Your rights are to be exercised without regard to sex, sexual orientation, cultural or ethnic group identification, color, economic, educational, or religious background, age, disability, or the source of payment for your care.

You shall be advised of, and given, a copy of your rights at admission.

You shall receive considerate and respectful care, and will be accorded dignity in personal relationships with staff and other persons.

You are to be accorded safe, healthful, and comfortable accommodations to meet your needs.

In our healthcare facilities (chemical dependency recovery hospitals and residential facilities), you have the right to facilitate your own healthcare decisions, accept or refuse medical treatment, and make an advance health care directive.  You will be informed of these rights upon admission.

You shall be told the name of the physician, nurse, and counselor with overall responsibility for your care.   

You have the right to express your preference regarding your counselor.  The Kiloby Center for Recovery will address your preferences as clinically appropriate and as staffing patterns allow.

You will be given information in sufficient time so you may actively participate in decisions regarding your treatment.  You will be informed of any special treatment interventions and their purpose.  To the extent provided by law, you have the right to refuse treatment, concurrent services, or involvement in research projects.

You shall be provided with confidentiality in accordance with federal regulations (42 CFR part 2, sections 2.1 through 2.67.1 and 45 CFR parts 160 and 164). Detailed information about the release of information is in the Privacy Notice provided to you at admission.  This includes your right to and procedures for access to your file.

You are to be informed by the attending physician or his/her delegate of your continuing health care requirements following discharge from a chemical dependency recovery hospital.

You have the right to examine and receive an explanation of your bill, regardless of the source of payment.

You shall know which program rules and policies apply to your conduct.

You may have all “Your Rights” apply to the person who may have a legal responsibility to make decisions regarding your care on your behalf.

You have the right not to be intellectually, emotionally, physically, or sexually abused by staff.

You have the right to services free of psychological abuse, including humiliating, threatening, or exploiting actions, neglect or retaliation.

You have the right to receive services free of fiduciary abuse.

You shall be free to attend religious services or activities of your choice and to have visits from a spiritual advisor if these services or activities do not conflict with your program requirements.  Participation in religious services will be voluntary only.

You are to receive reasonable responses to any reasonable request made for services.

You may leave treatment, even against the advice of the attending physician or staff.

You have the right to reasonable continuity of care, to know in advance the time and location of appointments, and the name of the person providing care.

You will be provided a referral to legal services to meet your needs.

You have the right to be informed by the Center of the procedures to file in case of grievance or to appeal discharge.  You may also contact:

Department of Health Care Services
Licensing and Certification Branch, MS 2600
PO Box 997413 MS 2600
Sacramento, CA 95899-7413
Attn: Complaint Coordinator
916-324-4505
Fax: 916-322-2658
TDD: 916-445-1942

Confidentiality of Client Records

It is the policy of The Kiloby Center for Recovery to assure that the information in the clients’ health records and any information pertaining to the identity of a client, the client’s diagnosis, prognosis, treatment, and condition are treated as confidential and disclosed only to authorized persons as stipulated by 42 Code of Federal Regulations, Part 2 governing the alcohol and drug abuse treatment records.  The Kiloby Center for Recovery client records is also protected under standards for privacy of individually identifiable health information 45 Code of Federal Regulations Parts 160-164 (also referred to as HIPAA).  When there is a conflict between the regulations, the most restrictive will be applied. 

It is the policy of The Kiloby Center for Recovery to assure that each client’s right to confidentiality is maintained in compliance with all applicable statutes and regulations that govern the disclosure of this information. 

The Center shall use health information only for purposes permitted by law and regulation or as further limited by its policy on privacy and shall disclose health information only as authorized by the individual served or as otherwise consistent with law and regulation.  

 

Guidelines 

All client records shall be kept in locked file cabinets when not in use by staff.  Staff shall return all client files to the secure and locked storage area before leaving work each day.  All records shall be kept in the office and the office shall remain locked when staff members are absent from the office.   

Clients’ health records are the property of The Kiloby Center for Recovery and shall not be removed from the facility for any other reason than in compliance with a court order or for storage at the corporate office. 

Only a client or his or her authorized representative may authorize the release of information by providing a valid written authorization to the facility. 

For each disclosure of information, the date the information was released and the signature of the staff member who released the information shall be recorded on the Record of Information Released and be part of the client record. 

Staff members and other persons having access to client records or client identifiable information shall be required to abide by the written policies regarding confidentiality of alcohol and drug treatment client records and disclosure of information in the records, as well as federal, state, and local laws, rules, and regulations. 

Confidentiality policy and procedure shall be reviewed with the employee and documented as part of the Director’s New Employee Orientation and reviewed with employees annually.  In addition, all employees must attend confidentiality training during the first year of employment.   

When using electronic client health records or databases, a password shall be used.  Staff shall log off the program when stepping away from their computer. 

All clients receiving alcohol and/or drug services must receive a Notice to the Client that summarizes 42 Code of Federal Regulations, Confidentiality of Alcohol and Drug Abuse Records, and a privacy notice as required by 45 CFR Parts 160-164 (HIPAA). These forms are provided as part of the intake appointment. 

