To assure the protection of all client rights to privacy and define the process through which Federal Confidentiality Guidelines are implemented.


Confidentiality is a fundamental component of quality clinical services.  It is therefore the policy of Center to safeguard the client right to privacy with respect to confidential information disclosed or revealed in the therapeutic setting.

In order to insure that client confidentiality is protected, upon employment all staff members of Center will be required to review Federal Confidentiality Regulations relating to the Confidentiality of Alcohol and Drug Abuse Patient Records, and other confidentiality laws that may be applicable at that time.  After having reviewed said laws and regulations, the employee will be required to sign a statement acknowledging their understanding of this material, the implications contained therein, and that the employee agrees to abide by all applicable confidentiality and privacy regulations.  A copy of this signed statement will be included in each employee’s personnel file.

Federal Confidentiality Regulations, 42 CFR Part 2 “Confidentiality of Alcohol and Drug Abuse Patient Records,” will define the basic framework within which all operating policies and practices of Center are to be conducted.  Any exceptions to the contents of this policy are to be enacted only in accordance with relevant clauses contained within the Federal Confidentiality Regulations, and then only upon approval of the Chief Executive Officer.  In the absence of the Chief Executive Officer, the Clinical Director will make such determinations as may be necessary.

The full text of the most recent federal confidentiality regulations will be available through the Chief Executive Officer.  In summary, these regulations state:

  • Program staff shall not convey to a person outside of the program that a client attends or receives services from the program or disclose any information identifying a client as an alcohol or other drug services client unless the client consents in writing for the release of information, the disclosure is allowed by a court order, or the disclosure is made to qualified personnel for a medical emergency, research, audit or program evaluation purposes.
  • Federal laws and regulations do not protect any threat to commit a crime, any information about a crime committed by a client either at the program or against any person who works for the program.
  • Federal laws and regulations do not protect any information about suspected child abuse or neglect being reported under state law to appropriate state or local authorities

Any violation of client confidentiality, or knowledge of such violation, shall be immediately reported to the affected employee’s direct supervisor; who will immediately inform the Chief Executive Officer.

Violation of client confidentiality by a staff member will result in disciplinary action that may include termination of employment.  Violation of one client’s confidentiality by another client may result in termination of services to the client who initiated the breach.

With the exception of situations previously referenced in this policy, and more fully described in the federal confidentiality regulations, confidential information held by Center may only be released or disclosed if the client in question has properly executed an Authorization to Use and Disclose Protected Health Information form.  Said information to be released or disclosed may include only information accumulated through the client’s involvement with Center Reports from other organizations may be released only by the organization from which the report originated, unless the client has signed a specific Authorization to Use and Disclose Protected Health Information form that allows Center to re-disclose such information.

Authorization to Use and Disclose Protected Health Information forms shall contain the following information:

  • Name of the organization or person to whom information may be disclosed,
  • Extent and nature of the information to be disclosed,
  • Purpose for the disclosure,
  • Date upon which the authorization to disclose information automatically expires,
  • Signature of the client about whom information is to be communicated; or, in the case of a minor client, the signature of a legal guardian,
  • Prohibition on Redisclosure Statement

Confidential client information may be disclosed among employees of the different departments comprising Center only to the extent necessary for said employees to perform the expected functions of their employment.  Graphically illustrated, confidential client information may be disclosed within a department and upwardly within the agency’s internal table of organization.  All other internal disclosures shall be limited to the extent necessary for the performance of one’s position responsibilities.

Information to be released to other organizations must be disclosed only in accordance with this policy, and with the best interest of the client as a paramount factor.  Such disclosures will contain only that information necessary to satisfy the professional obligations of Center Disclosure of incidental information shall be avoided whenever possible.

Authorized disclosures of confidential client information to other organizations will be conducted by the clinician who is primarily responsible for the treatment of said client.  If this is not possible or prudent, the Clinical Director or Chief Executive Officer shall oversee the disclosure of confidential client information.

Confidential records are to be maintained in locked quarters within the agency at all times.

In accordance with state law with regards to confidentiality, a client may request information pertaining to their clinical record.  Said request should be submitted in writing to either the Program Director or Chief Executive Officer.  Any information to be released shall include only elements detailed in the Clinical Records Policy (2.H).