Ariz. Admin. Code § 6-4-405

Current through Register Vol. 30, No. 45, November 8, 2024

Section R6-4-405 - Confidentiality

A. Definitions.

1. "Client information." Client information, written or otherwise, includes all medical, psychological, social, personal, financial, vocational and evaluative information which Vocational Rehabilitation acquires in the VR process.

2. "Informed consent of client." Informed consent is never presumed. A complete and signed authorization indicates "informed consent" in most cases. An authorization for release of information must include the following:

a. From whom the information is being requested;

b. The recipient of the information and his/her relationship to the client;

c. The type of information being requested;

d. The purpose for which information is being requested;

e. The duration for which client consent is being given;

f. An assurance, signed by the individual requesting the information, that information received will be treated as confidential and will not be used contrary to the expressed intent of the request.

3. "Primary source information." All that information which Vocational Rehabilitation acquired through personal interaction with client and evaluations and reports done at counselor's request and written specifically for VR.

4. "Secondary source information." All that information which Vocational Rehabilitation acquired from other sources but not originally done for or intended for Vocational Rehabilitation use.

5. "Direct administration of a client's rehabilitation program." Sharing information under the following circumstances constitutes sharing information in the direct administration of a rehabilitation program:

a. To assist in the diagnostic process; i.e., sharing existing medical and psychological information with other specialists on an as needed basis;

b. To develop an appropriate program of services; i.e., sharing such information as necessary or appropriate with rehabilitation facilities or other vendors who may become providers of rehabilitation services;

c. To search out and obtain similar benefit resources; i.e., sharing information with any similar benefit resource but only for the express purpose of determining eligibility for such similar benefits;

d. To ensure success of an IWRP (Program of Services); i.e., sharing information on a "need to know" basis with service providers and within the constraints of B.(below) to ensure the success of a Program of Services;

e. To assist the client in finding and obtaining or retaining employment; i.e., sharing such information with the (prospective) employer as is necessary to obtain, retain, or ensure suitable placement;

f. To provide continuity of services; i.e., sharing client information with other state VR personnel or between states as necessary to ensure continuity and consistency in Agency dealings with the individual.

6. "Individualized Written Rehabilitation Program (IWRP)." That part of the individual client case file which contains the program of services and all basic understandings and ensurances including client's consent to release of information in the administration of a rehabilitation program, and an assurance that otherwise client information will be held confidential.

7. "Client's representative." In the context of this Section, "representative" is an individual, so designated by the client, who is competent to handle personal client information and will do so responsibly for the benefit of the client.

B. Sharing client information in direct administration of VR program. VR counselor may release client information of which we are either primary or secondary source (without separate written authorization) to other individuals or agencies in the direct administration of a client's rehabilitation program as long as only necessary information is shared and that in the counselor's judgment, recipient can and will handle information in confidential manner. Consent for this release is given by client when he signs an application for services (see IWRP).

C. Answering requests for client information from clients or other individuals:

1. Information of which VR is not the primary source is only released in direct administration of a client's rehabilitation program. Requestors should be asked to contact the original source for secondary source information in possession of VR.

2. VR may release client information of which VR is primary source (other than under B. above) with client's informed written consent to only those other individuals or agencies who can give satisfactory assurance that information will be used only for the purpose for which it is provided, and that it will not be released to anyone else. In the adjudication of an individual's claim for Social Security or SSI benefits, Disability Certification Section has free access to primary source client information. VR counselors have free access to Disability Certification Section client information in the administration of a rehabilitation program.

3. With informed written consent of the client, federal regulations allow release of information (besides the IWRP which does not require special consent) to the client or, as appropriate, his parent, guardian or other representative. This shall be done with extreme care and may only be authorized by the counselor. The counselor will not normally copy actual medical, psychological or social reports to give to client. Such may be provided to the client's representative with proper written authorizations from client. It is advised, however, that the counselor dictate letters explaining Vocational Rehabilitation involvements in a general way when such information is requested by the client. Copies of such letters are placed in client's case folder. Interpretations of technical psychological or medical data shall only be provided by the originator of the report.