The regulations governing the release of information apply to all information or records of a client’s identity, presence in the program, diagnosis, prognosis, and treatment received. 

Any disclosure of information must be limited to information necessary in light of the need or purpose of the disclosure, whether the disclosure is made with or without client authorization. 

Any improper or unauthorized request for disclosure of information must be met with a non-committal response.   Disclosure of information (verbal or written) will be documented on the “Record of Information Released” form filed in the client’s record. 

Information may not be released on a subpoena alone.  The subpoena must be accompanied by an authorizing court order.  (See procedure on Subpoenas). 

Information may not be released to initiate or substantiate any criminal charges against a client or to conduct any criminal investigation of a client for a minor crime. 

Whenever records are copied, all pages of the copy will be stamped in red ink with a statement indicating the information is confidential and protected by federal and state regulations against re-disclosure.   

Consent for release of information must contain a statement that the client understands the information being released may contain psychiatric, drug, and/or alcohol abuse information. 

No individual other than those connected with the client care or The Kiloby Center for Recovery quality assurance and utilization management activities may review records, except as approved by the Director, Assistant Director or Clinical Supervisor.   

 

Consent for Disclosure- Special Situations 

Minors 

In California adolescents, 12 years and older may consent to alcohol and other drug treatment without parental consent.  Adolescents must also consent to the release of their own confidential treatment information.  This applies to the release of the information to the parent or guardian. 

Information may be shared with a parent without the minor’s consent only if all three of the following conditions are met: 

 The minor’s situation poses a substantial threat to the life or physical well being of the minor or another 

 The threat may be reduced by communicating with the parent or guardian, and 

 The minor lacks the capacity because of extreme youth or mental or physical condition to make a rational decision to disclose to the parents. 

 

Incompetent or Deceased Clients 

Where consent is required for disclosure, in the case of a client who has been adjudicated as lacking the capacity to manage his own affairs for any reason other than insufficient age, may be given by the guardian or other person authorized under state law to act in the client’s behalf. 

If the client is deceased, consent to disclosure can be given by an executor, administrator (appointed by a court), or other personal representatives, by the spouse, if no representative has been appointed, or any responsible family member if there is neither spouse nor representative.  Refer any requests that fall into this category to the Medical Records Manager for verification of authenticity. 

In the case of a deceased client, disclosures required under federal or state law involving collection of death and other vital statistics may be made without consent. 

 

HIV Status 

No information regarding HIV status, whether positive or negative nor any information regarding AIDS may be released without the specific written authorization of the client.  This requirement is in addition to all requirements regarding the release of alcohol and/or drug abuse records.   

California State regulations are explicit about the confidentiality and special authorizations required to release HIV antibody test results.  However, these special protections do not extend to a diagnosis of AIDS or AIDS-related diseases.  A diagnosis of AIDS is protected as the Confidentiality of Medical Information Act protects all medical information.   

It is the policy of The Kiloby Center for Recovery to uphold the special confidentiality requirements given to HIV antibody test results under California State law in order to protect the privacy and rights to confidentiality of our clients.  Confidentiality protections extend to HIV antibody test results regardless of whether the result is positive or negative. 

Confidentiality protections also apply to verbal disclosure of HIV antibody test results as well as the actual copy of the test result. 

It is the policy of The Kiloby Center for Recovery to protect the privacy and right to the confidentiality of clients with a diagnosis of AIDS.  The Kiloby Center for Recovery requires that any authorization to release client identifiable information that includes a diagnosis of AIDS will specifically state that AIDS diagnostic information may be released. 

The Kiloby Center for Recovery does not conduct HIV testing.  Therefore, any HIV test results in a client file have been obtained from another source and are not to be re-released. 

As with the release of confidential substance abuse and mental health information, the release of AIDS diagnosis requires authorization that specifically consents to the release of such information.  Appropriate The Kiloby Center for Recovery Authorization to Release Confidential Information forms contain this language. 

Improper disclosure carries the following civil penalties: 

 If due to negligence, a civil penalty may be imposed of not more than $1,000 plus court costs. 

 If due to a willful act, a civil penalty may be imposed of not less than $1,000 and not more than $5,000, plus court costs. 

 If improper disclosure results in economic, bodily, or psychological harm to the client, this may be considered a misdemeanor, and the individual who made the improper disclosure may be fined up to $10,000 or imprisoned for up to one year and may be liable to the client for all actual damages caused by the improper disclosure. 

 

Releasing Confidential Client Information 

The Kiloby Center for Recovery releases confidential client information when requested by the client and when it is necessary to release such information to provide services to the client. Valid written requests for the release of information will be honored within 5 working days of receiving the request. 

 

Information to be Released 

When releasing client information, the information released is limited to the minimum necessary.   When a Discharge Summary is requested, the following will be released: The Face Sheet and Discharge Summary. 

When a History and Physical exam is requested, the following will be released: The Face Sheet and History and Physical Exam, and the Nursing Assessment. 

When Departments of Public Social Services (i.e. SSI, Disability), Children and Family Services, etc. request records we send the Face Sheet, History and Physical, Discharge Summary and Laboratory reports.  The agency will notify us if more information will be required. 

