Court Administrative Rules 6 and7;
(8) identify the person(s) responsible for authorizing disclosure of confidential information;
(9) require documentation in the client record to support all information disclosed; and
(10) address a client’s request to review the client's case record. A client's review of the client's case record shall be recorded in the case record. Any denial of a client's request to review the case record shall be recorded in the case record, together with the reasons for denial of the review. By policy the supervising judge may permit the withholding from the client all or part of the client's record, including if:
(A) withholding is necessary to protect the confidentiality of other sources of information;
(B) it is determined that the information requested may result in harm to the physical or mental health of the client or another person;
(C) the consent was not given freely, voluntarily, and without coercion; or
(D) granting the request will cause substantial harm to the relationship between the client and the program or to the program’s capacity to provide services in general.
(b) A program must have a release of information form to inform each client in writing of the program’s policies and procedures described in subsection (a), and to obtain the client’s consent for the release of confidential information to specified individuals for certain purposes. The form must meet the following requirements:
(1) contain a signature line for the client to indicate that the client understands the rights described in the form;
(2) contain a signature line for a witness; and
(3) any blank lines remaining after the form has been completed must be crossed out or marked “NA” to ensure the forms cannot be altered after being signed by the client.
(c) The program must place the form with the client’s original signature or a facsimile copy of the form in the client’s record.