Verbal Records Release Policy and Procedure

Verbal Records Release Policy and Procedure

Purpose of Policy 

The Verbal Records Release Policy defines and manages clients requesting therapists to verbally consult with third parties regarding their care.  Use this policy to understand the process and cost of verbal release records.

MCO Verbal Records Definition

The provision to a third party by an MCO clinician of professional opinions, observations, and recommendations regarding counseling being provided.  This information can be provided to for a number of reasons, including coordination of care and referral to other providers, among other reasons.

Policy Procedure

The following steps should be followed once a current or former MCO client requests a Verbal Records Release.  This procedure is only to be utilized for non-legal situations.

1. The client makes a request, in writing, for their therapist to verbally release records via consultation with a third party.    This request can be the completed Authorization to Use & Release Personal Health Information (PH) Form.  In the case of couples records, both spouses must provide authorization for the release of any records including both individuals.  If only one person provides consent, only verbal records relating to their care may be released.  Nothing may be released with the other individual’s private health information.  **Therapists under supervision should inform clients they must consult with their supervisor prior to agreeing to speak with a third party. **
2. Assistant to the Clinical Director (ACD) received the completed ATD form and begins an email thread including the therapist, therapist’s supervisor, and accounting.
3. The ACD informs the client the therapist can provide brief consultations, free of charge, time-limited to 10 minutes.  In the even longer consultation is needed, clients are to be informed blocks of time in 30-minute increments can be reserved and will be billed in accordance with a clinician’s hourly rate.  This allows for therapist time in coordinating the meeting with the third party, records review and preparation, and the consultation itself.  ACD will determine with the client what is needed and add this to the email thread.  In the event paid services are needed, accounting will send the client an invoice to be paid for the correct amount of time.
4. Accounting will notify, via the email thread, that the invoice has been paid.  The therapist can now coordinate the consultation with the third party.  Therapist will add the date and time of the upcoming consultation to the email thread.  Therapist will consult with supervisor on upcoming consultation.
5. Therapist will notify the team, via the email thread, when the consultation has been completed.  ACD will add this to the Records Release Spreadsheet.

Therapist Professional Discretion

On occasion, a client may request their therapist provide verbal records regarding their counseling work. It is at the discretion of the therapist and their supervisor whether to agree to produce the requested records. Additionally, clients may request verbal records in regards to a specific issue as it relates to their counseling, but cannot dictate the clinician’s professional opinion or recommendations.