When records are subpoenaed or court-ordered to be released, all requested information except HIV information will be released.  HIV information will only be released if requested in writing by the client. 

 

Charges for Making Records Available 

Attorneys may be charged $.10/page, $4.00/quarter-hour for clerical costs, any off-site retrieval costs, postage, and other reasonable costs.  Copies are provided to Public Defenders without charge. 

All other requesters will be charged $.25/page, $4.00/quarter-hour for clerical costs, any off-site retrieval costs, postage, and other reasonable costs.  Exceptions will be continuing care, referral agencies, and others as appropriate. 

 

Record Required 

Whenever a disclosure is made, an entry is to be made on the Record of Information Released form showing the client’s name or case number, the date and time the disclosure was made, the nature of the emergency, the information disclosed, and the names of the individuals by whom and to whom it was disclosed,. The Record of Information Released shall be placed in the client’s file.  

 

Release of Information with Client Written Authorization 

Client information may be released with the written authorization of the client.  Examples of when information is usually released are: 

The following may have client identifiable information with appropriate written authorization: 

 Medical personnel or treatment or rehabilitation programs when necessary to better enable them to furnish services to the client. 

 Third-party payers or funding sources may receive the information necessary to discharge the legal or contractual obligations for payment of services. 

 Criminal justice personnel when the client was referred to the program as a provision or probation or parole.  A client whose release from confinement, probation, or parole is conditional upon his or her participation in an agency program may not revoke a consent given by him or her as outlined above until there has been a formal and effective termination or revocation of such release from confinement, probation, or parole. 

 Clients may have access to their own records under California Health and Safety Code section 123100 et seq. and 45 CFR Parts 160-164 (HIPAA). 

 

Completing the Authorization Form 

Staff will assist clients with Release of Information forms.  Staff will explain the client’s rights to confidentiality.  Staff will assure that the form is complete and accurate. 

The written authorization for the release of information must contain all of the following information.  Do not leave blank or incomplete lines on the authorization form or it may be invalid: 

 Program Name: This is included on most of the forms.  If it needs to be completed, enter the name of the program releasing the information, NOT the name of a particular individual.  Include the Program’s address. 

 Client’s name 

 The first and last name of person or name of the organization to which disclosure is to be made 

 Nature of the information to be released (drug and/or alcohol abuse treatment, etc.) 

 Purpose or need for the disclosure 

 Type of information to be release 

 A statement that the consent can be revoked, but not retroactively (i.e.: after the information has already been released) except for criminal justice referrals 

 The specific date, event, or condition upon which the consent will expire unless revoked earlier 

 The date that the consent is signed 

 Signature of the client or authorized individual 

 Signature of The Kiloby Center for Recovery staff/witness 

 

The Kiloby Center for Recovery has developed the following Authorization to Release Information forms to assist in completing the required information: 

General Release by The Kiloby Center for Recovery

Release to Family, Friends, Other 

Criminal Justice Referral 

Financial Reimbursements 

Department of Children and Family Services/Child Custody 

Substance Abuse and Crime Prevention Act (Prop 36) 

 

Release of Information over the Telephone 

Do not release information over the telephone unless you are absolutely sure of the identity of the caller and that the disclosure is authorized. 

Client information may be released over the telephone only under the following circumstances: 

 The identity of the caller is verified by returning the call and checking the source of the call; and 

 The caller has appropriate authorization on file in the client’s record to obtain the requested information or may by law have access to the information without client consent as stipulated elsewhere in this policy. 

 In the event of a medical emergency, i.e. the client is in an Emergency Room. 

Verify request to release information by checking for a signed release form authorizing the disclosure. 

 

If the request is not authorized, decline disclosure of any information, including the client’s presence in the program now or at any other time in the past with a non-committal response (i.e.  “I am sorry the records of this program are protected by federal regulations which restrict their disclosure”).  Do NOT mention that the records of an identified client are protected, but that the records of the entire program are protected. 

If the individual has never been a client, this information is not restricted. 

If the request is authorized, verify the identity of the caller or return the call and release only specifically authorized information. 

Complete the Record of Information released in the client chart.  

 

Procedures for Releasing Information 

Log the request in the Correspondence Log. 

Verify that client authorization is valid and complete  

If a valid authorization is not included with the written request, check the client’s record for a valid consent signed during the client’s stay. 

If the release of information is not authorized, is not valid, or there is no record of the individual has been a client then send the “Response to Request for Confidential Information” with the appropriate item(s) checked to the requesting party. 

If the release of information is authorized, then: 

 Copy requested information only or the Face Sheet, Discharge Summary, History, and Physical if specific information is not identified. 

 Stamp all pages of the copies with the “re-disclosure” stamp in red ink. 

 Prepare an invoice charging for copies, if applicable. 

 Mail copies with a copy of written request and invoice. 

 File request for information in client’s record. 

 Complete the Correspondence Log and Record of Information Released form. 

Note on the Record of Information Released the date of the release and the individual releasing the information. 

