N.J. Admin. Code § 13:34C-4.3

Current through Register Vol. 56, No. 24, December 18, 2024

Section 13:34C-4.3 - Access to copy of client record

(a) For purposes of this section, "authorized representative" means a person designated by the client, in accordance with the provisions of 42 CFR Part 2, incorporated herein by reference.

(b) A licensee or certificate holder shall require any record request to be in writing. The licensee or certificate holder shall provide a copy of the client record and/or billing records, including reports relating to the client, no later than 30 days from receipt of a request from a client or duly authorized representative. Limitations on this requirement are set forth in (g) and (h) below.

(c) Unless otherwise required by law, the licensee or certificate holder may elect to provide a summary of the record, as long as the summary adequately and accurately reflects the client's history and treatment.

(d) A licensee or certificate holder may charge a reasonable fee for the preparation of a summary and reproduction of records, which shall be no greater than an amount reasonably calculated to recoup the costs of transcription or copying.

(e) The licensee's or certificate holder's obligation hereunder to release information shall include the obligation to complete forms or reports required for third party reimbursement of client treatment expenses. The licensee or certificate holder may charge reasonable fees for completion of reports other than health insurance claim forms, for which no fee may be charged pursuant to N.J.S.A. 45:1-12.

(f) When a request is made for release of already completed reports to enable the client to receive ongoing care by another practitioner, or for use in judicial proceedings, the licensee or certificate holder shall not require prior payment for the professional services to which such reports relate as a condition for making such reports available. A licensee or certificate holder may, however, require advance payment for a report prepared for the licensee's or certificate holder's services as an expert witness.

(g) A licensee or certificate holder may withhold information contained in the client record from a client or the client's parent or guardian if in the reasonable exercise of his or her professional judgment, the licensee believes release of such information would adversely affect the client's health or welfare. That record or the summary, with an accompanying explanation of the reasons for the original refusal, shall nevertheless be provided upon request of and directly to:

1. The client's attorney;

2. Another licensed health care professional; or

3. The client's health insurance carrier.

(h) A licensee or certificate holder shall not be required to release to a minor's parent or guardian records or information relating to the minor's sexually transmitted disease, termination of pregnancy or substance abuse.

(i) A licensee or certificate holder shall only disclose information on HIV status contained in the client's record when consent is explicitly given by the client and such disclosure shall be in accordance with N.J.S.A. 26:5C-1 et seq. and any other applicable laws.

N.J. Admin. Code § 13:34C-4.3