Subsection 144-101-II-92.08 - DOCUMENTATION AND CONFIDENTIALITYIn addition to the requirements, above, and set forth in Chapter I, Section I, the BHHO and the HHP must maintain a specific record and documentation of services for each member receiving covered services.
A.Records. The member's record must minimally include: (1) Name, address, birthdate, and MaineCare identification number;(2) Diagnosis(es) that support eligibility for services herein, including the most recent documentation of diagnoses that substantiate ongoing eligibility for services;(3) The comprehensive assessment that must occur within the first thirty (30) days of initiating of services, and any reassessments that occur;(5) Correspondence to and from other providers;(6) Release of information statements as necessary, signed by the member or guardian;(7) Documentation/record entries (i.e. progress notes) for each service provided, including the date of service, the type of service, the place of the service or method of delivery (i.e., phone contact), the goal to which the service relates, the duration of the service, the progress the member has made towards goal attainment, the signature and credentials of the individual performing the service, whether the individual has declined services in the Plan of Care, and timelines for obtaining needed services.B.Confidentiality and Disclosure of Confidential Documents/Information. Providers shall maintain the confidentiality of information regarding these members in accordance with Chapter I, Section I of the MaineCare Benefits Manual, 42 C.F.R.§§ 431.301-306, 22 M.R.S.A. § 1711- C, and with all other applicable sections of state and federal law and regulation. C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-92, subsec. 144-101-II-92.08