(a) When a
client/patient, 14 years of age or older, understands the nature of documents
to be released and the purpose of releasing them, he shall control release of
his records. For a client who lacks this understanding, any person chosen by
the patient may exercise this right if found by the director to be acting in
the patient's best interest. In the event that the client/patient is deceased,
control over release of records may be exercised by the client's/patient's
chosen executor, administrator or other personal representative of his estate,
or, if there is no chosen personal representative, by a person otherwise
empowered by court order to exercise control over the records. In the event
that the client/patient is less than 14 years of age or has been adjudicated
legally incompetent, control over release of the client's/patient's records may
be exercised by a parent or guardian of the client/patient
respectively.
(b) The term "access"
when used in this section refers to physical examination of the record, but
does not include nor imply physical possession of the records themselves or a
copy thereof except as provided in this chapter.
(c) A person who has received or is receiving
treatment may request access to his record, and shall be denied such access to
limited portions of the record only:
(1) Upon
documentation by the treatment team leader, it is determined by the director
that disclosure of specific information concerning treatment will constitute a
substantial detriment to the patient's treatment.
(2) When disclosure of specific information
will reveal the identity of persons or breach the trust or confidentiality of
persons who have provided information upon an agreement to maintain their
confidentiality.
(d) A
patient may obtain access to his records through the facility, or in the case
of those records kept by the county administrator, through the physician or
mental health professional designated by the administrator. Any third parties
who are granted access to records may discuss this information with the patient
only insofar as necessary to represent the patient in legal proceedings or
other matters for which records have been released. Discussion of records with
patients should be part of the therapeutic process and is not to be undertaken
by other than mental health professionals.
(e) The limitations in subsection (c) are
applicable to parents, guardians, and others who may control access over
records as described in subsection (a) except that the possibility of
substantial detriment to the parent, guardian, or other person may also be
considered.
(f) If a person wishes
to enter a written reaction qualifying or rebutting information in their
records which they believe to be erroneous or misleading, they shall have the
right to prepare such statement for inclusion as part of their record. The
patient's written reaction shall accompany all released records.
(g) The director of the treatment team or the
facility director may require that a mental health professional, who is a
member of the treatment team, and who has reviewed the record in advance, be
present when the patient or other person examines the record to aid in the
interpretation of documents in the record. If the records pertain to a former
patient, an appropriate mental health professional may be designated by the
facility director.
(h) Access to
presentence reports, which may be part of the persons' records, is governed
Pa.R.Crim.P. No. 1404 (relating to disclosure of reports), and the patient may
have access to these records only upon order of the sentencing judge. Any
conditions of confidentiality imposed by the sentencing judge must be complied
with. Similarily, parole and probation reports shall be released or access to
them given only in accordance with 37 Pa. Code Part II (relating to Board of
Probation and Parole).
(i) If a
person is denied access to all or part of his record, this fact and the basis
for the denial shall be noted in the person's record.
(j) When records or information have been
forwarded from one agency to another agency, the receiving agency may not
refuse the client or patient access to the records received except in
accordance with subsection (c). Records received from other agencies become
part of the client/patient's active record and are subject to the controls
exercised over them by the client, patient, or those with authority over
records as defined in §
5100.31 (relating to scope and
policy).