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Medical Records

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Medical Records

Requirements about records, documentation, retention, authentication, and patient information.

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Records Health Information

Category

Medical Records

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9

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Citation

42 CFR § 2.11

In Medical RecordsConfidentiality Disclosure

Definitions.

For purposes of the regulations in this part:

Group

Definitions Scope Authority

Category

Definitions Context

Domain

Records

Topics

Substance use disorder records, Patient record confidentiality

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Citation

42 CFR § 2.13

In Medical Records

Confidentiality restrictions and safeguards.

This provision mandates strict confidentiality for substance use disorder patient records and limits disclosures to those necessary for the intended purpose.

Group

Records Health Information

Category

Confidentiality Disclosure

Domain

Records

Topics

Substance use disorder records, Patient confidentiality

Read

Citation

42 CFR § 2.22

In Medical RecordsPatient Rights

Notice to patients of Federal confidentiality requirements.

This provision mandates that substance use disorder treatment programs provide patients with a formal notice of their privacy practices, legal duties, and patient rights regarding the confidentiality of their records.

Group

Records Health Information

Category

Confidentiality Disclosure

Domain

Behavioral Health

Topics

Substance use disorder privacy notice, Patient privacy rights

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Citation

42 CFR § 2.25

In Medical RecordsHIPAA Privacy Security

Accounting of disclosures.

This provision mandates that part 2 programs provide patients with an accounting of disclosures of their substance use disorder records upon request.

Group

Records Health Information

Category

Medical Records

Domain

Behavioral Health

Topics

Accounting of disclosures, Substance use disorder records

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Citation

42 CFR § 2.31

In Medical Records

Consent requirements.

This provision specifies the required elements for written consent for the use or disclosure of substance use disorder patient records.

Group

Records Health Information

Category

Confidentiality Disclosure

Domain

Behavioral Health

Topics

Patient consent requirements, Substance use disorder records

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Citation

42 CFR § 2.32

In Medical Records

Notice and copy of consent to accompany disclosure.

This provision requires that any disclosure of substance use disorder records made with patient consent must be accompanied by a specific written notice and a copy of the consent.

Group

Records Health Information

Category

Confidentiality Disclosure

Domain

Behavioral Health

Topics

Disclosure notice requirements, Substance use disorder records

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Citation

42 CFR § 2.52

In Medical RecordsResearch Privacy Confidentiality

Scientific research.

This provision establishes the requirements for the use and disclosure of patient identifying information for scientific research, including researcher obligations, IRB approval for data linkages, and data security and retention standards.

Group

Research Human Subjects

Category

Human Subjects Protections

Domain

Records

Topics

Scientific research data disclosure, Substance use disorder record confidentiality

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Citation

42 CFR § 2.53

In Medical RecordsHIPAA Privacy Security

Management audits, financial audits, and program evaluation.

This provision establishes the requirements for disclosing patient identifying information from substance use disorder records for the purpose of conducting management audits, financial audits, and program evaluations.

Group

Records Health Information

Category

Confidentiality Disclosure

Domain

Records

Topics

Substance use disorder record disclosure, Audit and evaluation disclosure

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