Clinical File Requests (Third Party and/or Client) 

Clients have a legal right to their Clinical File. However, whenever possible, we do our best to avoid giving it to them without first going through proper policy and procedure. Some reasons for this are listed below:

• Clients are often not aware of privacy laws/policies 

• Clients may be surprised, disappointed or upset by what they read in their file

• Clients may not fully understand what is written in their file

Fees: We recommend you pro-rate your session rate for the duration of time it takes to complete the summary letter 

For providing a clinical file, we are limited to the PHIPA fee schedule: See below to calculate the fee you can charge

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Process:

• Upon receiving a request for a clinical file, upload the request to the client file under chart. Be mindful of the due date for the request.

• Set up a consultation with your client. In the consultation you should review the following:    

  • Risks and benefits associated with relinquishing an entire file

  • Alternatives to an entire file such as a summary report, and the benefits and risks of alternative options

  • Confirm that the client consents to whatever option they select, and that said consent was fully informed.

  • Inform client of the approximate cost of service (if not predetermined) and ensure they are agree to pay this

  • Be sure to chart ALL of the above.

• Send Consent to Disclose form directly from Jane. 

  • If it is a couple, we need both of them to sign the form and consent

  • If it is a child, we need both parents’ consent 

• Complete the summary letter using Rebound Total Health Letterhead  (make a copy of the file, then edit) OR  prepare the client file (depending on client choice)

• Inform admin of the total cost for the work completed, so we can add it to Jane as a product

• Confirm that all consents have been signed.

• Bill client following guidelines in Billing A Product document.

• Submit the file or summary letter to the client.

• Chart that the file or summary letter has been sent, attach summary letter to file, if applicable.

• Include this on your monthly invoice, billed at your split.

• Be sure to properly delete/dispose any files you’ve been working on on your computer as per phipa