4. Client has a right to copies of his IWRP and shall be given such.

5. With informed consent, information shall be made available for review (but not to be removed from client file or copies without subpoena) to such client, parent, guardian or other representative for purposes in connection with any proceeding or action for benefits or damage, including any proceeding or action against any public agency provided

a. That only such information as is relevant to the needs of the client shall be released, and

b. In the case of medical or psychological information, the knowledge of which may be harmful to the client, such information will be released to the parent, guardian or other representative of the client by the state agency or to the client by a physician or by a licensed or certified psychologist. The psychologist or medical VR consultant or the examiner should be consulted to determine whether information may be harmful.

6. Information shall be released to an organization or individual engaged in research only for purposes directly connected with the administration of the State Vocational Rehabilitation program and only if the organization or individual furnishes satisfactory assurance that the information will be used only for the purpose for which it is provided; that it will not be released to persons not connected with the study under consideration; and that the final product of the research will not reveal any information that may serve to identify any person about whom information has been obtained through the state agency without written consent of such person and the state agency.

7. In any case, where client's informed consent is in doubt and/or when information may be damaging, such as during litigation with client as defendant, counselor is advised to not release personal client information even with a signed authorization for such release. In such an instance, the information may be subpoenaed.

8. All client information released shall be stamped CONFIDENTIAL.

D. Vocational Rehabilitation requesting information on clients from others:

1. Information being requested must have direct relevance to establishing client's eligibility and to the success of client's rehabilitation program. Counselor must be selective in his approach to information gathering.

2. Request for information must be as specific as possible (fulfill the criteria as set in R6-4-305(A)(2)).

E. Informing client about confidentiality.

1. The client shall be told at the beginning of his/her relationship with Vocational Rehabilitation that records will be held confidential but also that there are limits to that confidentiality; e.g., client files may be subpoenaed in whole or in part and contents used in court.

2. The client shall also be told both at the beginning of relationship with counselor and any other time as necessary that:

a. The counselor must report any ongoing or future illegal activity to proper authorities, especially if it involves possible injury to other individuals or damage to property. That not doing so might make him/her legally accessories to the crime.

b. The counselor himself/herself may be subpoenaed and questioned in court in which case he must answer questions honestly and truthfully on the order of the judge.

3. When counselor is aware that client may be or may become in violation of the law, the counselor must inform the client of this and the possible consequences.

4. Counselor should know that counselor-client relationship is not protected by privileged communication laws in the same way that the doctor-patient, lawyer-client or clergyman-penitent relationship is.

F. Client files shall not contain information which the client does not want known beyond the client-counselor relationship. Moreover, if the client wants to reveal the details of an illegal act or source of information, the counselor should interrupt the client and advise him that he is interested only in the effects of such activity, not the act itself.

G. Client files must be kept in such a way that no unauthorized individual will have access to them. An unauthorized individual is anyone who is not directly connected with the administration of the rehabilitation program. All non-professional VR staff who have access to the client's records will be thoroughly briefed concerning the confidentiality standards to be observed.

H. When a client/applicant is involved in litigation and has an attorney, the rehabilitation counselor shall inform the client's attorney of Agency involvement and plans for providing services.

I. Subpoena of Vocational Rehabilitation counselor or client records.

1. Counselors receiving subpoenas must contact their supervisor and the Department's Legal Section immediately for assistance.

2. To provide full protection of the counselor, any subsequent legal actions taken by the VR counselor shall be on instruction from Legal Section.

3. Secondary source information such as medical or psychological data obtained from another agency shall not be released without advice from Legal Section even under subpoena. The counselor should explain that this information should be secured from the original source. SSA information shall never be released, even under subpoena 42 U.S.C. 1306(a).

J. All client information is the property of the Department and shall be used in conformance with the regulations and policies stated in this Section.

Ariz. Admin. Code § R6-4-405

Adopted effective June 14, 1977 (Supp. 77-3). Renumbered from R6-4-305 effective May 7, 1990 (Supp. 90-2).