 

Release of Information without Client Authorization 

The release of client information without written authorization is allowed in the following circumstances: 

 The information does not include client identifying information or identifying numbers. 

 Medical Emergency To report a crime to law enforcement personnel or to seek their assistance when a client commits or threatens to commit a crime on the premises or against staff, visitors or other clients.  To communicate information between or among program personnel who need such information in the course of their duties. 

 To communicate information between a program and a business associate/qualified service organization, such as a laboratory or other professional service, that is needed by the organization to perform its services. 

 To report incidents of suspected child abuse and neglect.  To release information to qualified personnel for the purpose of conducting research, management audits, or program evaluation.  To a court with an appropriate court order.  Refer to the policy on subpoenas. 

 To release information for vital statistics as required by law for deceased clients. 

 

Medical Emergencies 

Disclosure to emergency medical personnel is authorized without the consent of the client when and to the extent necessary to meet a bona fide medical emergency.  Generally, this means staff has called 911.  The only information needed by the medical personnel to provide emergency treatment is to be provided, i.e., information about known medical conditions, medications, etc. 

 

Notification of Family or Others 

When a client is removed from the facility to receive emergency medical treatment, the Director or designee shall notify the client’s emergency contact of the client’s medical status and location.  A general authorization to release information to the emergency contact is to be obtained from all clients at admission. 

 

Photocopy Company Requests 

Guidelines 

Photocopy companies are usually agents of third parties requesting client information. 

Photocopy companies may copy records of chemical dependency clients if they present a valid, written client authorization. 

Photocopy companies may not copy records of chemical dependency clients on the presentation of a subpoena because these records may be released only upon a court order directly to the court unless a valid client authorization is presented with the subpoena. 

A photocopy company may be charged $15.00 for having the record prepared and made available to them for copying. 

A photocopy company may copy records Monday through Friday at a reasonable time agreed to between the photocopying company and the Medical Records Department staff. 

 

Procedure 

Request the photocopying company submit the authorization in advance of copying the records to verify the validity of the authorization. 

If the authorization is not valid, i.e., does not specify alcohol and/or drug abuse records, or the individual was not a client, notify the company according to the steps specified above. 

If the authorization is valid, arrange a day and time with the photocopying company when they may copy the record. 

Prepare the record for copying.  Remove correspondence and nonprogram information.   

Review the record for references to HIV Test Results.  Copy any pages with HIV test results listed and block out the results and replace the copied pages temporarily for copying by the photocopying company.  (Exception:  There is a separate and distinct authorization specifically authorizing the release of HIV Test Results.) 

Obtain the $15.00 fee from the photocopying company prior to the record being copied. 

After the record has been copied, replace any information removed and any original pages containing HIV Test Results; complete the correspondence log and file the record. 

 

Transmission of Medical Records Information 

In most cases, confidential information will be sent by US Mail or by personal delivery.  When the speed of delivery is important, information may be sent by facsimile (Fax).  Because of the difficulty in securing transmissions over the Internet, The Kiloby Center for Recovery will only send confidential client information by email when it has been encrypted or when sent within and between Kiloby Center staff members on a safe and secure Gmail account, or when the client specifically authorizes the email transmission of the information. 

It is the policy of The Kiloby Center for Recovery to use caution in the use of facsimile transmission of client identifying information.  Client health information should be transmitted by fax only when photocopies delivered by mail will not serve.  The goal is to provide information timely and to prevent improper disclosure of client information and protect client confidentiality. 

 

Authorizations 

Written client authorizations to release information are acceptable if transmitted by fax.  The document will be considered an accurate facsimile of an original as long as there is no reason to believe that the original was not genuine.  It is similar to a photocopy of an authorization that has been received by mail or delivered.   

 

Medical Information and Faxing 

The following issues are considered in the transmission of medical information via fax machines:  (a) the information may be intercepted, (b) the information may be misdirected, (c) the information may be received by individuals not authorized to receive or have access to the information.  There is no prohibition against the transmission of confidential client information via fax machines. 

The healthcare information of The Kiloby Center for Recovery is sensitive information since it deals with the care and treatment of mental health and/or chemical dependence.  Therefore, it will be the policy of The Kiloby Center for Recovery to not transmit information via fax machines except under the following circumstances: 

 When information is released under this circumstance, it will be documented in the client’s record on the “Record of Information Released” form and will include the fact that the information was transmitted via fax machine. 

 To The Kiloby Center for Recovery corporate offices who are financially responsible for the program. 

 To other facilities within The Kiloby Center for Recovery to which the client is being referred.   

 To referring agencies when we can assure the receipt of information by the authorized party.  

 

Faxing Documents 

Any faxed information will be accompanied by a cover fax sheet that includes the sending and receiving facilities’ names, addresses, telephone numbers and fax numbers, the authorized receiver’s name, a disclosure statement, verification of receipt statement. 

Verify by telephone the availability of the authorized receiver to receive the information before beginning the transaction.   

Verify that the information was faxed to the correct number by comparing the fax number where the information was to be sent to the receiving fax number specified on the fax machine Transmission Report (if available). 

