INFORMED CONSENT FOR TREATMENT
1. Consent to Evaluate/Treat: I voluntarily consent that I will participate in substance abuse evaluation and/or treatment by staff from First Call Alcohol/Drug Prevention & Recovery. I understand that following the evaluation and/or treatment, complete and accurate information will be provided concerning each of the following areas:
a. The benefits of the proposed treatment
b. Alternative treatment modes and services
c. The manner in which treatment will be administered
d. Expected side effects from the treatment and/or the risks of side effects from medications (when applicable).
e. Probable consequences of not receiving treatment
f. Outcomes of diagnostic instruments used in this evaluation
The evaluation or treatment will be conducted by a certified substance abuse counselor or a licensed therapist or an individual supervised by any of the professionals listed.
2. Benefits to Evaluation/Treatment: It may be beneficial to me, as well as the referring professional, to understand the nature and cause of any difficulties affecting my daily functioning, so that appropriate recommendations and treatments may be offered. Uses of this evaluation include diagnosis, evaluation of recovery or treatment, estimating prognosis, and education and rehabilitation planning. Possible benefits to treatment include improved cognitive or academic/job performance, health status, quality of life, and awareness of strengths and limitations.
3. Charges: Assessment and treatment services are on a sliding scale and no one is refused services that cannot pay the fee. The fee paid is determined by the business office in consultation with the client, using the Standard Means Chart as a guide. I will be responsible for any charges not covered by insurance, including co-payments and deductibles. Fees are available to me upon request.
4. Confidentiality, Harm, and Inquiry: Information from my evaluation and/or treatment is contained in a confidential medical record and I consent to disclosure for use by Mobile MET staff for the purpose of continuity of my care. Per Missouri mental health law, information provided will be kept confidential with the following exceptions: 1) if I am deemed to present a danger to myself or others; 2) if concerns about possible abuse or neglect arise; or 3) if a court order is issued to obtain records.
5. Prohibition against Redisclosure: Information from my evaluation and/or treatment is protected by Federal confidentiality rules (42 CFR Part 2). The Federal rules prohibit any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse client.
6. Right to Withdraw Consent: I have the right to withdraw my consent for evaluation and/or treatment at any time by providing a written request to the treating clinician.
7. Expiration of Consent: This consent to treat will expire 12 months from the date of signature, unless otherwise specified.
I have read and understand the above, have had an opportunity to ask questions about this information, and I consent to the evaluation and treatment. I also attest that I have the right to consent for treatment. I understand that I have the right to ask questions of my service provider about the above information at any time.
COMBAT-CONNECTIONS NOTICE OF PRIVACY PRACTICES
Effective August 1, 2008
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU OR YOUR CHILD MAY BE USED AND DISCLOSED AND HOW YOU CAN ACCESS THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
The COMBAT-Connections is a multidisciplinary collaborative effort designed to enhance sustainability of recovery for substance abusing persons and their families. By coordinating services through the use of a shared web-based tool, the coalition can more effectively and efficiently provide services to those persons and their families. It also assists the participating agencies in the betterment of quality of service by coordinating, delivering, and managing client care through simplified processes and improved communications.
At the core of the COMBAT-Connections is a shared web-based tool that connects the agencies involved to a central data repository. Authorized users will access this tool using a web browser to share a uniform set of personal information (name, nickname, gender). Additional treatment and personal information will be entered into the tool in the event that you receive services at one of the participating COMBAT- Connections agencies. Although this data is being stored in a central data repository, only agencies that provide services to a client will be authorized to view the data and have access to the file. These files will remain locked to all other agencies until a client presents themselves for service to a new agency and authorizes the information to be released. Only those individuals authorized by each of the COMBAT-Connections agencies will have access to the information in the shared web-based tool.
As part of the COMBAT-Connections, follow-up health surveys are conducted with clients via telephone six and twelve months after exiting services. Data collected through the surveys is used to help the COMBAT-Connections improve services and treatment for clients in the future.
This Notice explains how agencies participating in the COMBAT-Connections may use and disclose your personal health care and treatment information. Generally, federal and state law requires health care information that identifies you be kept private (The Health Insurance Portability and Accountability Act (HIPAA) of 1996, 42 U.S.C. §1320d et seq., 45 C.F.R. Parts 160 & 164 and the Confidentiality Law, 42 U.S.C. § 290dd-2 and 42 C.F.R. Part 2.). Further, the agencies participating in the COMBAT-Connections must give you this information related to their legal duties and privacy practices with respect to any health care information they create or receive about you. The COMBAT-Connections participating agencies are required to follow the terms of the COMBAT Connections Notice of Privacy Practices that is currently in effect.
