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EFFECTIVE DATE: April 1, 2020



To establish the criteria required for the exchange and/or release of confidential client information in the course of service provision by a Subrecipient.



Subrecipient is an agency that has entered into a grant agreement with The Resource Group to provide services.


Confidential Client Information is any information that might disclose a client’s identity including, but not limited to, client name, address, phone number, social security number, or other identifying information.


Protected Health Information (PHI) under the US law is any information about health status, provision of health care, or payment for health care that is created or collected by a Covered Entity (or a Business Associate of a Covered Entity), and can be linked to a specific individual. This is interpreted rather broadly and includes any part of a patient's medical record or payment history.


Client is an individual seeking services from a funded Subrecipient. For the purpose of these policies, client includes legal guardians and/or powers of attorneys.


Informed consent is a process for getting permission before conducting a healthcare intervention on a person, or for disclosing personal information. A health care provider may ask a patient to consent to receive therapy before providing it, or a clinical researcher may ask a research participant before enrolling that person into a clinical trial. Informed consent should be given based upon a clear appreciation and understanding of the facts, implications, and consequences of an action. Adequate informed consent is rooted in respecting a person's dignity. To give informed consent, the individual concerned must have adequate reasoning faculties and be in possession of all relevant facts.

Primary client record (PCR) describes the systematic documentation of a single client’s medical history and care including support services offered at the agency, across time within one particular health care provider’s jurisdiction. The primary client record (PCR) provides an account of each episode in which a client visited or sought treatment and received care or a referral for care (including support services) from a specific Subrecipient.


Subrecipients that receive funding from The Resource Group must establish a procedure for releasing confidential client information and/or protected health information. This procedure must include written consent from the client via an Exchange/Release of Information or equivalent form. This form is designed to document client’s informed consent for confidential client information/protected health information to be disseminated by the Subrecipient and protects the Subrecipient from violating applicable confidentiality laws.



1. Upon receiving funding from the Resource Group, Subrecipients must develop a policy that covers the exchange/release of confidential client information/protected health information.

2. The policy should require the Subrecipient staff to obtain written informed consent from a client prior to releasing or exchanging confidential client information with a third party. 3. The policy should include a provision that allows the Subrecipient to, under emergency conditions such as a life-threatening situation or when a client’s condition precludes the possibility of obtaining written consent, provide pertinent information to the medical personnel responsible for the client’s care. The staff member responsible for the release of this information shall enter all pertinent information about the transaction into the primary client record.

4. The policy should also address the Subrecipient’s requirement to provide information under circumstance involving a court order or subpoena.

5. As part of that policy, the Subrecipient must develop a written consent for the exchange/release of information form that includes the following required elements:

a. Name of agency/agencies to which the information is disclosed

b. General information to be disclosed

c. General purpose of disclosure

d. Signature of client and date the consent was signed e. Expiration date (no greater than two years from date of original signed consent)

6. When client information is disclosed, the client record must contain the following:

a. The consent to release information

b. The actual date the information release

c. The signature of the staff member disclosing the information

7. Clients must be allowed to withdraw their consent to exchange/release information to any individual or organization at any time. This withdraw of permission should be documented within the file.

8. Subrecipient staff should review signed consents at a minimum every two (2) years and reobtain consent as part of the required annual update.

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