A finished report has to reach the right parties — and, just as importantly, must not reach the wrong ones. Service and confidentiality are two sides of the same obligation.
Service of medical-legal reports is governed by §36.5the regulation governing service of medical-legal reports and the proof of service: a report is served on the claims administrator and the injured worker, and on the worker's attorney if the worker is represented. The proof of service documents that this happened. One routing detail trips up newcomers — the RFA is served separately from the report, on its own track to utilization review.
The exception to direct service is the Form 121 protective route. When the evaluator determines that releasing the report to the worker risks significant adverse medical consequences, the report is not served on the worker directly. Instead it goes to a designated physician, the worker's attorney, or the claims examiner together with the I&A officer — protecting the patient from being handed a document that could harm them.
Confidentiality narrows what leaves the clinical record at all. CMIA (the Confidentiality of Medical Information Act) and the Welfare & Institutions Code limit the employer to a functional work-status summary — the function-and-restrictions rule from the document-set lesson, enforced here as law, not preference.
Across service and disclosure, the employer's view is restricted to functional work status and restrictions. Diagnoses, symptoms, and treatment content do not flow to the employer under any of these routes. When in doubt about an employer-bound disclosure, default to function only.
Two further limits shape clinical disclosures. The psychotherapy-notes exclusion keeps raw process notes out of the disclosed record; what is shared is the summary of diagnosis, prognosis, treatment plan, symptoms, and progress — not the verbatim session notes. And the minimum-necessary principle governs everything: disclose only what the claim actually requires, never more.
Under the psychotherapy-notes exclusion, what does the disclosed record include?