Requests for Reports

Standard 5.2: Requests for Reports

The Professional Practice Standards regarding requests for reports. This includes the two standards, examples in demonstrating the standard, definitions, and related resources.

Requests for Reports

Standard 5.2: Requests for Reports

The Professional Practice Standards regarding requests for reports. This includes the two standards, examples in demonstrating the standard, definitions, and related resources.

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The Standard

 

5.2.1 Upon request, registrants provide, within a reasonable time, a report or certificate relating to treatment performed, unless there is reasonable cause not to do so.

 

5.2.2 When providing a report or certificate, registrants indicate whether they are providing opinion, stating objective fact, or summarizing information provided by a client.

Standard 5.2

Demonstrating the Standard

  • Standard 5.2

    • Responding fully to a request for a report or certificate from a client or their authorized representative.
    • Ensuring compliance with Standard 3.1 – Confidentiality throughout the reporting process.
    • Delivering the response within 30 days of receiving the request.
    • When a delay is unavoidable, alerting the party initiating the request, sharing the reason for the delay, and providing a firm date by which the request will be met.

Key Definitions

  • Key Definitions

    Report or certificate

    A report or certificate includes a letter, summary, or form, whether formal or informal, regarding the treatment of a client. It does not include providing a copy of the client record itself, which is addressed in Standard 5.1.

Standard 5.2

Commentary

Background

One reason registrants maintain effective record-keeping systems is for issuing timely reports when requested by a client or their authorized representative. When a registrant has any doubt as to whether another person is acting on a client’s behalf, they should verify with the client that they have agreed for the person to do so.

 

A proper response is one that is delivered in writing and responds fully to the request, insofar as the registrant is able to do so within their scope of competence. That is, registrants do not state facts that are outside their knowledge or opine on matters outside their expertise.

 

In many cases, the information or document requested is required for legal proceedings, employment, or insurance matters. When a registrant reasonably believes that a requested report would contain sensitive information, they should explain to the client the nature of the information that would be included. The registrant should document whether the client wishes to proceed with having the report prepared and released.

 

Delays (or refusal) to satisfy the request could seriously disadvantage a client. Reasonable causes for delay might include the unavailability of a critical piece of information, illness of the registrant, or the need to inform other individuals, e.g., a family member who attended some of the sessions. In complex situations, the registrant may require time to obtain legal advice.

 

There are also some situations where it may be appropriate for an RP to refuse to provide a requested report. These situations are limited, but include:

 

  • Not having the competence to provide the information sought, although a registrant may still be able to provide factual information, such as treatment dates and presenting issues.
  • Not having the appropriate consent or legal authorization to disclose the information.
  • Where a report could cause significant harm (not in the best interests of a child, etc.).

 

Registrants are generally permitted to charge reasonable fees for preparing requested reports as long as they have first given the payer an estimate of the fee. For example, it would be appropriate for registrants to base the fee on their pro-rated hourly therapy fee. However, registrants cannot refuse to prepare a requested report or release a requested document simply because the client is unable to pay. Similarly, registrants cannot refuse to prepare a requested report or release a requested document simply because of a dispute with the client.

Providing information to clients about services

Registrants are required to reply appropriately to a reasonable request by a client or a client’s authorized representative for information about a service or product provided or recommended by a registrant.

Confidentiality and Reporting

Upon receiving a request for a report, registrants should first seek express consent from their client, or their authorized representative to provide the report and discuss the requested content. Registrants should ensure that only relevant and requested information is provided, and provide clients the opportunity to review the report prior to submission. Finally, registrants must ensure that reports are sent through secure means.

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