N.J. Admin. Code § 13:44G-12.4

Current through Register Vol. 56, No. 21, November 4, 2024

Section 13:44G-12.4 - Release of client record

(a) For purposes of this section, "authorized representative" means, but is not limited to, a person designated by the client or a court to exercise rights under this section. An authorized representative may be the client's attorney or an agent of a third-party payor with whom the client has a contract, which provides that the third-party payor be given access to records to assess a claim for monetary damages or reimbursement.

1. Unless otherwise ordered by a court, if the client is a minor, a parent or legal guardian will be deemed to be an authorized representative.

2. Unless otherwise ordered by a court, when the client is 14 years of age or older, but has not yet reached the age of majority, an authorization shall be signed by the client and by the client's parent or legal guardian.

(b) At the written request of the client or authorized representative, a social worker shall provide the client record or a summary thereof, within 30 days of the request directly to:

1. The client or the client's guardian, except that:

i. A social worker may withhold information contained in the client record from a client or the client's guardian if, in the reasonable exercise of his or her professional judgment, the social worker believes release of the information would adversely affect the client's health or welfare; and

ii. Pursuant to 9:17A-1 et seq. the social worker shall not be required to release to a minor client's parent or guardian records or information relating to the minor's sexually transmitted disease, termination of pregnancy or substance abuse.

2. The client's health insurance carrier. Only the following basic information shall be provided. The information provided shall be marked "Confidential" and forwarded to the attention of a specific individual if identified by the client or authorized representative.

i. The client's name, age, sex, address, educational status, identifying number within the insurance program, date of onset of difficulty, date of initial consultation, dates and character of sessions (individual or group) and fees;

ii. Diagnostic information, defined as therapeutic characterizations of the type found in the current version of the DSM or in another professionally recognized diagnostic manual;

iii. Status of the client (voluntary or involuntary; inpatient or outpatient);

iv. The reason for continuing social work services, limited to an assessment of the client's current level of functioning and level of distress. Each aspect shall be described as "none," or by the term mild, moderate, severe or extreme; and

v. Prognosis, limited to an estimate of the minimal time during which treatment might continue.

3. Another licensed health care professional, hospital, nursing home or similar licensed institution which is providing or has been asked to provide treatment to the client.

(c) A social worker may elect to provide a summary of the client record, as long as the summary adequately reflects the client's history and treatment, unless otherwise required by law. A social worker may withhold information contained in the client record from a client or a client's guardian if, in the reasonable exercise of his or her professional judgment, the social worker believes the release of such information would adversely affect the client's health or welfare. That record or the summary shall be accompanied with an explanation of the reasons for the refusal.

(d) A social worker may charge a reasonable fee for the reproduction of the client record or the preparation of a summary. The fee shall be no greater than an amount reasonably calculated to recoup the costs of copying or transcription.

(e) A social worker shall not charge a fee for completion of health insurance claim forms.

(f) A social worker may charge a reasonable fee for completion of reports required for third party reimbursement of client treatment expenses when the third party makes a separate request for reports to be completed.

1. If additional information is requested by a third party, the social worker shall procure informed consent from the client for release of the specific information requested.

(g) When a report is needed to enable a client to receive ongoing care by another practitioner or for use in judicial proceedings, a social worker shall not require advance payment as a condition for releasing the report; except that a social worker may require advance payment for release of a report prepared by the social worker as an expert witnessor as a custody/parenting evaluator pursuant to 13:44G-13.6.

(h) This section shall not apply to a social worker in an agency setting who does not, by agency policy, have control over or authority to release client records.

N.J. Admin. Code § 13:44G-12.4

Amended by R.1998 d.66, effective 1/20/1998.
See: 29 N.J.R. 4388(a), 30 N.J.R. 372(b).
In (f), added "when the third party makes a separate request for reports to be completed" at the end of the first sentence, and added 1.
Amended by R.2003 d.265, effective 7/7/2003.
See: 35 N.J.R. 380(a), 35 N.J.R. 2936(b).
In (a), inserted "written" preceding "request" in the introductory paragraph; deleted (b) and recodified former (c) through (h) as (b) through (g).
Amended by R.2009 d.176, effective 5/18/2009.
See: 40 N.J.R. 6388(a), 41 N.J.R. 2136(a).
Added new (a); recodified former (a) through (g) as (b) through (h); in (c), inserted the last two sentences; and in (g), inserted "or as a custody/parenting evaluator pursuant to N.J.A.C. 13:44G-13.6".