CONSUMER RECORD INDEX (form update 8-28-14)
1 INTAKE PAGES
1 Consumer Record Index
2-3 Initial Client Intake
4 Statement of Eligibility Checklist
5 Emergency Contacts
7 Consumer Choice
8 Consent for Treatment
9-10 Additional Consents
11-12 Authorization forms
13 Accounting Release and Disclosure
14-15 Privacy Practice
16-17 Consumer Rights
18-19 Limits of Confidentiality
20 Safety Plan
21 Consumer Orientation Checklist
22 Substance Abuse
23-26 Child Forms (Minor under 18)
a. Behavioral Assessment /Reassessment
b. Introductory Service Plan / Individualized Plan
d. Order of Service / Ongoing order of service
a. Medical Necessity
d. Medication Profile
e. Nursing Assessment
I consent to the administration of emergency medical procedures and treatment by qualified staff of this agency (First Aid/CPR). In case of an emergency, I agree to be transported to the nearest appropriate medical facility and to assume all cost for transportation and treatment.
In the event emergency medical aid/treatment is required due to illness or injury during the process of participating in services, or while being on the property of CompServ Health Service and its’ owners, I authorize CompServ Health.to:
Secure and retain medical treatment and transportation if needed
Release consumer records upon request to the authorized individual or agency involved in the medical emergency treatment.
This authorization includes x-ray, surgery, hospitalization, medication, and any treatment procedures deemed “life –saving” by the physician. This provision will truly only be invoked if the person(s) above is unable to be reached
My signature below shows that I understand and agree with all of these statements.
Domestic Violence Policy
CONSENT TO PARTICIPATE IN ACTIVITIES
CONSUMER RIGHTS & RESPONSIBILITIES
24/7 ON-CALL SERVICE ACCESSIBILITY & CRISIS SERVICES
SECLUSION AND RESTRAINT POLICY
CONSENT TO TRANSPORTATION
FAMILY INVOLVEMENT CONSENT/DENIAL
I consent to have the family members listed below involved in the planning and delivery of the services that I shall be receiving from CompServ Health for this period of service. I understand that, without this consent, the agency’s employees will not be allowed even to acknowledge to any family member that I am a consumer of their services.
I do not consent to have family members involved in the planning or delivery of the services I shall be receiving in this period of services..
Family members to be involved:
(If parent or legal guardian is indicated under "Relationship" then that individual may sign future forms as the representative of a child consumer)
I have received a copy of the Emergency Contact Sheet that provides me with information on how to get assistance in case of an emergency during the day or after hours.
The appointment times given to you are assigned to you alone. Please make every effort to make your schedule appointment. If you need to cancel an appointment please call the staff member working with you and/or the office as soon as possible.
I have received a copy of the brochure/questionnaire on Advance Directive. I understand if I choose to participate, I will notify my primary care provider and submit a copy of my decision to be filed in my service record.
Purpose: The purpose of this disclosure of information is to improve assessment and treatment planning, share information relevant to treatment and when appropriate, and to coordinate treatment services.
If other purpose, please specify: Medical or Life Threatening Emergency
Revocation: I understand that I have a right to revoke this authorization, verbally or in writing, at anytime by sending written notification to CompServ Health . I further understand that a revocation of the authorization is not effective to the extent that action has already been taken in reliance on the authorization.
I further understand that CompServ Health . will not condition my treatment on whether I give authorization for the requested disclosure. However, it has been explained to me that failure to sign this authorization may have the following consequences:
If services are hindered, prevent clinician from properly advocating or acting in the client’s best interest, or create a danger due to clients refusal to sign authorization then CompServ Health may choose not to continue services to client.
Form of Disclosure
Unless you have specifically requested in writing that the disclosure be made in a certain format, we reserve the right to disclose information as permitted by this authorization in any manner that we deem to be appropriate and consistent with applicable law, including, but not limited to, verbally, in paper format, or electronically.
Federal law prohibits the person or organization to whom disclosure is made from making any further disclosure of substance abuse treatment information unless further disclosure is expressly permitted by the written authorization of the person to whom it pertains or as otherwise permitted by 42 C.F.R. Part 2. Other types of information may be re-disclosed by the recipient of the information in the following circumstances:
If you are signing as a personal representative of an individual, please describe your authority to act for this individual (power of attorney, healthcare surrogate, legal guardian).
