12 Case Documentation
Revised: 08/03
12-05 Protection, Use, and Release of Information
Participant provision of information is voluntary, but failure to provide pertinent information may result in case closure or delay in case development. A copy of the "Authorization for Release of Records or Information" will be used to document records and information that the participant has authorized DVR to use and/or disclose. Retain a copy in the participant file and provide a copy to the participant. The participant has the right to revoke this authorization at any time by writing, to the organization holding records or the DVR counselor.
All information obtained by DVR will be held confidential and will not be given to any person or agency without written consent of the participant except by order of the court.When staff members receive subpoenas for client records, the DVR staff attorney should be immediately consulted. The exception to this rule is through cooperative agreements between DVR, the Social Security Administration, the Department of Labor, and the Human Services Department. Information related to employment status and wages can be provided to or requested from these agencies.
DVR may use and disclose participant information without their consent when considered necessary to reduce or prevent a serious threat to a participant’s health and safety or the health and safety or another individual or the public. Participants have the right to file a complaint if they believe their privacy rights have been violated. Complaints may be submitted, in writing, to DVR or the Secretary of the Health and Human Services.
Division of Vocational Rehabilitation
435 St. Michael’s Drive, Bldg. D
Santa Fe, NM 87505
- OR -
Region IV, Office of Civil Rights
U.S. Department of Health and Human Services
1301 Young Street, Suite 1169
Dallas, TX 75202
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12-05-01 Release to Other Agencies
Information in a case file may be divided into two categories:
Information or reports generated by DVR, including reports of evaluations or treatment that were performed at the request of DVR and paid for by DVR.
Information released to DVR by another individual or agency which was not for purposes originally related to a rehabilitation program, but later requested for reasons related to a rehabilitation program, such as previous school or medical records.
Information generated by DVR may be released to any other agency or individual with the written consent of the participant.
Information not generated by DVR but contained in the case file through request to another agency may not be further released even with the participant's written request. Different agencies may have different rules and regulations pertaining to release of information, so requests for such information should be referred to the source that generated the information.
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12-05-02 Release to Participants
Any information in the case file that was generated by DVRmust be released to the participant or representative upon request.
The only exception to this is in situations where the counselor has good reason to believe that the information would be harmful to the participant. Inthese situations the information may be released to arepresentative of the participant as deemed appropriate in the judgment of the counselor.
Information requested that was not generated by DVRcannot be released by DVR and a referral should be made to the originating agency.
Copying information in the case file for release to the participant is discouraged, as participant inquiries concerning their record can generally be handled by reviewing the information with the participant and explaining medical and psychological terminology in layman's terms.When the participant insists on receiving copies, the agency must comply with the request with the exception noted above.
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12-05-03 Other Releases
Information requested for purposes of external audits, program evaluations, or research should be directed to the Deputy Director of Rehabilitation Services when such requests are not made through written consent of the participant.
Information may be shared with any unit of DVR for purposes related to administration of the VR program without written consent of the client.
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12-05-04 Reproduction Costs
The out-of-ordinary consts for reproducing and sharing information to non-agency recipients not directly related to rehabilitation purposes will be borne by those recipients at rates set by DVR.
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12-05-05 Ethical Issues
DVR staff shall not abuse the privilege of viewing participant records.A staff member who is a personal friend or relative of a participant shall remove himself / herself from any involvement in the case, including viewing the case record or discussing the case with other staff members. Exceptions should be made based on professional judgment and discretion.In all cases, Policy 126 shall be followed.Violations of this trust may be considered grounds for disciplinary action.
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