3700, Client Records Management

Revision 22-2; Effective April 1, 2022

HHSC contractors must have an organized and secure client record system. The contractor must ensure that records are organized, readily accessible and available to the client upon request with a signed release of information. Records must be kept confidential and secure, as follows:

  • Safeguarded against loss or use by unauthorized individuals;
  • Secured by lock when not in use and inaccessible to unauthorized persons; and
  • Maintained in a secure environment in the facility, as well as during transfer between clinics and between home and office visits.

The written consent of the individual is required for the release of personally identifiable information, except as may be necessary to provide services to the individual, or as required by law, with appropriate safeguards for confidentiality. If the individual is a minor, the minor’s parent, managing conservator or guardian, as authorized by Chapter 32 of the Texas Family Code or by federal law or regulations, must authorize the release. Emancipated or married minors authorize the release of their own information. HIV information should be handled according to state and federal Law, Rules, and Authorization.

When information is requested, contractors must release only the specific information requested. Information collected for reporting purposes may be disclosed only in summary, statistical or other form that does not identify individuals. Upon request, individuals transferring to other providers must be provided with a copy or summary of their record to ensure continuity of care. Electronic records are acceptable as medical records.

Contractors, providers, subrecipients and subcontractors must maintain for the time specified by HHSC all records of client services, contracts and payments. 

Requirements are found in Title 1, Part 15 TAC §354.1003, relating to time limits for submitted claims, and in Title 22, Part 9 TAC §165, relating to maintenance of medical records. Contractors must follow contract provisions, maintain medical records for at least seven years after the close of the contract and follow the retention standards of the relevant licensing entity. All records relating to services must be accessible for examination at any reasonable time to representatives of HHSC and as required by law.