File the original cover sheet and the Transmission Report provided by the fax machine indicating the information on the transmission including the number of the receiving fax machine. 

 

Receiving Faxed Documents 

Remove faxes immediately. 

Verify all pages received. 

Review cover fax sheet and follow any instructions. 

Notify the authorized receiver that a fax has been received. 

 

Misdirected Faxed Documents 

If a fax transmission fails to reach the recipient, check the internal logging system of the fax machine to obtain the recipient’s fax number.  This is the machine’s Transmission Report form printed after each transmission. 

Fax a request using the incorrect fax number, explain the misdirected information, and ask for the destruction of all documents received from the facility. 

Complete an incident report and forward it to Administration. 

 

 

Warrants:  Arrest or Search 

It is the policy of The Kiloby Center for Recovery not to release clients or client records when presented with a search or arrest warrant that is not accompanied by a court order.  This is in compliance with the Code of Federal Regulations 42 Part 2 Confidentiality of Alcohol and Drug Abuse Client Records. 

 

Definitions 

Search Warrant for Medical Records 

Records of clients receiving services for alcohol and/or drug abuse may not be released pursuant to a search warrant unless accompanied by a court order (42 CFR Part 2 Section 2.61) or with the client’s written consent (42 CFR Part 2 Section 2.33). 

 

Search Warrant or Arrest Warrant for a Client 

The presence of an individual in alcohol and/or drug abuse program may not be revealed pursuant to a search warrant or arrest warrant unless accompanied by a court order or with the client’s written consent.  (42 CFR Part 2 Section 2.13(c)).  The warrant is not a court order for purposes of federal law.  The court order must state that the client is in an alcohol and drug treatment program and that the court is aware of the confidentiality protections and that the need for the client information meets the requirements of the federal law for a serious crime. 

 

Hot Pursuit – Arrest Warrants For a Client 

The program may bring the client to the officers.  The client’s flight may constitute a crime, committed on the program premises by the individual’s presence.  Use caution in making this interpretation.  The client must literally have entered the program being chased by the police. 

Procedure 

When law enforcement personnel present a search warrant for medical records or a search or arrest warrant for a client, they will be notified that to obtain records or clients in this manner is illegal pursuant to federal regulations and any information so obtained will be considered unlawful and possibly subject to damages. 

Attempt to obtain the client’s cooperation and agreement in writing to comply with a search or arrest warrant for the client. 

Notify the Director or in the absence of the Director the Assistant Director, immediately of the presence of a law enforcement official with a search or arrest warrant for a client.   

The Director, or in the absence of the Director the staff person in charge, shall determine the action to be taken should a client refuse to cooperate.  The action shall take into consideration the individual client’s rights of confidentiality, the rights of confidentiality of other clients in the program, and the overall safety of the program. 

Search warrants for medical records are very rare.  Notify the Director or Assistant Director immediately of the presence of a law enforcement official with a search warrant for medical records. 

The individual handling the situation shall complete an incident report describing the situation and the action taken. 

 

Confidential Communications:  Criminal Activity 

Current criminal activity against staff, other clients, or program property may be reported to the police without client authorization. Confidential communications made by a client to a program in the course of diagnosis, treatment, or referral for treatment may not be disclosed unless a court order is obtained and one of the following applies: 

 The disclosure is necessary to protect against an existing threat to life or of serious bodily injury, including circumstances that constitute suspected child abuse and neglect and verbal threats against third parties.  (These restrictions do not apply to the submission of a report of child abuse pursuant to state regulation.) 

 The disclosure is necessary for connection with the investigation or prosecution of an extremely serious crime. 

 The disclosure is in connection with litigation or an administrative proceeding in which the client offers testimony or other evidence pertaining to the content of the confidential communications. 

Information may not be released to initiate or substantiate any criminal charges against a client or to conduct any criminal investigation of a client for a non-serious crime. The client’s disclosure of past crimes is not to be reported. 

 

Redisclosure Statement  

All copies of documents disclosed shall be stamped in red ink with: 

“This information has been disclosed to you from records whose confidentiality is protected by Federal confidentiality rules (42 CFR Part 2 and 45 CFR Parts 160-164).  The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2 and 45 CFR Parts 160-164.  A general authorization for the release of medical of other information is NOT sufficient for this purpose.  The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse client.”   

 

External Reviews 

These rules apply to any examination carried out for the purpose of or an aid to ascertaining the accuracy or adequacy of a program’s financial or other records, of the efficiency or effectiveness of its financial, administrative, or medical management, or its adherence to financial, legal, medical, administrative, or other standards, regardless of whether such examination is called an audit, an evaluation, an inspection, or by any other name.  Persons conducting such reviews shall be advised of the confidentiality regulations and shall agree not to copy or redisclose any information they are privy to. 

 

Record of Information Released 

All clients have a right to receive an accounting of protected health information disclosed by The Kiloby Center for Recovery upon written request.  To comply with such a request, the person releasing the information shall document each disclosure of client information.  The Record of Information Released form, shall be used to record all such releases of information.  Disclosures within The Kiloby Center for Recovery for purposes of treatment, payment and health care operations need not be recorded.   

