Written Records Release Policy and Procedure

Written Records Release Policy and Procedure

Purpose of Policy 

This Records Release Policy is to define and manage clients requesting written records.  Use this policy to understand the process and cost of releasing records.

MCO Records Definition

MCO Records which can be released upon the request of a client or authorized third party include the following documents:

• Signed Informed Consent Document
• Intakes
• First Contact Record
• Authorization to Use & Release Personal Health (PH) Form
• 3rd Party Authorization to Disclose and Release PHI
• Sexual Identity Therapy Advanced Information Consent
• Payment Plan Request Form
• Scholarship Agreement
• Insurance Processing Request Form
• Court Service Request Form
• MCO Prepared Letters & Reports
• Routine Progress Notes

MCO Records which cannot be released include:

• First Contact Record 2 (payment information)
• 3rd Party Financial Responsibility Agreement
• Any records not produced by or originating with MCO (ie: copy of a psychological evaluation, reports from a hospital stay, client tax returns, etc).
• Psychotherapy Notes (notes kept by the therapist on a case that are not part of the medical file and only for the therapist’s use, different than Routine Progress Notes).

Policy Procedure

The following steps should be followed once a current or former MCO client requests their records.

1. Assistant to the Clinical Director (ACD) receives 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 records relating to their care may be released.  Nothing may be released with the other individual’s private health information.
2. ACD contacts the client/s and confirms what records are being released.  ACD creates an email thread including the clinician, clinician’s supervisor, and the accounting office stating a records release has been requested and the nature of that release.
3. ACD calculates the cost of the records. MCO is a company based in the State of Missouri.  As such, the cost of creating said records is based on the Missouri Department of Health & Senior Services recommended standards (last updated 02-1-2022).
   1. The new maximum fees for copying will be $27.46 plus $0.63 per page for the cost of labor and supplies for copies provided in paper form and $25.71 for additional costs if records are maintained off-site.
   2. The new maximum fees for copying will be $27.46 plus $0.63 per page, or $120.32 total, whichever is less, for copies provided electronically.
4. ACD lets the client know the cost of producing records and confirms if the client is ready to have their card on file charged.
5. Once the client confirms the cost and allows for payment to be processed, ACD emails on the thread to Accounting@MyCounselor.online for payment to be processed.
6. ACD requests approval of records release from the COD or CTD. Once approved, ACD downloads the progress notes requested and emails/faxes them to the client or the party designated by the client/authorized third party.
7. ACD puts a PDF copy of the records released in the client’s file under Reports.  The copy should be labeled with the date of release, Records Release, and client last name first name (ie: 2022-03-22 Records Release – Smith – John).
8. ACD records the details of the release in the Records Release Spreadsheet.