Am I allowed to disclose mental health treatment and counseling records to SSA?
Mental health treatment records are a necessary and integral part of the evidence needed for DDS to make a disability determination for someone alleging mental illness as an impairment. You are permitted and encouraged to support a claimant’s application with the disclosure of your records (with proper authorization). The records that are excluded from this authorization are “psychotherapy notes,” which are a specific type of note not typically a part of most medical records, especially in publicly funded settings.
As HIPAA defines the term, “psychotherapy notes means notes recorded in any medium by a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session and that are separated from the rest of the individual’s medical record. Excluded from “psychotherapy notes” are medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date.
If you keep psychotherapy notes separate from your other medical records, you can send the set of records without the psychotherapy notes. If you do not keep psychotherapy notes separate from other parts of the medical records, you can legally disclose all of the records. However, you can choose to black out or remove the parts of the records that would be considered psychotherapy notes. Another option is to prepare a report that details the critical current and historical aspects of the applicant’s treatment and functional information, such as a SOAR Medical Summary Report.
For more information, see SSA’s Fact Sheet for Mental Health Care Professionals: http://www.ssa.gov/disability/professionals/mentalhealthproffacts.htm