CHAPTER 2 -- CASE RECORDS
CHAPTER 2
CASE RECORDS
CASE RECORDS 2
A. Purpose 2
B. Policy 2
Public Disclosure Process 3
A. What is a Public Disclosure Request? 3
B. When You First Receive a Public Disclosure Request 3
C. Responding To A Request 3
D. Determining Whether the Information is Releasable 4
E. Tracking Your Public Disclosure Time 4
F. Notifying Third Parties 5
G. Preparing the Response 5
H. Charging for Copies 6
I. Notifying Requestors of Appeals 7
Obtaining CONSENT to Share Confidential Information (DSHS 14-012) 8
CASE FILE Standards 9
A. Retention 9
B. Original Signatures and Faxes 9
C. Organization of Files 9
Case transFER Guidelines 11
A. Transferring a Case 11
B. Returning a Case 12
C. Tracking Returned Cases 12
Appendix a: Public Disclosure Contacts 14
A. HCS Public Disclosure Coordinators 14
B. DDD Coordinators 15
Appendix B: Situations When Release is Required 16
APPENDIX C: Letter Samples 19
A. FIVE-DAY LETTER SAMPLES 19
B. DENIAL EXAMPLE 21
Attachment
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CASE RECORDS
A. Purpose
The purpose of this chapter is to ensure:
· Confidentiality of record contents;
· Compliance with public records disclosure laws;
· Statewide consistency in the information transferred between Aging and Disability Services Administration (ADSA), Home and Community Services (HCS) Division, and the Area Agencies on Aging (AAA) case management agencies;
· File content remains intact during transfers in order to comply with federal regulations pertaining to Medicaid clients;
· The continuity of information to perform case management duties; and
· Promote understanding and use of proper forms for Client Consent and Authorization.
B. Policy
RCW 42.17.310[1] / Certain Personal and Other Records ExemptRCW Chapter 70.02 / Medical Records-Health Care Information Access and Disclosure
RCW 70.24.105 / Disclosure of Antibody Test or Testing or Treatment of Sexually Transmitted Diseases-Exchange of Medical Information.
RCW 74. 04.060 / Records, Confidential-Exceptions-Penalty
RCW Chapter 74.34 / Abuse of Vulnerable Adults
WAC Chapter 388-01 / DSHS Organization/Disclosure of Public Records
Administrative Policy 6.09 / HIV/Acquired Immune Deficiency Syndrome
Administrative Policy 5.02 / Public Disclosure of Department Records
Administrative Policy 5.01 / Safeguarding Personally Identifiable Information
Public Disclosure Process
A. What is a Public Disclosure Request?
A request for a public (DSHS) record may include documents, audio and video recordings, pictures, e-mail, computer disks and electronic data.
NOTE: Chapter 6 provides information on APS public disclosure issues such as procedures related to disclosure and release of APS investigative information and APS-related information contained in the HCS/AAA Case file.
B. When You First Receive a Public Disclosure Request
If you are NOT a public disclosure coordinator, you should:
1. IMMEDIATELY refer all requests for information to the public disclosure coordinator for review (Please refer to Appendix A: HCS Public Disclosure Coordinators).
2. Make this referral either the same day as the request comes in or the next possible day. DO NOT DELAY!
3. Keep accurate notes including the date, the name of the person requesting the information, the address or a way to contact him/her (phone, email, etc.), and a specific list of information that he/she is requesting.
4. Remember that people can request information over the phone, via email, in writing, etc. Requests do not have to be in writing, as described in WAC 388-01-060.
C. Responding To A Request
When the Public Disclosure Coordinator receives the request, he/she will:
1. Keep accurate notes including the date, the name of the person requesting the information, their address and a phone number you can reach them at, and the specific information that he/she is requesting.
2. Compose and send a letter within 5 days. To count five days remember the following:
o The day the request comes into the agency is “Day Zero.”
o The 5-day letter is due (postmarked) by the close of business on “Day Five.”
o Don’t count weekends or holidays. Count business days only.
