Letter to the GP or psychiatrist: content and confidentiality release
A letter to the GP or the psychiatrist is short and has a clear reason. It contains what the recipient needs for their task, and it leaves your practice only with the patient's consent, by which the patient releases you from confidentiality.
Note: This guide explains the usual structure of a letter and a release. It replaces neither the rules of your professional code nor legal advice. Check specifics of your state and your professional association.
Reasons for a letter
- Requesting a consultation report needed for the application
- Informing the co-treating GP about the start, course or end of treatment
- Coordinating with the psychiatrist when treatment is shared
- Asking for somatic clarification of a finding the patient reports
Content in the order it is read
- Salutation and reference: patient's name and date of birth, date of the release.
- Reason and question: one or two sentences on what you want to know or communicate. You formulate the question yourself.
- Diagnosis: your diagnosis per ICD-10-GM, where relevant for the recipient.
- Brief course: start of treatment, method, status so far in a few dated sentences.
- Patient's statements on medication: mark them as the patient's own statement if you did not prescribe.
- Specific request: for example sending the consultation report, feedback or coordination, with a deadline if needed.
- Closing, contact details, signature.
Write only what the recipient needs. Session details that are not necessary for the task do not belong in the letter.
Confidentiality release: components
Psychotherapists are bound to secrecy (§ 203 of the German Criminal Code). Exchanging information with other providers is in principle permitted only with the patient's consent or on another legal basis. A written release should contain the following:
| Component | Example |
|---|---|
| Who releases | Name and date of birth of the patient |
| Who is released | Your name and practice |
| Towards whom | Name and address of the GP or specialist |
| Which content | For example diagnosis, course, question; name it specifically, not generally |
| For what purpose | For example consultation report for the application, coordination of co-treatment |
| In which direction | Only from you to the recipient, or in both directions |
| Duration and revocation | Time limit or until revoked; note that the release can be revoked at any time with effect for the future |
| Place, date, signature | Signed by the patient personally |
Keep the signed release in the treatment documentation. The patient may receive a copy of the letter on request.
Data protection in transmission
Health data is specially protected (Art. 9 GDPR). Send letters by a protected route, for example by post or encrypted, and check address and recipient before sending. Unencrypted email is not suitable.
Typical mistakes
- Letter goes out without a release
- Release is general and names no content
- Too many details from the sessions
- Patient's medication statements appear as your own finding
- No specific request, so it stays open what the recipient should do
How software can help
You enter the GP's address once per case; it then appears in the letter automatically. The Application Copilot assembles letter, consultation request and certificates from your case file, each with a source. The question and diagnosis stay your own text; the Copilot sends nothing. To the waitlist or the sample report. How the consultation report fits into the application is shown in the documents checklist.
Frequently asked questions
Do I need a release for every letter to the GP?
In principle yes, unless another legal basis applies. One release can cover several letters for the same purpose if it says so explicitly.
May I request a consultation without a letter?
The request itself passes on the patient's data and therefore also requires consent. The patient can also ask for the consultation report themselves and hand it to you.
What if the patient refuses the release?
Then you may not transmit. Discuss the consequences for the application, for example a missing consultation report, and document the conversation.
Sources
- § 203 StGB (breach of private secrets), gesetze-im-internet.de
- Art. 9 GDPR (processing of special categories of personal data), eur-lex.europa.eu
- Bundespsychotherapeutenkammer (BPtK): model professional code on confidentiality, bptk.de (state codes may differ; reference unverified)
- Kassenärztliche Bundesvereinigung (KBV): Psychotherapie-Vereinbarung on the consultation report, kbv.de
- BfArM: ICD-10-GM, current version, bfarm.de