Embrace Nondisclosure and Confidentiality Policy
I. GENERAL CONFIDENTIALITY PRINCIPLES
To ensure the safety and privacy of adult, youth and child program participants, it is the policy of Embrace Services, Inc. (Embrace) to protect the confidentiality of those who seek services. All program staff and volunteers are charged with maintaining the confidentiality of program participants as outlined in these policies.
Embrace shall not disclose any personally identifying information or individual information collected in connection with requested services, utilized, or denied through its programs nor reveal any individual program participant information without the informed, written reasonably time-limited consent of the person about whom information is sought, or in accordance with other guidelines as set forth in these policies. All program participants, denied or assisted, whether they are receiving services in person or on the telephone, will be informed of the confidential nature of our services.
Program staffs’ continued employment/involvement with Embrace is contingent upon strict adherence to confidentiality.
The obligation to maintain confidentiality does not end when service to a program participant or employment/involvement with the program concludes. Confidentiality extends to all current and former program participants, including those who were denied service, and to all current and former program staff.
II. WRITTEN AGREEMENT TO MAINTAIN CONFIDENTIALITY
All Embrace personnel, including staff, volunteers, interns, contractors, and Board Directors, must sign a written agreement to maintain confidentiality. This agreement shall be placed in the personnel files of the staff.
III. RELEASES OF INFORMATION
Confidential information and/or program records may be released only in accordance with the guidelines set forth in this section. Staff may disclose personally identifying information or individual information only if the program participant gives informed, written, reasonably time-limited consent to do so; the program participant must sign a written release of information prior to disclosure of information or records outside Embrace.
Program participants must be clearly advised of the alternatives to and possible consequences of any release of confidential information by the Embrace. The program participant should also be informed that any statement addressed to workers of an outside agency is not covered by the advocate-program participant privilege and may be used against them or be discoverable to the opposing party in a legal proceeding.
A. Process for Obtaining Informed, Written, Reasonably Time-Limited Consent
Before signing a release for Embrace to disclose confidential information and/or records, the program participant shall review the information to be released and evaluate the benefits and drawbacks of releasing that information. Staff shall help the program participant determine whether there is an alternative way to meet their needs without disclosing confidential information and/or records. Staff shall ensure that the program participant is informed of the scope of the information to be disclosed, the purpose for which the information is to be released, the duration for which the release is valid, and the potential consequences of disclosure.
1. Consent must be informed
Informed consent means that the program participant gave explicit permission after all of the following:
a. the situation was explained to them fully and carefully;
b. the information was conveyed in a language and style that they understood;
c. the information was conveyed in their first language; and
d. the program participant had the opportunity to say no or to change their mind.
2. Consent must be in writing
Releases must be in writing, signed, and dated. The written release must:
a. specify the information being released;
b. include the purpose for which the information is being released;
c. state that it is a limited release, intended only for the limited purpose noted;
d. designate the individual or agency to whom the information is being released;
e. specify a time limit for the release that may not be extended without the program participant’s permission;
f. state that it is revocable at any time by the program participant; and
g. include a statement acknowledging that the program participant has read the form, been informed of the alternatives to and risks and benefits of disclosure, and the potential consequences of authorizing the release of information to third parties.
h. Whenever possible, program staff should witness the program participant’s signing of the release. After the release is signed, it shall be placed in the program participant’s file.
Separate releases should be provided for different agencies or third parties and for different pieces of information being relayed to the same agency or third party.
3. Consent must be reasonably time limited
Reasonably time-limited is determined by the circumstances, based on the program participant’s needs.
4. Consent must not be coerced
When obtaining releases, program staff should exercise care to ensure that the program participant has not been coerced into signing the release. The program participant should be informed both verbally and in writing that they may choose not to sign the release of information.
5. Consent must not be a condition of eligibility for services
A program participant cannot be required to provide consent to release their personally identifying information as a condition of eligibility for the services provided by the Embrace.
6. Consent from unemancipated minors and those with legal guardians.
Embrace cannot release personally identifying or confidential information regarding the minor without a release signed by the minor and/or the protective parent. See Embrace’s Policy on Providing Services to Minors and Protecting Confidentiality.
B. Program Participant Revocation of Consent
If a program participant verbally revokes a release of information or records, program staff should attempt to get the revocation in writing. Even without written revocation, however, program staff must honor the verbal revocation immediately and not release any information. Program staff shall record the verbal revocation in the program participant’s file.
C. Verbal Authorization to Release Information
It is the policy of Embrace to obtain a written release of information before disclosing any confidential information and/or records whenever possible. If program staff is unable to obtain a written release of information due to compelling circumstances, program staff may accept a verbal authorization. If possible two staff should confirm a verbal release of information. Program staff should obtain a written authorization confirming the verbal authorization at the first possible opportunity. A faxed copy or email of a written release of information is sufficient if verbally confirmed over the phone.
D. Release Forms from an Outside Agency
Release forms received from another agency, even if signed by a program participant, are not sufficient to allow the Embrace to release confidential information and/or records. When Embrace receives an outside release of information requesting confidential information and/or records, program staff should contact the program participant to ensure that the release was informed and voluntary. If the program participant wishes that the information be released to the outside agency, the program participant will sign Embrace’s written release of information.