 

Subpoena Protocol 

It is the policy of The Kiloby Center for Recovery to assure that client health records requested by subpoena are released only with a court order or with written authorization of the client as stipulated by federal law. 

 

Subpoena Protocol Guidelines 

Drug and alcohol abuse records may not be released on a subpoena alone.  Federal law (42 Code of Federal Regulations, Part 2) requires a court order authorizing the release of alcohol or drug abuse records.  Records may be released on a valid authorization.  However, all subpoenas must be checked for validity and the issuing party notified of the status of the subpoena including the need for a court order or written client authorization.   

The California State Attorney General has ruled that the Worker’s Compensation Appeals Board is a “court” and subpoenas from Worker’s Compensation Appeals Board will be considered a subpoena to court. 

No release may be made to, nor ordered by, a notary public, hearing officer, referee, administrative agency (except Worker’s Compensation Appeals Board), or other quasi-judicial body. 

A court order that authorizes but does not direct the release of information must have an accompanying subpoena. 

The subpoena and/or court order must state the client’s name and be addressed to the specific The Kiloby Center for Recovery program. 

All subpoenas for client records should be accepted by the Medical Record Department or the Director.  If the program, agency, or a physician on staff is a party to the subpoena, refer the subpoena server to the Director. 

Civil subpoenas must be personally delivered.  Criminal subpoenas may be delivered by mail or messenger. Subpoenas will not be considered properly served if delivered via FAX machine.    

A Civil subpoena is properly served only if a copy of the subpoena is given to the witness personally and witness fees and mileage are paid in advance if the fees are demanded by the witness. 

The Medical Record Department or the corporate office will prepare and respond to all subpoenas for client records. 

File the subpoena and any correspondence, and court order or authorization to release information with the medical record. 

 

Certificate of Notice 

If the subpoena seeks client identifiable information in a state Civil proceeding before a California court, the client must be served with a Certificate of Notice that his records were subpoenaed and that he can object in court to their release.  This requirement does not apply to: 

 Subpoenas for non-medical records, 

 Federal subpoenas, criminal subpoenas, administrative subpoenas (Workers’ Compensation Appeals Board) or investigative subpoenas from California administrative agencies 

When the party issuing the subpoena is a state or local governmental agency 

 See Proof of Service 

 

Court Order 

An order by a court, signed by a judge, authorizing the disclosure of the information is required to release information without authorization.  To release the information, the court order must also direct the release of the information or be accompanied by a subpoena. 

The program must be notified that a court order was being sought.  A proper court order will state specifically that it is being issued pursuant to the federal confidentiality laws and regulations.  42 CFR Part 2 section 2.56 only permits court orders to be issued for the purpose of investigating or prosecuting a client when the crime is extremely serious.   

 

Proof of Service  

Proof of service of the Certificate of Notification assures that the party issuing the subpoena has given adequate notice to the client of records having been subpoenaed.  Proof of Personal Service of a Certificate of Notice must show service at least 10 days prior to the required production date for records.  Proof of service by mail must show service at least 15 days prior to production date if served in California, 20 days if outside California and 30 days if outside the United States. 

 

Subpoena 

A subpoena is a command to appear at a certain time and place to give testimony or to produce documents upon a certain matter.  A subpoena alone is not sufficient to produce client identifiable medical records containing psychiatric or drug and/or alcohol abuse information.  However, a subpoena cannot be ignored. 

 

Validity of the Subpoena 

Check the validity of the subpoena on all of the following points: 

 Properly served 

 Designates specific The Kiloby Center for Recovery program or the Custodian of Records of the specific program 

 Has a proper affidavit 

 Has a Certification of Notice to the client or Proof of Service (for civil cases only). (This may be sent later when not accompanying a subpoena.). 

 Issued by a court, administrative agency, attorney 

 Signature of issuing party (attorney, clerk of the court, judge); maybe typewritten 

 Specifies the documents sought 

 Includes the time and place for the appearance of the witness or the production of records.  If appearance is required, it is within the legal distance limits. 

 Names the client. 

 Fees are paid (request $15.00 at time of service with an itemized bill to follow, if requested) (Fees will often not be paid when a subpoena is issued on behalf of the government, state or federal, or by a Public Defender) 

 There is an accompanying court order (records may be prepared and taken to court where the judge will issue the order) 

 The appropriate time frames are met. 

 

Response to the Subpoena 

Staff receiving a subpoena should notify medical records or the Kiloby Center for Recovery custodian of records immediately.  Note the time, date, and amount of money received and initial the right upper corner of the subpoena. Medical Records staff or the custodian of records will notify the attorney or other issuing party immediately by telephone and in writing of any areas where the subpoena is defective. 

Directing Release to Non-Court Entity 

Response to subpoena without a court order or authorization to release to an entity other than a court, i.e; Notary Public, attorney, and administrative agency: 

Notify the subpoenaing party immediately and send a letter indicating that the information is protected under the Code of Federal Regulations, Title 42, Section 2.61 and may only be released to a court or with the client’s written authorization.  Include an authorization form with the letter.  

