LOS ANGELES COUNTY
DEPARTMENT OF MENTAL HEALTH
  POLICY 300.03 Clinical Correspondence Concerning Clients
 
  PROCEDURES
  1. Prior to providing a response to a request correspondence:
     
    1. The appropriate authorization must be obtained pursuant to DMH Policy 500.01, Use and Disclosure of Protected Health Information Requiring Authorization, unless the response is pursuant to DMH Policy 500.02, Uses and Disclosures of Protected Health Information Not Requiring an Authorization.
       
      1. A valid Authorization for Use or Disclosure of Protected Health Information in accordance with DMH Policy 500.01 must be obtained and filed in the Clinical Record.
         
    2. The request, authorization (if applicable), and proposed response must be reviewed and approved by an administrative supervisor.
       
  2. Information in the response to a request for correspondence must meet the following standards:
     
    1. Correspondence must be addressed to the specific active/inactive client or outside agency/individual to whom the correspondence is being transmitted and may NOT be addressed "To Whom It May Concern".
       
    2. If an active/inactive client or outside agency/individual requests clinical correspondence based on historical information from the client's record, the correspondence may be provided and filed as correspondence in the clinical record whether or not the client is an active client. 
       
    3. If an active/inactive client or outside agency/individual requests information regarding the client's current status/condition, the information may only be provided when the client is actively receiving mental health treatment:
       
      1. If the client is currently inactive and a decision is made to provide information regarding the client's current status/condition, the client must be re-activated per the Short-Doyle/Medi-Cal Organizational Provider’s Manual.
         
      2. If the client is currently active, it is the clinician's responsibility to determine if updated clinical documentation in the clinical record is required for the documentation to comply with this policy.
         
    4. Requests for documentation determining a client's ability to return to work: A practitioners' response to requests from active clients for documentation regarding the client's ability to return to work related to his/her mental health treatment shall be based upon information contained in the clinical record. Examples of the correspondence:
       
      1. My assessment of the client is that the previous symptoms that he/she states have interfered with his/her ability to work have improved. He/she is responding to treatment and participating in recommended treatment modalities.
         
      2. My assessment of the client is that the previous symptoms that he/she states have interfered with his/her ability to work are still present.