Clients may request letters, summaries, assessments, or copies of their clinical records for a variety of reasons. Requests may come directly from clients or from third parties such as insurance companies, lawyers, schools, employers, or other organizations. This article explains how therapists should handle Documentation Requests, including the different types of documentation, associated fees, therapist responsibilities, and delivery methods.

All standard Documentation Requests are submitted through Ruh Care's centralized Documentation Request form.

The form covers the following types of requests:

It is important to distinguish standard documentation requests from special program reports, such as those required for IFHP, CVAP, or ICBC. Special program reports are part of service delivery for eligible clients and follow the requirements of the applicable program rather than the standard Documentation Request process. Special program reports and assessments are not submitted through the Documentation Request form. Refer to this article (coming soon) for relevant program-specific guidance when completing documentation required by a funder or program.

A Treatment / Service Verification Letter provides basic confirmation that a client has received or is receiving services through Ruh Care.

Cost: Free

Therapist compensation: None

Therapist involvement: None expected

These letters are intended to be generated through the Ruh Care system where possible, so therapists should not need to prepare them manually.

A Full Client Record Release provides the client with a copy of their clinical record.

This is not the default documentation option and should only be provided when appropriate. A treatment summary is generally preferred when a client needs information about their care, as it provides relevant clinical information without unnecessarily disclosing the client's complete record.

Cost: Based on applicable program requirements. If no funding is available, there is generally no charge for the record itself, although registered-mail costs may apply.

Therapist compensation: None

Therapist involvement: Review and redaction may be required

Delivery: Through the client's secure Documents section on the Ruh Care platform; physical records, where required, are sent by registered mail.

The Client Care Team will coordinate the release of the record. However, the therapist may be asked to review the record and identify information that should be redacted before it is released.

If you receive a request for a Full Client Record Release:

Records should generally be released to the client, rather than directly to a third party, even when the client has provided authorization for the third party to receive the records.

A Treatment Summary is a clinician-prepared summary of the client's treatment. Depending on the purpose of the request, it may include relevant presenting concerns, treatment goals, interventions, progress, and other clinically appropriate information.

Cost:

Therapist compensation: Applicable rate split

Expected therapist time: Approximately 30–60 minutes

Completion: Therapist completes the summary using the appropriate template.

If the therapist is unavailable or on leave, the Clinical Leadership Team may complete the summary where appropriate.

Before completing a Treatment Summary, ensure that you have sufficient clinical information to accurately describe the client's treatment. Do not include information that you cannot reasonably support based on your clinical records or professional knowledge.

Accommodation Letters may be requested for school, work, housing, or other circumstances where a client is seeking reasonable accommodations.

Common examples include accommodations related to:

Cost: $75

Therapist compensation: Applicable rate split

Expected therapist time: Up to 30 minutes

Completion: Therapist completes the letter using the appropriate template.

Accommodation Letters should not be completed solely because a client has requested one. Therapists should have sufficient clinical information and treatment history to determine whether the requested accommodation is appropriate.

Some clients may require more detailed assessments or reports for purposes such as:

These requests require more therapist involvement than a standard Treatment Summary or Accommodation Letter.

Cost:

Therapist compensation: Applicable rate split

Expected therapist time: Approximately 1–2 hours

Completion: Therapist completes the assessment or report manually.

If you anticipate that the request will require more than two hours, do not proceed with the additional work without first having the request reviewed.

Do not complete an assessment or report if you do not have sufficient clinical information, treatment history, or expertise to provide the requested opinion.

If you are unsure whether you can appropriately complete the request, consult Clinical Leadership before proceeding.

If a client asks you directly for a letter, report, assessment, or copy of their records:

This ensures that requests are reviewed consistently and that the appropriate fees, privacy requirements, and clinical safeguards are applied.

A client's request does not automatically mean that the requested documentation should be provided.

Before completing any documentation, consider:

If you are unsure, pause before completing the request and consult your supervisor or Clinical Leadership.

For more information, refer to related documentation and program-specific articles in the Help Center. If you need further assistance, contact the Client Care Team or Clinical Leadership.