3. The “five-day letter” must do one of three things:
o Fill the request;
o Deny the request and explain why, citing the statute or legal basis; or
o Request additional time to gather information to fill the request. “Additional time,” is generally a maximum of thirty business days to ensure that there is enough time to process the request. Use the maximum thirty days[2] especially if you have a request that is agency-wide or is high profile.
4. The “five-day letter” must include the following:
o The date of the request;
o Any changes to the request;
o Copy and cost information (if you know it);
o Your contact name and phone number/email address;
o If you are denying or redacting, give the reason, a citation and appeal information; or
o If you need more time, tell how long it will take, give the reason, and cite RCW 42.17.320. You can take more time to fill a request based on a need to:
- Clarify the intent of the request;
- Locate and assemble the information requested;
- Notify third person or agencies affected by the request; or
- Determine whether any of the information requested is exempt.
D. Determining Whether the Information is Releasable
The Public Disclosure Coordinator will then:
1. Determine if the information is releasable by looking at WAC and RCW. Check if the information requested requires an authorization (release) or other administrative procedure such as a court order to obtain. (See Appendix B, Authorizations.)
2. Contact the requestor if you need to further clarify the request.
3. Contact your HCS headquarters coordinator anytime you have:
o A question regarding a request;
o A request that appears to affect other administrations;
o Reason to suspect that this request may be high profile and/or a potential media request.
E. Tracking Your Public Disclosure Time
Public Disclosure Coordinators must track all time (and related information) spent on public disclosure using the Public Disclosure Log. As indicated on the instructions, send this log to the HQ Public Disclosure Coordinator quarterly.
Headquarters PDC staff are also logging time into a spreadsheet designed and used across ADSA. This information helps DSHS to understand how much time is spent on public disclosure.
RCW 42.17.330
WAC 388-01-140
F. Notifying Third Parties
The Public Disclosure Coordinator will:
1. Determine if within the request there are names of third party people such as witnesses, employees, or other organizations, contact them and give them time to block the release of their information.
2. Include information in the notice that states:
o The record(s) being requested;
o The date you intend to release the record; and
o How the individual or organization can prevent release of the record (see RCW 42.17.330) and the deadline to take that action.
3. Send a written notice to the requestor informing him/her that:
o The individual or organization whose personal information is contained in the requested public record has been notified;
o You expect a response from the individual or organization regarding disclosure of their personal information by a specified date; and
o Disclosure may be denied.
4. Release the record if no one objects or the party does not respond by the specified date. If the third party does object to the information being released, they can prevent release of the record by petitioning the court for protection of the record. If you need to allow more time for someone to get a court order or for some other reason, inform the requestor of the revised date.
The superior court for the county in which the person named in the record resides, or in which the record is maintained, may grant protection of the record if the court agrees that such examination would clearly:
o Not be in the public interest and would substantially and irreparably damage any person; or
o Would substantially and irreparably damage vital government functions.
G. Preparing the Response
1. Gather releasable information and make 2 copies.
2. Make sure all original files stay in their original office.
3. Redact one copy of the records (See redaction section).
4. Make a copy of the redacted records.
5. Make sure that you cannot see redacted information through the copy and send a bill for copies (see copies section below) and postage to the requestor. Call the requestor and ask them if they would like to avoid the postage charge by picking up the package at your office.
6. When you receive the check in the appropriate amount from the requestor, send them the package.
7. Keep one clean copy and one redacted copy for your files. Currently the retention period for public disclosure files is one year from the response or final action.
8. Cc any collateral contacts and inform them that the information has been sent out. You do not need to send them the entire packet of information. Send only a copy of the cover letter. Collateral contacts may include your co-worker(s) that were involved in the request, third parties that did not attempt to block the release of their information, your supervisor, etc.
