Law & Ethics for Clinicians Working With Children & Families

CLINICAL RECORD
Client:
Clinician:
Prepared by Michaele P. Dunlap, Psy.D. for
Pragmatics of HIPAA Training 2-28-03
Start Stop Tx Mode Summary recorded this session:
(T) Tests/Results, (M) Med .(D) Diagnosis, (S)
Symptoms (F) Functional Status (Tx P) Treatment
plan, (Prog) Progress to Date (E) Prognosis
Per Federal Regulation the above information is documented at each client visit, and may be used or disclosed upon specific written consent of the client or the client=s
authorized representative for treatment, payment or healthcare operations. No other information about this client will be released by this mental health professional/mental
health care entity unless specific, fully informed authorization from the client or an authorized representative is obtained in writing, or as otherwise allowed or required by
law.
Statutes and regulations in this State may be more restrictive than Federal Regulation, further limiting disclosure of the above and other individually identifiable health
information.
AS THE RECEIVING ENTITY, YOU MAY BE SUBJECT TO CIVIL AND FEDERAL CRIMINAL PENALTIES FOR IMPROPER RE-
DISCLOSURE OF THIS INFORMATION.