6800 APPENDIX 7 Limits ofConf Health Info (DOC-1923).doc
DOC document 52 KB Posted
- Contract number
- 410036-M19-CJO6800-RFB-00
- Issued by
- Wisconsin
About this file
This document is a Wisconsin Department of Corrections (DOC) form DOC-1923 titled "Limits of Confidentiality of Health Information" that establishes confidentiality protocols for health care information within Wisconsin's correctional system. The form applies to the Department of Corrections Office of the Secretary and involves multiple divisions including the Division of Adult Institutions (DAI), Division of Juvenile Corrections (DJC), and Division of Community Corrections (DCC). The document references compliance with Wisconsin Statutes 48.981, 51.30, 146.81-84, 252.15, and 938.78, as well as federal regulations 42 CFR Part 2 and 45 CFR Parts 160, 162, and 164.
The form outlines the confidentiality rights and limitations for offender health care information across Wisconsin's correctional facilities. It specifies that DOC health care providers include physicians, nurses, psychiatrists, psychology staff, dentists, physical therapists, substance use disorder treatment providers, and supervised staff who document interactions in various records including Medical Charts, Dental Records, and Psychological Services Unit Records. The document establishes that offenders have limited confidentiality rights, with DOC staff having access to minimum necessary health information based on job requirements. The form requires mandatory reporting of confidential information when it involves threats to safety, sexual activity or assault, escape plans, drug or weapon possession, suspicious deaths, or unknown criminal conduct that poses risks to correctional facilities or public safety. External disclosure of health information requires either signed authorization, valid court orders, or legal permission under Wisconsin or federal law.
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Text version
DEPARTMENT OF CORRECTIONS
OFFICE OF THE SECRETARY
DOC-1923 (Rev. 5/2018)
WISCONSIN
Wisconsin Statutes
§ 48.981, 51.30,146.81-84, 252.15, 938.78
Federal Regulations
42 CFR Part 2
45 CFR Parts 160, 162 and 164
LIMITS OF CONFIDENTIALITY OF HEALTH INFORMATION
NOTE:
· DAI uses WICS ORPT170/DOC-2468 for inmates upon admission to a DAI facility.
· DAI Psychological Services Units, DJC and DCC may use this form, as appropriate.
OFFENDER NAME
DOC NUMBER
THIS FORM EXPLAINS YOUR CONFIDENTIALITY RIGHTS FOR HEALTH CARE INFORMATION. READ IT CAREFULLY
1. Department of Corrections (DOC) health care providers include physicians, nurses, psychiatrists, psychology staff, dentists, physical therapists, substance use disorder treatment providers, other health professionals, and staff supervised by those providers.
2. Health care providers document every interaction with you in your Division of Adult Institutions (DAI) / Division of Juvenile Corrections (DJC), Health Care Record, such as your Medical Chart, Dental Record and Psychological Services Unit Record, Division of Community Corrections (DCC) Mental Health File, and in limited circumstances in your DAI/DJC Social Services File and DCC/DJC Field Case File.
3. You have a right to limited confidentiality of your health information within the DOC. DOC staff with a job-based “need to know” may have access to the minimum amount of health information contained in a DOC record pertaining to you.
4. Health care providers have the right to access all health information necessary to meet your health care needs.
5. Non-health care employees, including but not limited to, Wardens/Superintendents, Correctional Officers, Inmate Complaint Examiners, Social Workers, Bureau of Offender Classification and Movement Specialists, Parole Commission/Joint Planning Review Commission /OJOR members, Probation/Parole Agents, and Youth Counselors may have access to the minimum amount of health information needed to make decisions related to your custody level, safety, movement and release, to resolve your complaints, and to supervise you in the community.
6. Health care providers must report otherwise confidential information to the appropriate DOC authorities if it raises concern about a threat to you, a DAI or DJC correctional facility, community corrections operations, and/or public safety. This may include the following:
a. Overt/covert threats or harm to yourself or others.
b. Reports of any alleged sexual activity between an offender and any other person.
c. Reports of any sexual assault or intimidation between an offender and any other person.
d. Plans to riot or escape and possession of drugs or weapons.
e. Suspicious or unexplained deaths (homicides, suicides).
f. Unknown past criminal conduct that increases the potential risk to a correctional facility, community corrections operations, and/or the public, including self-reported acts of homicide, attempted homicide, and first or second degree sexual assault.
7. DOC shall not permit individuals outside the DOC to access health information about you unless one of the following applies:
a. You or a person legally authorized to act on your behalf, signs an Authorization for Use and Disclosure of Protected Health Information (DOC-1163A), or equivalent form, authorizing the disclosure.
b. A judge issues a valid court order authorizing the DOC to disclose the information.
c. A Wisconsin or federal law permits the disclosure by the DOC without a signed authorization.
I have read (or had read to me) the above information and have been given the opportunity to ask questions. I understand the limits of confidentiality of my health information explained in this document.
| OFFENDER OR PERSON AUTHORIZED TO SIGN ON BEHALF OF OFFENDER |
| DATE SIGNED |
DISTRIBUTION:
DCC: Original – DCC Offender Case File or DCC Mental Health File; Copy – Contract Agency File (if applicable); Copy – Signer upon request DJC: Original (DJC) - PSU Record, Legal Documents/Consents/Outside Records Section; Copy – Signer upon request DAI-PSU: Original - PSU Record, Legal Documents/Consents/Outside Records Section; Copy – Signer upon request signing
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