HIPAA/ 45 CFR 160 and 164:
Release of Information demonstrates compliance with the Health Insurance Portability and Accountability Act (HIPPA), Standards for Privacy of Individually Identifiable Health Information (Privacy Standards), 45 CFR 160 and 164, and all federal regulations and imperative guidelines promulgated there under. I understand that information received or medical records prepared after this release form is completed, regarding my condition and the service I have received in the course of my diagnosis and treatment, may be subject to release to authorized parties in compliance with federal and state law and the terms of this form. I understand that information to be released may include information regarding drug abuse, alcohol abuse, psychological/psychiatric/psychosexual impairments, HIV and/or AIDS or physical conditions. I understand that the Federal Privacy Rule (HIPAA) does not protect the privacy of information if re-disclosed and therefore request that all information obtained from this person or agency be held strictly confidential and not be further released by the recipient. I further understand that my eligibility for benefits, treatment or payment is not conditioned upon my provision of this authorization. I intend this document to be a valid authorization conforming to all requirements of the Privacy Rule. I understand that unless otherwise limited by state or federal regulations and except to the extent that action has been taken which was based on my consent, I may withdraw this consent at any time. If not previously revoked, this consent will terminate one year from the date appearing below.
I do hereby request that this authorization to disclose health information to be rescinded effective____________________. I understand that any action taken on this authorization prior to the rescinded date is legal and binding.
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW THIS NOTICE CAREFULLY.
Your health record contains personal information about you and your health. This information about you that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services is referred to as Protected Health Information (“PHI”). This Notice of Privacy Practices describes how we may use and disclose your PHI in accordance with applicable law. It also describes your rights regarding how you may gain access to and control your PHI.
We are required by law to maintain the privacy of PHI and to provide you with notice of our legal duties and privacy practices with respect to PHI. We are required to abide by the terms of this Notice of Privacy Practices. We reserve the right to change the terms of our Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHIS that we maintain at that time. We will provide you with a copy of the revised Notice of Privacy Practices by posting a copy on our website, sending a copy to you in the mail upon request or providing one to you at your next appointment.
HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU
For Treatment. Your PHI may be used and disclosed by those who are involved in your care for the purpose of providing, coordinating, or managing your health care treatment and related services. This includes consultation with clinical supervisors or other treatment team members. We may disclose PHI to any other consultant only with your authorization.
For Payment. We may use and disclose PHI so that we can receive payment for the treatment services provided to you. This will only be done with your authorization. Examples of payment-related activities are: making a determination of eligibility or coverage for insurance benefits, processing claims with your insurance company, reviewing services provided to you to determine medical necessity, or undertaking utilization review activities. If it becomes necessary to use collection processes due to lack of payment for services, we will only disclose the minimum amount of PHI necessary for purposes of collection.
For Health Care Operations. We may use or disclose, as needed, your PHI in order to support our business activities including, but not limited to, quality assessment activities, employee review activities, licensing, and conducting or arranging for other business activities. For example, we may share your PHI with third parties that perform various business activities (e.g., billing or typing services) provided we have a written contract with the business that requires it to safeguard the privacy of your PHI. For training or teaching purposes PHI will be disclosed only with your authorization
Required by Law. Under the law, we must make disclosures of your PHI to you upon your request. In addition, we must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining our compliance with the requirements of the Privacy Rule.
Without Authorization. Applicable law and ethical standards permit us to disclose information about you without your authorization only in a limited number of other situations. The types of uses and disclosures that may be made without your authorization are those that are:
We may use or disclose your information to family members that are directly involved in your treatment with your verbal permission.
With Authorization. Uses and disclosures not specifically permitted by applicable law will be made only with your written authorization, which may be revoked.
YOUR RIGHTS REGARDING YOUR PHI
You have the following rights regarding PHI we maintain about you. To exercise any of these rights, please submit your request in writing to our Privacy Officer at [101 North Seventh Street Louisville Ky ]:
If you believe we have violated your privacy rights, you have the right to file a complaint in writing with our Privacy Officer or with the U.S. Secretary of Health and Human Services at 200 Independence Avenue, S.W. Washington, D.C. 20201or by calling (202) 619-0257. We will not retaliate against you for filing a complaint.
I hereby acknowledge that I have received and have been given an opportunity to read a copy of CompServ Health. Notice of Privacy Practices.
Your rights as a consumer, including confidentiality of your participation in evaluation and treatment services, will be observed in accordance with O.C.G.A. 37-3-166, 37-4-125, 37-7-166, DHR Rules and Regulations for Consumer Rights, Chapter 290-0-9; 42 U.S.C. 290dd-2,and CompServ Health . Consumer Rights and Responsibilities Policy #2330, CompServ Health . program policies and any other applicable laws, regulations, and policies, including the federal Health Insurance Portability and Accountability Act (HIPAA) privacy regulations. A summary of these rules and regulations will be reviewed with you and are available for inspection at each service location. You also will be provided a copy of the CompServ Health . HIPAA Privacy Notice. This information will be reviewed on an annual basis with you.