RCW 42.17.300
WAC 388-01-080
13
Revised 12/04
CHAPTER 2 -- CASE RECORDS—CONFIDENTIALITY, DISCLOSURE, AND TRANSFER
H. Charging for Copies
According to RCW 42.17.300 and WAC 388-01-080(2), DSHS may charge fifteen cents per page for normal photocopies plus postage. Typically, cost of processing and accounting for a check is $10.00. Collect any copy charge above $10.00. If requestors come in to view the record, they may avoid charges. Only charge requestors for actual copies made. If the requestor prefers to view the record, it still must be processed per normal public disclosure procedure (e.g. you must still make copies and redact exempt information).
When mailing a record, charge the requestor postage. Call the requestor in advance and ask them if they would like to avoid paying the charge for postage by picking up the package.
Checks for public disclosure should be made payable to DSHS (with a note: “For public disclosure costs”) and sent to:
DSHS/ADSA
Attn: Deb Cherry
PO Box 45600
Olympia, WA 98504-5600
The requestor may send the check directly or they can submit it to the public disclosure coordinator and the coordinator can forward it to the address above. Be sure to include the note on or with the check informing Deb Cherry that the check is for PUBLIC DISCLOSURE.
I. Notifying Requestors of Appeals
If you deny any part of the record requested or redact any information, you need to inform the requestor of the right to appeal the denial. Under WAC 388-01-130(1), requestors may request an internal review within DSHS.
If you receive an appeal (a petition for review), forward it immediately to your headquarters public disclosure coordinator for processing. The response time for appeals is only two business days.
Requestors may also seek review from the Office of the Attorney General or may appeal a denial in court. Contact your coordinator if you have additional questions related to the appeals process.
Obtaining CONSENT to Share Confidential Information (DSHS 14-012)
You are required to obtain consent prior to sharing confidential information about a client. Use form DSHS 14-012 to document this consent.
The client or representative (e.g. DPOA or guardian)[3] may sign this form. The instructions on the consent form (DSHS 14-012) under the signatures portion of the instructions explain who can sign the consent form. In those cases where the client understands, but can only make a mark in the signature box, a mark is sufficient. In these cases, a witness should sign and then make a note about the client's inability to properly sign and the reason.
You must use this form in order to obtain, use, or share confidential information about a client for the purpose of providing services to the client. If you need to list multiple providers on the consent form and cannot fit all the information in the blanks provided, you may mark the box, “See attached list,” and attach a list to the consent form to accommodate all information.
Potential Providers-
When looking for the appropriate provider for a client, only list the provider’s name and address if known. If you do not know the names and addresses of the providers you will be seeking out, in the blank space provided state, “Searching for appropriate provider”. This will allow you to research multiple providers for a client in order to locate the one that best fits the client’s needs.
CASE FILE Standards
This section outlines standards for retaining files, obtaining original documents/signatures, and organizing files.
A. Retention
1. The active file contains material two years old or less. The most current Acknowledgement of Services Form (14-225) and all legal documents must remain in the active file even if it is over two years old. All client files must be maintained for three years.
2. Inactive files contain material over two years old.
o Retain the file on local office’s shelves until the old volume is one inch or more in width (Support staff: See Manual E for splitting records). Send the volume to a retention center per record retention procedures.[4]
o If material in an older, multi-volumed file is needed, request this material from the retention center according to retention center procedures.
B. Original Signatures and Faxes
Certain forms require that the original signatures and the original document be filed in the case record. Examples of this are the (DSHS 14-225) Acknowledgement of Services and the (DSHS 16-172), Rights and Responsibilities form. Typically, you can obtain these signatures during the face-to-face contact with the client.
On occasion, a document must be faxed. Fax transmissions are acceptable as long as the original document is accounted for properly. Although more widely used, faxing is not a substitute for properly forwarding and filing the original document. Some source documents (containing original signatures) may be maintained by different entities or organizations. If this is the case, include a note in the file of where the original is maintained.
C. Organization of Files
Use four loose sections bound by brads in the organizational structure outlined below. Individual AAAs may choose to organize their files differently as long as written policy outlines the organization of files and it is consistent with HCS organization when transferred.