 

Directing Release to Court 

Response to subpoena, without court order or authorization, directing release to court (this includes subpoenas issued by Worker’s Compensation Appeals Board): 

Notify the issuing party that a court order will be needed to release the records and try to have them obtain it.  Otherwise: 

Prepare the record as specified in Preparing Records for Court. 

Prepare the appropriate court order for the production of records, and make a photocopy. 

Take the prepared photocopy of the record, the prepared court order, and the prepared photocopy of the court order to court.  

Notify the Clerk of the Court of your arrival and inform the clerk of your need to appear before the judge in his chambers. 

Explain to the judge the reason he/she needs to review the records and sign a court order for their release if they are necessary. 

Have the court order and the copy completed and signed.  Leave the original order with the court. 

 

Preparing Records for Court 

Check the time for response to the subpoena.  If the time frame is too short, notify the attorney and try to make other arrangements. 

Verify that the appropriate time has elapsed before producing the records for a state civil subpoena that must be accompanied by a Certificate of Notice to Client. 

Check the subpoena for the records desired.  This may include financial records.  Do not include correspondence. 

Pull only records subpoenaed. If the request is too broad or ambiguous, then contact the attorney. 

If the records requested are other than client identifiable medical records, prepare the record as if it is going to court if copies may be delivered. 

Prepare the record as specified for taking original records if original records are required. 

Mail photocopies directly to the judge as stipulated in the court order. 

Do not mail photocopies if: 

The Kiloby Center for Recovery or one of the agency’s programs is a party to the action 

 Personal appearance is required 

Copy only requested information. 

Complete and sign one copy of the Declaration of the Custodian of Records. 

Prepare an itemized Invoice setting forth the reproduction and clerical costs incurred (if reimbursement is possible), if they have not been paid. 

Place the copies of the record, a copy of the subpoena, and the Declaration in an inner sealed envelope with the title and number of the action, name of the witness, and the date of the subpoena on the outside of the envelope. 

Enclose the sealed envelope in an outer sealed envelope and address the envelope to the judge. Mail the records certified mail, return receipt requested. 

 

Personal Court Appearance Requested 

Notify Administration and determine if agency legal representation is needed and if the location is within the legal limits on distance. 

Prepare the records as stipulated in mailing photocopies. 

Notify the Clerk of the Court of your presence and that the records have been demanded pursuant to a subpoena and/ or court order. 

Follow the steps specified in the section on Response to a Subpoena without a Court Order if there is no court order. 

 

Delivery of Original Records 

It is The Kiloby Center for Recovery policy not to deliver original client records.  If original records are requested, contact the Director.  If it is determined that The Kiloby Center for Recovery must provide the original documents, we will 

 Always deliver in person. 

 Prepare a copy to be retained by the facility. 

 Return of Original Records from Court 

 Review the legal file every six months and request, by mail, the release of the records if the case is closed. 

 Pick up the records ready for release at the Exhibit Clerk’s office at the time specified by the Clerk. 

 

Witness Fees 

State Subpoenas 

Civil, Administrative, Investigative Proceedings 

Witness fee = $35.00/day 

Mileage = $.20/mile round trip 

Additional $3.00/day for each full day away from business 

Clerical costs = Reasonable costs 

 

Criminal Proceedings 

No automatic right to fees 

 

Federal Subpoenas 

Civil, Criminal, Administrative, and Investigative Proceedings 

Witness fee = $30.00/day 

Mileage = $.25/mile round trip 

No fees if the party issuing the subpoena is the United States, a Federal agency, or a federal office 

 

Alternative Response Recovery Costs – Mailing 

Mailing of copies when a court order or authorization is received 

$.10 per page for standard copies  

$4.00 per quarter hour for clerical work in preparing records 

Actual postage 

Actual fees paid to third-party for retrieval of stored records 

Any other reasonable costs 

 

Time Allowed for Response 

Time Between Issuance and Production 

Twenty (20) days during pretrial discovery 

Twenty (20) days when taken to a deposition 

Fifteen (15) days in other cases 

 

Time Between Service and Production 

Fifteen (15) days during pretrial discovery 

Fifteen (15) days when taken to a deposition 

 

Between Notice to Client and Date of Service of Subpoena 

Five (5) days when notice personally served 

Ten (10) days when notice mailed to the client in California 

Fifteen (15) days when notice is mailed to client outside of California, but in the United States 

Twenty-five (25) days when notice is mailed to client outside of the United States 

 

Between Notice to Client and Production of Records 

Ten (10) days when notice personally served 

Fifteen (15) days when notice mailed to the client in California 

Twenty (20) days when notice is mailed to client outside of California, but in the United States

Thirty (30) days when notice is mailed to client outside of the United States 

 

Photocopy Company Serving Subpoena 

Records may be released to a photocopy company only with the client’s authorization.  The request should be accompanied by a check for $15.00.  If not, request the fee when scheduling the appointment for copying the record.  Only medical records staff or the Kiloby Center for Recovery custodian of records should arrange for the copying of records.  Other staff receiving a request to copy records should refer the requester to medical records or the custodian of records as appropriate.

