How The Information In Your Record Is Utilized
The laws of California and the standards of our profession require that psychotherapists keep treatment records. The information in your medical record is utilized in a number of ways. Your therapist may use it to plan your treatment and keep a record of the significant issues that are addressed in your treatment. We also use the information to coordinate your treatment with other professionals or to provide information to significant others or family members. In order to release any information to another party, we will ask that you sign an Authorization to Release Information. You may revoke your Authorization at any time.
Information in your medical record may also be required by your insurance company or health plan so that the treatment you receive from us can be paid for. You can read more about how insurance companies may use your information under Insurance Reimbursement.
For patients under eighteen years of age, please be aware that the law provides parents the right to examine treatment records. It is our policy to request an agreement from parents that they agree to give up access to minor patient’s records. If they agree, we will provide them only with general information about the treatment, unless we feel there is a high risk that the minor patient is facing serious jeopardy or harm. In that case, we will notify parents of our concern. We will also provide them with a summary of your treatment when it is complete. Before giving parents any information, we will discuss the matter with the minor patient, if possible, and do our best to handle any objections the minor patient may have with what we are prepared to discuss.
In general, the privacy of all communications between a patient and a psychologist is protected by law, and we can only release information about our work to others with your written permission.
Exceptions To Your Confidentiality
There are some exceptions to your protections, and in general, we will provide information from your record when required to do so by local, state or federal law. In most legal proceedings, you have the right to prevent your therapist from providing any information about your treatment. In some proceedings involving child custody and those in which your emotional condition is an important issue, a judge may order your therapist’s testimony if he or she determines that the issues demand it.
There are some situations in which we are legally obligated to take action to protect others from harm, even if we have to reveal some information about a patient’s treatment. For example, if we believe that a child, a person over age 65, or a disabled person is being abused or mistreated, we may be required to file a report with the appropriate state agency.
If we believe that a patient poses a serious risk to someone, we are required to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the patient. If the patient threatens to harm him or herself, we may be obligated to seek hospitalization for him or her or to contact family members or others who can help provide protection.
We may occasionally find it helpful to consult other professionals about a case. During a consultation, we make every effort to avoid revealing the identity of our patients. The consultant is also legally bound to keep the information confidential.
If a situation occurs that requires that we share information without your written permission, we will make every effort to fully discuss it with you before taking any action.