La. Admin. Code tit. 48 § I-505

Current through Register Vol. 50, No. 11, November 20, 2024

Section I-505 - Confidentiality and Disclosure

A. Medical records shall be confidential and may only be disclosed as authorized by these rules.

B. Patient's medical records shall continue to be confidential after the patient is discharged from an agency or is no longer receiving treatment from an agency.

C. Secondary medical information shall be disclosed in the same manner as primary medical information for disclosures made pursuant to §509 of these rules. For disclosures made pursuant to §507 an agency shall disclose secondary medical information only if such disclosure is clearly intended by the patient and if the preparer of the secondary medical information authorizes its disclosure. Whenever an agency denies a request for disclosure of secondary medical information pursuant to this rule, the agency shall refer the person requesting the secondary medical information to the preparer of the information. For purposes of this rule, primary medical information means medical information that has been prepared by a person who is an employee of or a contractor with the agency which has custody of the information. Secondary medical information means medical information that is contained in the agency's patient record that was prepared by someone who is not an employee of or a contractor with the agency.

D. Any disclosure made pursuant to these rules, whether with or without the patient's consent, shall be limited to information necessary in light of the need or purpose for the disclosure, as is determined by the superintendent.

E. Records Concerning Disclosure

1. When medical information is disclosed pursuant to §507 of these rules, a copy of the consent form shall be placed in the patient's record. A notation shall be made on the consent form indicating the time and date disclosure was made and the name of the person by whom disclosure was made. When medical information is disclosed pursuant to §509 of these rules, except pursuant to §509 A, a written memorandum shall be made in the patient's record containing the following information:

a. the name of the patient;

b. the time and date on which disclosure was made;

c. the purpose of the disclosure;

d. the person to whom disclosure was made;

e. the person by whom disclosure was made;

f. the information disclosed;

g. a brief description of the basis for disclosure such as patient consent, medical emergency, scientific research, program evaluation, audit, etc. If disclosure does not contain any patient identifying information, no disclosure record is required. (A sample disclosure record is attached.)

2. No person or agency to whom medical information has been disclosed shall further disclose such information except as authorized by these rules.

3. Whenever a written disclosure of medical information is made under the authority of these rules, a notice shall accompany the medical information. This notice shall state: "The medical information contained herewith is confidential pursuant to the law of Louisiana and the rules of the Department of Health and Human Resources. Further disclosure of this information in a form which contains patient identifying information and in a manner inconsistent with state law and regulations is prohibited." Whenever medical information is disclosed orally, the recipient shall be warned that redisclosure is prohibited.

4. Before any disclosure of medical information is made, the superintendent shall use reasonable means to verify the identity and/or status of the person whom disclosure is to be made.

F. Copies of Records. The agency shall charge the person to whom disclosure is made a fee of $1 per copied page to defray the cost of photocopying. If the person to whom disclosure is to be made is a court of competent jurisdiction, a physician, a health facility, a state or federal agency or a school, no fee shall be charged.

G. Medical Information Concerning Minors. Except as is provided in §509 of these rules, medical information concerning a minor can only be disclosed upon the written consent of the parent or tutor of the minor. However, if the minor has consented to medical treatment pursuant to R.S. 40:1095 (treatment for illness or disease), R.S. 40:1095 (treatment for drug abuse), or R.S. 40:1065.1 (treatment for venereal disease), medical information can only be disclosed upon the consent of the minor. Consent to disclosure of medical information which has been executed by a minor shall not be subject to a later disaffirmance by reason of his minority. Upon the advice and direction of a treating physician, a physician or a member of a medical staff may, but shall not be obligated to, inform the spouse, parent or tutor of the minor as to the treatment given or needed and this information may be given or withheld without the consent and over the express objection of the minor.

H. Medical Information Concerning Interdicts. Except as provided in §509 of these rules, medical information concerning an interdict shall only be disclosed upon the written consent of the curator of the interdicted patient.

I. Medical Information Concerning Deceased Persons. Except as provided in §509 of these rules, medical information concerning a deceased person shall be disclosed upon the written consent of the administrator or executor of the succession of the decedent. In the event no administrator or executor has been appointed, the decedent's spouse, parent, or any child of the age of majority is authorized to execute the written consent.

J. Medical Information Concerning Incapacitated Patients. Except as is provided in §509 of these rules, medical information concerning a patient who is temporarily incapacitated from consenting to disclosure because of physical or mental infirmities as is determined by the attending physician, shall be disclosed only upon the written consent of the patient's spouse, major child, or parent.

K. Refusal to Consent to Disclosure of Records. Except as otherwise provided in these rules, all patients have the right to refuse to consent to the disclosure of medical information concerning themselves and no agency shall refuse medical treatment to a patient solely because he refuses to consent to the disclosure of medical information about himself.

L. Delegation of Authority by the Superintendent. Whenever these rules assign a function or responsibility to a superintendent, the superintendent may delegate this function or responsibility to any employee under his control, who, in the superintendent's opinion, is qualified to perform the function or responsibility.

La. Admin. Code tit. 48, § I-505

Promulgated by the Department of Health and Human Resources, Office of the Secretary, LR 13:246 (April 1987).

AUTHORITY NOTE: Promulgated in accordance with R.S. 44:7.