YOU HAVE THE RIGHT:
HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY PRIVACY PRACTICES
AS A CONSUMER OF COMPSERV HEALTH. AND ITS PROGRAMS, IT IS YOUR RESPONSIBILITY:
I have read the above summary of Consumers' Rights & Responsibilities and have been given the opportunity to ask questions and have been given a copy of this form. I have been offered a copy of CompServ Health . and its programs’ HIPAA Notice of Privacy Practices.
The contents of a counseling, intake, or assessment session are considered to be confidential. Both verbal information and written records about a client cannot be shared with another party without the written consent of the client or the client’s legal guardian. It is the policy of this organization not to release any information about a client without a signed release of information. Noted exceptions are as follows:
Duty to Warn and Protect
When a client discloses intentions or a plan to harm another person, the health care professional is required to warn the intended victim and report this information to legal authorities. In cases in which the client discloses or implies a plan for suicide, the health care professional is required to notify legal authorities and make reasonable attempts to notify the family of the client. In addition, it may be necessary for the health care professional to take steps for the client to be placed in a restricted hospital environment to ensure the safety of the client and of others.
Abuse of Children and Vulnerable Adults
If a client states or suggests that he or she is abusing a child (or vulnerable adult) or has recently abused a child (or vulnerable adult), or a child (or vulnerable adult) is in danger of abuse or neglect, the health care professional is required to report this information to the appropriate social service and/or legal authorities.
Prenatal Exposure to Controlled Substances
Health care professionals are required to report admitted prenatal exposure to controlled substances that are potentially harmful.
In the event of a Client’s Death
In the event of a client’s death, the spouse or parents of a deceased client have a right to access their child’s or spouse’s records.
Other health care professionals must report professional misconduct by a health care professional. In cases in which a professional or legal disciplinary meeting is being held regarding the health care professional’s actions, related records may be released in order to substantiate disciplinary concerns.
Health care professionals are required to release records of clients when a court order has been placed. Clients who are on probation, court-ordered to treatment or referred by the Department of Juvenile Justice, Department of Human Resources or the county Juvenile Court may have waived certain rights to confidentiality when entering the treatment program.
Parents or legal guardians of non-emancipated minor clients have the right to access the client’s records.
In the event it becomes necessary to audio and/or videotape a client for treatment or supervision purposes, a specific consent form for the purpose of audio and/or video will be required. No recordings of any kind will be conducted without the expressed consent of the client.
CompServ Health . does not conduct research on any of their clients. Outcome measures, as it pertains to the effectiveness or non-effectiveness of the treatment services are collected and analyzed to ensure that the best quality treatment is provided. No personal information on any client is disclosed, nor can any client be identified by any of the outcome information collected.
Insurance companies and other third-party payers are given information that they request regarding services to clients. Information that may be requested includes type of services, dates/times of services, diagnosis, treatment plan, and description of impairment, the progress of therapy, case notes, and summaries.
Information about clients may be disclosed in consultations with other professionals in order to provide the best possible treatment. In such cases the name of the client, or any identifying information, is not disclosed. Clinical information about the client is discussed.
In some cases notes and reports are dictated/typed within the clinic or by outside sources specializing (and held accountable) for such procedures.
When couples, groups, or families are receiving services, separate files are kept for individuals for information disclosed that is of a confidential nature. The information includes (a) testing results, (b) information given to the mental health professional not in the presence of other person(s) utilizing services, (c) information received from other sources about the client, (d) diagnosis, (e) treatment plan, (f) individual reports/summaries, and (h) information that has been requested to be separate. The material disclosed in conjoint family or couples sessions, in which each party discloses such information in each other’s presence, is kept in each file in the form of case notes.
In the event in which the company or mental health professional must telephone the client for purposes such as appointment cancellations or reminders, or to give/receive other information, efforts are made to preserve confidentiality. Please list where we may reach you by phone and how you would like us to identify ourselves. For example, you might request that when we phone you at home or work, we do not say the name of the clinic or the nature of the call, but rather the mental health professional’s first name only.
Please check where you may be reached by phone. Include phone numbers and how you would like us to identify ourselves when phoning you.
The client rights’ has been provided as part of the consumer orientation. A check of the item and the signatures below indicate that each area has been fully explained and is understood by the consumer. After 1 year of service each consumer will be re-issued client rights’ Information.
The purpose of these disclosures if to provide for further, in depth substance abuse assessment for consumer within COMPSERV HEALTH Services as well as the community at large and to coordinate and plan appropriate intervention and treatment services as indicated by assessment data.