Directive to Protect Mental Health Information

 

A NOTE FOR CLINICIANS:

This “Directive to Protect Mental Health Information” intends to increase the probability that clients’ mental health records will stay private and confidential after their deaths and decrease the possibility that these confidential records will be accessed or reviewed by the executor of the estate, descendants, or other people or agencies.

While therapists should keep the original signed Directive in the clients’ files, it is recommended that clients include a copy of the Directive in their medical will and/or living trust. Clients are advised to discuss this directive with the executor of their estate.

The first form is designed for California psychotherapists and the second for therapists in states other than California.

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This is copyrighted material. This material is not to be sold, reprinted, shared or posted online. It may be reproduced for the sole use of the INDIVIDUAL practitioner who ordered the form.

This document does not intend to be a substitute for legal, ethical, or clinical advice or consultation. Therapists must explain to clients that this Directive does NOT assure that records would not ultimately be released to the executor of the estate, descendants, coroner’s office, or other people or agencies who may request to review the records. Patients should understand that a coroner or other people or agencies may have the legal right to access the records and should discuss the Directive and their intentions with their attorney, their descendants, executor of their estate or other appropriate people.

You may modify the form according to your personal and professional needs and according to your state laws and regulations. You must remember that this form does not change the period of records retention that is mandated by your state.

Ofer Zur, Ph.D.
Director, Zur Institute, Inc.
http://www.zurinstitute.com

© 2008 Zur Institute, Inc.

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DIRECTIVE TO PROTECT MENTAL HEALTH INFORMATION
[CA Version]

I hereby appoint [THERAPIST’S NAME] as custodian of my mental health records after my death. This Directive refers to confidential records created while under his/her care. I authorize [THERAPIST’S NAME] to refuse to disclose any Protected Health Information under the Standards for Privacy of Individually Identifiable Health Care Information (45 CFR Parts 160 and 164) under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), the California Confidentiality of Medical Information Act (“CMIA”), and the Lanterman-Petris-Short Act, whether now existing or hereafter created, related to my mental health.

Such Protected Health Information or mental health records shall not be provided to my spouse, my lineal ancestors or descendants, my Personal Representative, my Personal Representative’s respective attorneys, any court, attorney, licensing board, coroner office or medical examiner personnel, other governmental, state or other agency, or any other persons or entities.

If I have authorized someone to receive my Protected Health Information under the Standards for Privacy of Individually Identifiable Health Care Information under HIPAA, CMIA, or the Lanterman-Petris-Short Act, such authorization shall not apply to [THERAPIST’S NAME]

Dated: ____________________

__________________________
Patient’s Name

___________________________
Patient’s Signature

© 2008 Zur Institute, Inc., www.zurinstitute.com

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DIRECTIVE TO PROTECT MENTAL HEALTH INFORMATION
[States other than CA version]

I hereby appoint [THERAPIST’S NAME] as custodian of my mental health records after my death. This Directive refers to confidential records created while under his/her care. I authorize [THERAPIST’S NAME] to refuse to disclose any Protected Health Information under the Standards for Privacy of Individually Identifiable Health Care Information (45 CFR Parts 160 and 164) under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) or other confidential medical records, as defined in [STATE] state law, whether now existing or hereafter created, related to my mental health.

>Such Protected Health Information or mental health records shall not be provided to my spouse, my lineal ancestors or descendants, my Personal Representative, my Personal Representative’s respective attorneys, any court, attorney, licensing board, coroner office or medical examiner personnel, other governmental, state or other agency, or any other persons or entities.

If I have authorized someone to receive my Protected Health Information under the Standards for Privacy of Individually Identifiable Health Care Information under HIPAA, or other state’s laws, such authorization shall not apply to [THERAPIST’S NAME]

Dated: ____________________

_________________________
Patient’s Name

_________________________
Patient’s Signature

© 2008 Zur Institute, Inc., www.zurinstitute.com

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Disclaimer, Copyrights and Liability:

This document does not intend to be a substitute for legal, ethical, or clinical advice or consultation. You must modify the form so it is in compliance with your state law, professional organizations’ codes of ethics and guidelines. This copyrighted material is not to be sold, distributed, or shared by electronic or any other means. The written permission of the author is required for any other reproduction, transmission, or use of the material or portion of the material. Unless otherwise prohibited by law, Zur Institute, Inc., will not be liable to you or to any other third part for: (a) any direct, indirect, incidental, special, punitive, or consequential losses or damages, including, but not limited to, loss of profits, loss of earnings, loss of business opportunities, or personal injuries resulting directly or indirectly from use of the form; or (b) any losses, claims, damages, expenses, liabilities, or costs (including legal fees) resulting directly or indirectly from use of the form. The conditions in this paragraph apply to any acts, omissions, and negligence of Zur Institute, Inc., that would give rise to a course of legal action. You agree to indemnify and hold harmless Zur Institute, Inc., against all claims and expenses (including attorney fees) arising from the use of the form. The form document is provided “as is,” without warranty of any kind. The Zur Institute, Inc., hereby grants you a non-exclusive, perpetual, irrevocable, and non-transferable right to use the form in your private office or private practice. You shall have the right to copy or modify the materials in the Kit only for use in your private office or practice. You shall not have the right to sell, transfer, use it for educational purposes, or give the form to another individual or entity, in whole or in part.

To order more copies of the above Directive, click here.

For Clinical Forms, click here.