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Organization Policy on the Use or Disclosure of Psychotherapy Notes for Research (Policy No. HIPAA 164.3)

January 2007

Definitions

Disclosure means the release, transfer, provision of, access to, or the divulging in any manner of PHI to persons or entities outside of the Johns Hopkins Covered Entities and Related OHCA Participants.

HIPAA means the Health Insurance Portability and Accountability Act of 1996.

Johns Hopkins Covered Entities and Related OHCA Participants -- see Johns Hopkins HIPAA website for HIPAA Forms/Policies Templates or http://www.insidehopkinsmedicine.org/hipaa/ohcan.cfm

Johns Hopkins means the Johns Hopkins University School of Medicine (JHU SOM).

Privacy Regulations means the regulations promulgated by the Secretary of the Department of Health and Human Services to implement portions of HIPAA that concerns the confidentiality of health information, as amended from time to time; these regulations currently include 45 CFR §§ 160 and 164, subparts A and E.

Psychotherapy notes means notes recorded in any medium by a mental health provider documenting or analyzing the contents of conversation during an individual or group counseling session, provided that such notes are separated from the rest of the medical record.  Psychotherapy notes do not include information about session start and stop times, medications, modalities and frequency of treatment, results of clinical tests, or any summary of the following:  diagnosis, functional status, treatment plan, symptoms, prognosis, and progress to date.

Use means the sharing, employment, application, utilization, examination or analysis of PHI within the Johns Hopkins Covered Entities and Related OHCA Participants. 

Policy

It is the policy of Johns Hopkins to protect the privacy rights of all patients, health plan members, employees, students and donors; to maintain the confidentiality of patient information, health plan information, medical records, research information and business operations; and to comply with all applicable laws and regulations, including the Privacy Regulations under HIPAA.

Johns Hopkins may permit the use and disclosure of psychotherapy notes for research only pursuant to a completed and signed Authorization for Use or Disclosure of Psychotherapy Notes For Research

Procedure

  1. When a research protocol requires use or disclosure of psychotherapy notes, the Principal Investigator should complete the Authorization for Use or Disclosure of Psychotherapy Notes For Research form in addition to the privacy authorization form or combined authorization/informed consent form.  The Principal Investigator should take care to ensure that all necessary uses and disclosures of health information are described accurately and completely in the authorization form.
  1. The JH IRBs may not waive the requirement for HIPAA authorization for the use or disclosure of psychotherapy notes.  The Authorization for Use or Disclosure of Psychotherapy Notes For Research may not be combined with the informed consent form or with any other HIPAA authorization. 
  2. If a person or organization is not included on the Authorization for Use or Disclosure of Psychotherapy Notes For Research form, that person or organization may neither receive psychotherapy notes nor use or disclose psychotherapy notes for research purposes. 


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