Policy: Confidentiality and Release of PHI Policy Number:  7.3 

Section: Client Rights

Reviewed Date: 3/6/20

Effective Date: 3/9/20

Revised Date:   11/18/19


The purpose of this policy is to establish procedures for accessing client records while maintaining the confidentiality at Discovery Institute. It also governs the external release of confidential information.  (42 CFR Part 2) (IM.02.01.01) (10:161A -3.6.5, 10:161A-17.2)


It is the policy of Discovery Institute to adhere to all federal and state guidelines regarding client confidentiality. Discovery Institute is mandated to follow the procedures outlined by the Health Insurance Portability and Accountability Act of 1996 and Federal Regulation, 42 C.F.R. Part 2, which protects client identifying information. 


Protected Health Information (PHI)

All information contained in the client’s record that is individually identifiable health information is protected health information (PHI). PHI includes but is not limited to:

  • Name
  • Address
  • Birthdate
  • Social Security Number
  • Contact Information
  • Information about an individual’s physical or mental health
  • Treatment services provided to the individual 
  • Billing records
  • Claim information
  • Referral authorization 
  • Research records
  • Explanation of benefits forms
  • Any other information that connects the individual to treatment at Discovery Institute. 

Client Consent

Upon admission, clients will be able to complete a Release of Information consent form which will dictate how the client authorizes Discovery Institute to release specific information from their clinical record. All consents and Releases of Information will be located in the client’s record. 

To obtain a client’s consent, the following conditions must be met:

  • The client is informed in a manner to assure his/her understanding of the specific types of information that has been requested, and the benefits and disadvantages of releasing the information. 
  • The client gives consent freely and voluntarily, also not under the influence of any illicit substance.
  • The client is informed that treatment services are not contingent upon the client’s decision concerning the release of information. 

42 CFR Part 2 establishes the following requirements for authorizations to disclose individually identifiable patient health information:

  1. The specific name or general designation of the program or person permitted to make the disclosure
  2. The name or title of the individual or the name of the organization to which disclosure is to be made
  3. Client name
  4. Purpose of disclosure 
  5. How much and what kind of information is to be disclosed
  6. The signature of client or legal representative 
  7. The date on which the release is signed
  8. A statement that the release is subject to revocation at any time 
  9. The date, event, or condition upon which the release will expire if not revoked.
  10. The death of the patient in which case information my legal given to, or with the permission of the estate executor. 

The purpose of a release should never be as broad as “for all client care”. Blanket releases will not be accepted. 

Subpoenas will not be honored for release of any client records. Court orders permit release of records after the court has made the finding that a “good cause” exists. All court orders must be signed by a judge or they will not be accepted. 

Reviewed for Medical & Clinical Accuracy by The Digital Intellect