Current through October 28, 2024
Section DHS 92.03 - General requirements(1) TREATMENT RECORDS. (a) All treatment records or spoken information which in any way identifies a patient are considered confidential and privileged to the subject individual.(b) If notes or records maintained for personal use are to be made available to other persons, they shall be placed in the treatment record, become part of that record and be governed by this chapter.(c) The department and every board, treatment facility and service provider shall designate in writing one or more persons to serve as record custodians.(d) The department and every board, treatment facility and service provider shall develop a notice describing the agency's treatment record access procedures. The notice shall be prominently displayed and made available for inspection and copying.(e) Information requests shall be filled as soon as practicable. If a request is denied, specific reasons shall be given for denying the request.(f) No personally identifiable information contained in treatment records may be released in any manner, including oral disclosure, except as authorized under s. 51.30, Stats., this chapter or as otherwise provided by law.(g) Whenever requirements of federal law regarding alcoholism and drug dependence services in 42 CFR Part 2 require restrictions on the disclosure of treatment records greater than the restrictions required by this section, the federal requirements shall be observed.(h) No personally identifiable information in treatment records may be re-released by a recipient of the treatment record unless re-release is specifically authorized by informed consent of the subject individual, by this chapter or as otherwise required by law.(i) Any disclosure or re-release, except oral disclosure, of confidential information shall be accompanied by a written statement which states that the information is confidential and disclosure without patient consent or statutory authorization is prohibited by law.(j) Members and committees of boards shall not have access to treatment records. In meetings of boards and board committees, the program directors shall ensure that patient identities are not revealed or made obvious by description of particular patient situations.(k) All treatment records shall be maintained in a secure manner to ensure that unauthorized persons do not have access to the records. (L) Pupil records of minor patients in educational programs within treatment facilities, which are disclosed pursuant to s. 118.125, Stats., shall not contain any information from other treatment records unless there is specific informed consent for release of that information as required under s. DHS 92.06.(m) No treatment record information may be released to a person previously unknown to the agency unless there is reasonable assurance regarding the person's identity.(n) Whenever information from treatment records is disclosed, that information shall be limited to include only the information necessary to fulfill the request.(o) Any request by a treatment facility for written information shall include a statement that the patient has the right of access to the information as provided under ss. DHS 92.05 and 92.06.(p) The conditions set forth in this section shall be broadly and liberally interpreted in favor of confidentiality to cover a record in question. Note: If a person requesting information does not qualify for it under the section cited in this chapter, other sections should be reviewed to determine if the requester qualifies under another section.
(2) DISCLOSURE OF PATIENT STATUS IN RESPONSE TO INQUIRIES.(a) No person may disclose information or acknowledge whether an individual has applied for, has received or is receiving treatment except with the informed consent of the individual, as authorized under s. 51.30(4) (b), Stats., or as otherwise required by law and as governed by this subsection.(b) The department and each board and treatment facility shall develop written procedures which include a standard, noncommittal response to inquiries regarding whether or not a person is or was receiving treatment. All staff who normally deal with patient status inquiries shall be trained in the procedures.(3) INFORMED CONSENT. Informed consent shall be in writing and shall comply with requirements specified in s. 51.30(2), Stats., and this subsection.(a) Informed consent shall be valid only if voluntarily given by a patient who is substantially able to understand all information specified on the consent form. A guardian may give consent on behalf of the guardian's ward. If the patient is not competent to understand and there is no guardian, a temporary guardian shall be sought in accordance with s. 54.50, Stats.(b) Informed consent is effective only for the period of time specified by the patient in the informed consent document.(c) A copy of each informed consent document shall be offered to the patient or guardian and a copy shall be maintained in the treatment record.(d) Each informed consent document shall include a statement that the patient has a right to inspect and receive a copy of the material to be disclosed as required under ss. DHS 92.05 and 92.06.(e) Any patient or patient representative authorized under s. 51.30(5), Stats., may refuse authorization or withdraw authorization for disclosure of any information at any time. If this occurs, an agency not included under s. 51.30(4) (b), Stats., that requests release of information requiring informed consent shall be told only that s. 51.30, Stats., prohibit release of the information requested.(4) RELEASE OF TREATMENT RECORDS AFTER DEATH. (a) Consent for the release of treatment records of a deceased patient may be given by an executor, administrator or other court-appointed personal representative of the estate.(b) If there is no appointment of a personal representative, the consent may be given by the patient's spouse or, if there is none, by any responsible member of the patient's family.(c) Disclosures required under federal or state laws involving the collection of death statistics and other statistics may be made without consent.Wis. Admin. Code Department of Health Services DHS 92.03
Cr. Register, May, 1984, No. 341, eff. 6-1-84; correction in (3) (a) made under s. 13.92(4) (b) 7, Stats., Register November 2008 No. 635.