We reserve the right to change this Notice. We reserve the right to make the revised or changed Notice effective for health information we already have about you as well as any information we receive in the future. We will post a copy of the current Notice in each of the participating COMBAT-Connections agencies. A copy of the current Notice in effect will be available at the receptionist’s desk at each of the participating agencies.
This Notice applies only to the personal health care and treatment information that is generated by participants in the COMBAT-Connections and received by the COMBAT-Connections shared web-based tool and database. All references to health information in this document describe information about the treatment and services provided by participating COMBAT-Connections agencies.
Contact: If you have any questions about this notice, please contact the Privacy Officer at (816) 531.7788 for any updated information.
USE AND DISCLOSURE OF YOUR HEALTH INFORMATION
Generally, you must sign a written authorization before COMBAT-Connections participating agencies can share health information about you to anyone outside the agency. For example, we must get your written authorization before we can release information to your health insurer for payment. You may cancel your authorization in writing at any time. If you revoke your authorization, we will no longer use or disclose health information about you for the reasons covered by your written authorization but we will be unable to take back any disclosures we have already made with your permission, and we are required to retain our records of the care that we provided to you.
Federal law allows us to release information without your written permission for the following reasons:
Business Associates: Some services of participating COMBAT-Connections agencies are provided through contracts with business associates such as accreditation agencies, management consultants, and quality assurance reviewers. We may disclose your health information to these business associates so they can perform the job a participating agency has asked them to do.
Commitment of a Crime: A participating agency may report crimes committed on its premises or against its program personnel, or a threat to commit such crimes.
Suspected Child Abuse or Neglect: We may disclose information about suspected child abuse or neglect to appropriate state and local authorities.
Health Oversight Activities: We may disclose health information to a health oversight agency for activities authorized by law. These oversight activities include audits, investigations, inspections and licensure. These activities are necessary for the government to monitor the health care system, government programs and compliance with civil rights laws.
Medical Emergencies: We may provide your medical and treatment information to medical providers responding to your medical emergency.
Required by law: We will disclose health information about you without your permission when required to do so by court order or federal, state, or local law.
YOUR HEALTH INFORMATION RIGHTS
Although your record is the physical property of the COMBAT-Connections participating agency from which you receive services, the information belongs to you. You have the right to:
Copy: Obtain a copy of this Notice of Information Practices upon request.
Inspect: Inspect and request a copy of your health record for a fee. We may deny your request under very limited circumstances. If you are denied access to health information, you may request that another health care professional, chosen by someone on our health care team, review the denial. We will abide by the outcome of that review.
With respect only to the records held by the COMBAT-Connections participating agencies that must comply with federal HIPAA privacy laws, you have the right to:
Restriction: Request a restriction on certain uses and disclosures of your information. We are not required by law to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you with emergency treatment.
Amend: Request an amendment to your health record if you feel the information is incorrect or incomplete. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. Also, we may deny your request if the information was not created by the COMBAT-Connections participating agency’s health care team, is not part of the information kept by one of the participating agencies in the coalition, is not part of the information which you would be permitted to inspect and copy, and if the information is accurate and complete. Please note that even if we accept your request, we are not required to delete any information from your record.
Accounting: Obtain an accounting of certain disclosures of your health information during the six years prior to your request, but not earlier than April 14, 2003.
Confidential: Request communication of your health information by alternative means or locations.
If you believe your privacy rights have been violated, you may file a complaint. This complaint must be in writing to: Privacy Official, COMBAT Jackson Co. Courthouse 415 E. 12th St., 9th Floor, Kansas City, MO 64106 (816) 881-1400 FAX: (816) 81-1416. There will be no retaliation or punishment for filing a complaint.
You also have the right to share your complaints with the Secretary of the Department of Health and Human Services. Secretary, Dept. of Health and Human Services, 200 Independence Ave. S.W., Washington, D.C. 20201 – Phone (202) 619.0257.
Violation of the federal Confidentiality Law by a program is a crime. Suspected violations may be reported to the United States Attorney in your district or the MO-WRO/ Alcohol and Drug Abuse Services.