N.H. Admin. Code § He-M 503.11

Current through Register No. 45, November 7, 2024

Section He-M 503.11 - Record Requirements for Area Agencies and Provider Agencies

(a) Area agencies, service coordinators, and other provider agencies, or their designees shall maintain a separate record for each individual who receives services and ensure the confidentiality of information pertaining to the individual, including:

(1) Maintaining the confidentiality of any personal data in the records;

(2) Storing and disposing of records in a manner that preserves confidentiality; and

(3) Obtaining a release of information pursuant to He-M 503.04(h) prior to release of any part of a record to a third party.

(b) An individual's record shall include, as applicable:

(1) Personal and identifying information including the individual's:

a. Name;

b. Address;

c. Date of birth; and

d. Telephone number;

(2) All information used to determine eligibility for services pursuant to He-M 503.05 and He-M 503.06;

(3) Information about the individual that would be essential in case of an emergency, including:

a. Name, address, and telephone number of legal guardian, representative, or next of kin or other person to be notified;

b. Name, address, and telephone number of current providers; and

c. Medical information as applicable, including:

1. Diagnosis(es);

2. Health history;

3. Allergies;

4. Do not resuscitate (DNR) orders, as appropriate;

5. Advance directives, as determined by the individual;

6. Current medications; and

7. Any correspondence related to medical information relevant to the individual;

(4) A copy of the individual's current service agreement;

(5) Copies of all service agreement amendments;

(6) Progress notes on goals and support services provided as identified in the service agreement;

(7) All service coordination contact notes and quarterly assessments pursuant to He-M 503.10(i)(2)-(4);

(8) Copies of evaluations and reviews by providers and professionals;

(9) Copies of correspondence within the past year with the individual and guardian, area agency, provider agencies, providers, physicians, attorneys, state and federal agencies, family members, and others in the individual's life;

(10) Other correspondence or memoranda concerning any significant events in the individual's life;

(11) Information about transfer or termination of services, as appropriate; and

(12) Proof that the individual was given choice of provider agencies.

(c) All entries made into an individual record shall be legible and dated and have the author identified by name and position.

(d) In addition to the documentation requirements identified in He-M 503, each area agency, service coordinator, provider agency, and provider shall comply with all applicable documentation requirements of other department rules.

(e) Each billing entity shall:

(1) Retain records supporting each Medicaid bill for a period of not less than 6 years; and

(2) Retain an individual's social history, medical history, evaluations, and any court-related documentation for a period of not less than 6 years after termination of services.

N.H. Admin. Code § He-M 503.11

#1969, eff 2-25-82; ss by #2615, eff 2-6-84; ss by #2962, eff 1-22-85; ss by #5211, eff 8-28-91; EXPIRED: 8-28-97

New. #6581, INTERIM, eff 9-19-97, EXPIRED: 1-17-98

New. #6932, eff 1-27-99; ss by #8805, eff 1-27-07

Amended byVolume XXXV Number 06, Filed February 12, 2015, Proposed by #10774, Effective 1/27/2015, Expires7/27/2015.

Amended by Volume XXXV Number 32, Filed August 13, 2015, Proposed by #10900, Effective 7/25/2015, Expires7/25/2025.

Amended by Number 2, Filed January 11, 2024, Proposed by #13841, Effective 12/29/2023, Expires 12/29/2033.