65E-5.250. Clinical Records; Confidentiality

(1) Except as otherwise provided by law, verbal or written information about a person shall only be released when the competent person, or a duly authorized legal decision-maker such as guardian, guardian advocate, or health care surrogate or proxy provides consent to such release. When such information is released, a copy of a signed authorization form shall be retained in the person’s clinical record. Recommended form CF-MH 3044, Feb. 05, “Authorization for Release of Information,” which is incorporated by reference and may be obtained pursuant to Rule 65E-5.120, F.A.C., of this rule chapter may be used as documentation. Consent or authorization forms may not be altered in any way after signature by the person or other authorized decision-maker nor may a person or other authorized decision-maker be allowed to sign a blank form.

(2) Facility staff shall inform each person that he or she has the right to waive, in writing, the confidentiality of his or her presence in a receiving or treatment facility and to communicate with all or a group of individuals as specified by the person. Recommended form CF-MH 3048, Feb. 05, “Confidentiality Agreement,” as referenced in subsection 65E-5.190(1), F.A.C., may be used for this purpose.

(3) For purposes of Section 394.4615(3)(b), F.S., a “qualified researcher” is one who after making application to review confidential data and who, after documenting his or her bona fide academic, scientific or medical credentials and describing the particular research which gives rise to the request, is determined by the administrator of a receiving or treatment facility or by the Secretary of the department, to be eligible to review such data. In making that determination the administrator or the Secretary shall weigh the person’s right to privacy against the benefit of disclosure and shall determine whether the disclosure is in the best interest of the state. Person identifying information obtained by such a qualified researcher shall not be further disclosed without the express and informed consent of the person or individual authorized to provide consent for him or her.

(4) When a person’s access to his or her clinical record or any part of his or her record is restricted by written order of the attending physician such restriction shall be documented in the person’s clinical record. If the request is denied or such access is restricted, a written response shall be provided to the person. Recommended form CF-MH 3110, Feb. 05, “Restriction of Person’s Access to Own Record,” which is incorporated by reference and may be obtained pursuant to Rule 65E-5.120, F.A.C., of this rule chapter may be used for such documentation.

(5) Each receiving facility shall develop detailed policies and procedures governing release of records to each person requesting release, including criteria for determining what type of information may be harmful to the person, establishing a reasonable time for responding to requests for access, and identifying methods of providing access that ensure clinical support to the person while securing the integrity of the record.

Specific Authority 394.457(5) FS. Law Implemented 394.4615, 394.4615(3)(b) FS. History–New 11-29-98, Amended 4-4-05.