Clinician Professional Letter & Report Policy and Procedure

Clinician Professional Letter & Report Policy and Procedure

Purpose of Policy 

This Professional Letter & Report Policy is to define the conditions and process of MCO clinicians producing professional documentation regarding clients to third parties.  These produced documents are for non-legal purposes only. 

MCO Processional Letter & Report Definition

A professional letter or report is a document created by an MCO clinician including information about the care and treatment of a client/s.  The documents can either be a letter or a report, as defined below:

Letters: Typically include a client’s identifying information (name, date of birth & contact information), client defined presenting problem for treatment, the frequency and duration of treatment (when the client was first seen, how long they have been in counseling, and how often, example: 1 time per week), treatment goals, and progress on treatment goals.  Generally 1-2 pages in length.  The content of this letter can be modified at clinician discretion and in agreement with their supervisor if needed.  Billed at 1 therapy hour.

Report: Typically includes all the items listed in the Letter.  It also includes, treatment diagnostic information, psychosocial history, and treatment recommendations.  Generally 4-5 pages in length.  Billed at 2 therapy hours.

Policy Procedure

The following steps should be followed once a current or former MCO client requests their counselor produce a letter or report.

1. The clinician should direct the client to complete the Authorization to Use & Release Personal Health Information (PH) Form on the MCO website specifying the individual/group who will be provided with the document.
2. Authorization to Disclose form is received by the Assistant to the Clinical Director (ACD). ACD creates an email thread with the clinician, clinician’s supervisor, and the accounting office.  In this email, ACD will indicate what type of document is being requested, letter or report.  ACD will direct the clinician to discuss both with the client and their supervisor the request.
3. The clinicians will inform the client they will discuss the requested document with their immediate supervisor. It is at the discretion of the therapist and their supervisor whether or not to agree to produce the requested document. Additionally, clients may request a document in regards to a specific issue as it relates to their counseling, but cannot dictate the content of the document or a clinician’s professional opinion or recommendations.
4. Upon reaching a decision with their supervisor, the counselor will inform the client if the document will be produced. The clinician can process with the client concerns leading to not producing the document if that is the decision.  If the document is to be produced, continue with the steps below.
5. The clinician should inform the client that clinician’s professional opinions and recommendations expressed in the letter are at the discretion of the clinician.
   1. Sample Language “Please be aware that I am not able to produce a document simply saying what you might prefer I say, but instead, the document will contain my professional opinions and recommendations, which you may or may not agree with. I would be happy to discuss with you now, as a part of our session, what my clinical opinions is on the matter in question. If you hear my opinion and do not want me to produce the document, simply let me know.  If you choose to have me produce the document the cost will be (1 or 2) therapy hour/s billed at my hourly rate.  This fee is non-refundable.”
6. The clinician will respond on the email thread their client does or does not want to have the documents produced. The ACD will inform the client they will be billed by the MCO Accounting Office at the rate specified (1 therapy hour for letters or 2 therapy hours for reports), confirming having their card on file run.
7. The ACD will notify the Accounting Department on the email thread, who will produce an sales receipt billing the client. The clinician will wait to produce the document until accounting will confirm on the email thread that payment has been received.
8. The clinician will produce the document and allow their supervisor to review and approve/make edits. Once the document is approved by the immediate supervisor, it will be sent to the recipient by the Assistant to the Clinical Director. A copy can also be sent to the client for their records.
9. ACD will put a copy of the document in the clients file under reports labelled with the date, Letter/Report, and client last name first name (ie: 2022-03-22 Letter- Smith-John).
10. ACD records the details of the release in the Records Release Spreadsheet.

 ***Important Disclaimers***

• MCO does not produce any documents or sign any forms for either FMLA or disability hearings.
• MCO does not produce letters simply for the client to have and use when at their own discretion (ie: a letter “To Whom it May Concern” asking for accommodations for a certain client struggle).
• MCO counselors do not provide letters advocating for clients to have therapeutic animals.