Pa. Code 5100.33

Patient's access to records and control over release of records

This regulation governs patient rights regarding access to and control over the release of mental health treatment records in Pennsylvania. Patients 14 years of age or older who understand the nature of the documents control release of their own records, while parents, guardians, or designated representatives may exercise that right for younger or legally incompetent patients. Facilities may deny access only in limited circumstances, such as when disclosure would substantially harm the patient's treatment or reveal confidential informants. Patients also have the right to submit written rebuttals to information they believe is erroneous in their records.

55 Pa. Code § 5100.33 - Patient's access to records and control over release of records 

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(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).

Notes

55

 Pa. Code §
 
5100.33

This section cited in 55 Pa. Code §
 
3800.20
 (relating to
 confidentiality of records); 55 Pa. Code §
 
5100.4
 (relating to scope); 55 Pa.
 Code §
 
5100.31
 (relating to scope and
 policy); 55 Pa. Code §
 
5100.34
 (relating to consensual
 release to third parties); 55 Pa. Code §
 
5200.47
 (relating to other
 applicable regulations); 55 Pa. Code §
 
5210.26
 (relating to records); 55
 Pa. Code §
 
5210.56
 (relating to other
 applicable regulations); 55 Pa. Code §
 
5221.52
 (relating to notice of
 confidentiality and nondiscrimination); 55 Pa. Code §
 
5230.17
 (relating to
 confidentiality); and 55 Pa. Code §
 
5320.26
 (relating to
 confidentiality).

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