IV. PROHIBITION ON DISCLOSING INFORMATION OUTSIDE THE PROGRAM
Program staff shall respond to inquiries regarding a program participant in ways which do not explicitly or implicitly reveal whether a program participant is or is not at the Embrace. Program staff may only say “I can neither confirm or deny the location of a person or whether a person is receiving services from the Embrace. You can leave a name and contact number.”
A. Contact with Program participants in Community/Public Place
Embrace staff will protect a program participant’s confidentiality in the community and in public places. Program staff should discuss the possibility of public encounters with the program participant in advance if possible and let them know how they plan to respond.
B. General Public
All materials used for teaching, public announcements, community education, or written or verbal reports directed to sources outside Embrace shall not identify the program participant involved. The only exception is if the program participant asks the Embrace to identify them and gives their written permission for the Embrace to do so. The program participant should sign a release of information.
C. Memorandums of Understanding (MOU) with Outside Agencies
If Embrace enters into a MOU with an outside agency, Embrace must continue to maintain program participants’ confidentiality. To the extent possible, MOUs should explicitly prohibit the sharing of confidential program participant information between Embrace and the outside agency without a written release of information and if applicable a waiver of nondisclosure. Even if an MOU does not explicitly prohibit the sharing of confidential program participant information, Embrace is still prohibited from sharing confidential information without a release of information.
D. Audit by Funding Source
Funders who are mandated to audit program files must sign a confidentiality agreement before viewing any records that may contain protected information. Personally identifying information and/or individual information shall be covered, redacted or removed from records before they are viewed by auditors/funders. Auditors/funders are prohibited from removing, copying, or taking pictures of any contents and/or information contained in a program participant’s file.
E. Participation on Outside Inter-or Multi-disciplinary Teams/Committees
A program staff who participates as a member of an inter-or multi-disciplinary team/committee shall continue to maintain program participants’ confidentiality and comply with all confidentiality laws. Program staff may not reveal any confidential or personally identifying information without a release of information and, if applicable a waiver of nondisclosure.
V. PROHIBITION ON DISCLOSING INFORMATION TO LAW ENFORCEMENT
Program staff shall respond to law enforcement inquiries regarding a program participant in ways which do not explicitly or implicitly reveal whether a program participant is or is not receiving services. Program staff may only say “I can neither confirm or deny the location of a person or whether the person is receiving services from the Embrace.”\
A. Protections for Battered Immigrant Victims
Program staff shall not disclose confidential information about program participants who are not U.S. Citizens, whether documented or undocumented. Program staff are prohibited from contacting immigration authorities or law enforcement regarding the status of an undocumented immigrant battered victim.
Law Enforcement cannot perform enforcement actions at protected locations, including: shelters, rape crisis centers, community based organizations, supervised visitation centers, and family justice centers or at a courthouse, if a victim is present at the courthouse for any action in connection with a crime (See 8 U.S.C. Section 1129(e) and INA Section 239(e).
B. Exceptions to Prohibition on Disclosing Information to Law Enforcement
1. Release of Information and Waiver of Non-Disclosure
If the program participant has signed an Embrace Release of Information and Waiver of Non-Disclosure to law enforcement, program staff may release the specified information during the specified time frame to law enforcement.
2. Warrants and Welfare Checks
See procedures below for verifying and providing information to comply with warrants and welfare checks in Section VII Law Enforcement Warrants and Welfare Checks.
3. Other Situations
There may be very limited circumstances where Embrace staff believe that confidentiality and privilege may be dismissed and contact with law enforcement is necessary (such as death of a program participant or program staff, or program participant has asserted that they are going to cause great bodily harm to themselves or others). In these circumstances and if time allows, program staff should consult with the Executive Director before dismissing confidentiality and disclosing any information to law enforcement.
a. If it is a non-emergency, Staff Members should do their best to solve the issue without law enforcement involvement. De-escalation techniques of mirroring, empathizing, and validating the person’s feelings to avoid and reduce confrontation should be used.
b. Advise the survivor a report will be made to the appropriate agency for their protection and the protection of others. Encourage the survivor to report alongside staff and sign a release of information form to the appropriate agency.
c. Law enforcement officers are only allowed in the waiting area without a search warrant or felony arrest warrant so as to not disclose the identity of other residents. Any interior or secondary doors between the officer and survivors must remain shut and locked.
d. Embrace Staff Members should ask the involved program participants to meet in the front office/waiting room or go with law enforcement in order to avoid disruption of others (prevent a search of the Shelter/Office) and maintain others’ confidentiality.
e. Embrace Staff Members are not allowed to identify other program participants or residents in the Shelter/Office who are not involved in the incident, and should do their best to avoid disruption of others and maintain their confidentiality.
4. Child Abuse and Neglect (CAN) Reporting Policy
There are exceptions to confidentiality as detailed in Embrace’s Child Abuse and Neglect Reporting Policy.
If you have questions or would like to know more about the full policy and procedure, contact Katie at katie@embracewi.org.