SAMPLE 

DATE: 

Re: Subpoena of Records of ________________________________ 

 Case No.:____________________________________________ 

 

Dear Sir/Madame: 

 

We have received a subpoena, which you caused to be issued, for the records of the above-named individual.  Although The Kiloby Center for Recovery may have these records, this subpoena is improper due to the nature of our records. 

This is to advise you that the medical records of this facility contain information protected under Section 2.1 et seq. of Title 42 of the Code of Federal Regulations Part 2 (42 CFR Part 2) relating to special restrictions on the release of information and records of alcohol and/or drug abuse client records.  Under these laws, we are prohibited from releasing information and records pursuant to a subpoena to any entity except a court with a specific court order or with the specific written authorization of the client.  [42 C.F.R., Part 2, section 2.61]. 

Our client records may be released directly to the court having jurisdiction over the case.  

Alternatively, records may be disclosed to any person designated by our clients.  A consent form authorizing disclosure has been enclosed for your convenience.  Upon receipt of the completed written authorization or the submission of a court order and subpoena directly to a court, we will initiate processing of your request as directed. 

Sincerely, 

_______________________________________ 

Medical Record Custodian 

Enclosures 

ORDER FOR PRODUCTION OF DRUG/ALCOHOL ABUSE RECORDS 

SUPERIOR COURT OF THE STATE OF CALIFORNIA 

FOR THE COUNTY OF LOS ANGELES 

 

In the Matter of the Petition of No:  _________________________________ 

___________________________________  

 ORDER RE PRODUCTION OF MEDICAL 

RECORDS OF 

___________________________________  

 ____________________________________ 

 

It appearing to the Court that: 

 

1. A valid subpoena duces tecum served on _______________________, Custodian of Records; and 
2. Said subpoena seeks the medical records of one _______________________________; and 
3. ______________________________ has produced said records for the preliminary review of the court; and 
4. Said records contain information relating to alcohol or drug abuse and, for that reason, may be subject to the confidentiality requirements of 42 CFR Part 2, section 2.1 et seq.; and 
5. Disclosure of the information contained in said records is necessary to the proper adjudication and disposition on the matter now pending before the court; and 
6. Disclosure of the information contained in said records can be effectively limited to the court, parties, and counsel in the case and, as so limited, cause no substantial injury to the client, to the physician-client relationship, and to the treatment services; and 
7. The public interest will best be served by disclosure of said information. 

 

Now, Good Cause Appearing Therefore, It Is Ordered that _____________________________ is directed to deliver said record to this court for use only in these proceedings and the Clerk of the Court shall, upon direction of the Court, seal from public access such of said records as may contain references to alcohol and drug abuse and as may become part of this Court’s records, whether as evidence or otherwise. 

 

 

_______________________________________________ _______________________ 

Judge’s Signature      Date  

 

CLIENT RECORD CONTENT AND DOCUMENTATION 

 

It is the policy of The Kiloby Center for Recovery to assure that each client’s health record contains sufficient detail and is organized in a manner that: 

 A health care provider who participates in the client’s treatment or care will be able to understand the client’s history and provide effective care 

 Provides medico-legal documentation, information for facility planning, education and training 

 Supports quality improvement and peer review activities 

 Complies with facility accreditation and licensure standards, substantiates the care for reimbursement and to meet third party payer requirements  

 

Guidelines – Content 

 

The client record serves a multitude of purposes including primary client care, continuity of client care, quality improvement, and business record documentation. 

 

The client record should not contain irrelevant observations, teaching notes, professional disputes or disagreements, or entries unrelated to the client’s care and treatment. 

 

Administration and the quality improvement and utilization management committees shall approve the content, forms and format of the client record. 

 

In programs that have a Medical Director, the Medical Director or the designated alternate shall be responsible for the preparation of a complete medical record on each client.  In non-medical programs, the Director shall be responsible for client records.   

 

This record shall include where applicable: admitting diagnosis, identification data, chief complaint, present illness, past history, family history, present mental status, physical examination, provisional diagnosis, clinical laboratory reports, consultations, treatment plan, progress notes, final diagnosis, condition on discharge, discharge summary and any other pertinent reports. 

 

All entries in the client’s record shall be dated and authenticated.  Authentication means to establish authorship by written signature. 

 

Responsibility for Client Records 

 

Client records shall be developed at each program by staff providing services.  Upon discharge from the program, the client record shall be completed and transferred to the custodian of records for filing and maintenance.  The custodian of records is responsible for all releases of information, for the filing and maintenance of records of discharged clients, and for the recording and destruction of records, unless such task is delegated to a case manager or other individual. 

 

 

Laboratory Tests 

 

The client record shall contain reports of laboratory tests when performed.  All records of drug tests must be entered into the client record, signed by the Case Manager.   

 

 

Authorizations, Consents and Other Information 

 

The record shall contain all consent forms signed by the client and/or appropriate guardian.  This includes consent for admission, treatment, evaluation, aftercare or research including refusal of medication and treatment, and authorizations for release of information. 

 

Transfer and referral information shall be documented in the client record