New Health Pain Treatment Centers offers evaluation and treatment to its patients. By signing this “Consent to Treatment” form, the patient agrees to receive the treatment included in this specific program and authorizes NHPTC, to provide medical and behavioral health services to myself. I understand that this authorization applies to all health maintenance services and to all services available for acute and chronic medical conditions and behavioral health.
The services authorized by this consent include those provided under the auspices of NHPTC by physicians, nurse practitioners, physician assistants, child health associates, medical technologists, behavioral health providers, nurses, health educators, registered nurses, medical assistants, behavioral health therapists and patient navigators. I consent to treatment by health professionals-in-training under supervision of responsible health professionals employed by NHPTC.
I understand that my medical records are to be kept confidential and will not be released to any unauthorized person or agency without my consent.
I have been provided a copy of NHPTC “Patient Rights” to review, which includes my right to make a complaint or grievance.
Therapeutic Services: NHPTC therapeutic programming meets for a scheduled amount of group time and/or individual sessions. This program is for adults seeking treatment for substance use disorders, co-occurring disorders, related behaviors and Pain Management Coping Skills. Urine drug screen testing and breathalyzer testing is a requirement upon admission and throughout treatment. The frequency of urine drug screens and breathalyzer tests are set during the course of treatment and may vary depending on therapeutic and medical necessity. Urine testing and breathalyzer testing are conducted and supervised by NHPTC staff.
I, the undersigned patient, hereby attest that I have voluntarily entered into treatment at NHPTC. The rights, risks, and benefits associated with the treatment have been explained to me and may be provided to me in writing at my request. I understand that treatment may be discontinued, and I may be discharged from the program at any time by either party. I understand that upon discharge I will receive recommendations for continuing care. Recommendations will vary depending on length of treatment program, reason for discharge and other clinical factors.
Voluntary Discharge: Patients have the right to terminate treatment prior to successfully completing NHPTC. In such cases, clinical staff will attempt to discuss the reasons for the desired discharge, possible risks associated with an early discharge and will attempt to keep the patient in treatment. The treatment team attempts to handle all early discharges in a way to minimize any harm or injuries to the patient and least disruptive to the treatment of the other patients.
Therapeutic Discharge: A non-voluntary termination/discharge may include but is not limited to: a) the need for a more appropriate level of care; b) physical violence, verbal abuse, any use or possession of weapons, engaging in illegal acts i.e.: introduces drugs or drug paraphernalia onto any of the properties of NHPTC; c) the patient refuses to comply with treatment recommendations; d) the patient does not comply with the rules, regulations, policies or guidelines of NHPTC e) the patient does not make payment or payment arrangements in a timely manner. The clinical team will notify the patient of a Therapeutic Discharge. In these cases, there will be no refund whatsoever granted to the patient for any and all monies previously received on the patient’s behalf by NHPTC.
Notice of Confidentiality: The confidentiality of patient records maintained by NHPTC is protected by Federal law as well as Colorado State law. NHPTC Staff may disclose patient information to others outside of the organization only with a Release of Information signed by the patient. Some of the information that can be disclosed with a signed Release of Information is: a) notification that the patient is at NHPTC; b) is being treated for alcohol, drugs, and/or other mental health issues/disorders and/or pain/wellness groups; c) any other identifying information such as the patient’s name; d) pertinent treatment information specific to the person outside of the organization (i.e., courts, probation, referral sources, etc.). The exceptions to this general rule of confidentiality are: 1) the disclosure is mandated by Court order: 2) the disclosure is made to medical personnel in a medical emergency; 3) the patient is a danger to self or others including those identifiable by their association with a specific location or entity; 4) the patient discloses child abuse and/or neglect; or, 5) the abuse or exploitation of an at-risk elder or the imminent risk of abuse or exploitation; 5) a crime being committed on the premises. In addition, there may be other exceptions to confidentiality as provided by HIPAA regulations and other Federal and/or Colorado laws and regulations. You will be notified should these exceptions arise. Healthcare professionals may be required under Federal law and Colorado State law to report admitted prenatal exposure to controlled substances that are potentially harmful to the unborn fetus.
Regulation and Reporting Misconduct: The Department of Regulatory Agencies (“DORA”) and the Office of Behavioral Health (“OBH”) regulate the mental health professionals and staff at NHPTC. Colorado Department of Regulatory Agencies (DORA), Division of Professions and Occupations (“DOPO”) has the general responsibility of regulating the practice of Licensed Psychologists, Licensed Clinical Social Workers, Licensed Professional Counselors, Licensed Marriage and Family Therapists, Certified and Licensed Addiction Counselors and Registered individuals who practice psychotherapy. The agency within DORA that specifically has responsibility is the:
Mental Health Section
1560 Broadway, Suite #1350, Denver, CO 80202
Specifically, the State Board of Addiction Counselor Examiners regulates Certified and Licensed Addiction Counselors, the State Board of Licensed Professional Counselor Examiners regulates Licensed Professional Counselors, and the State Board of Registered Psychotherapists regulates Registered Psychotherapists and can be reached at the address listed above. Patients are encouraged, but not required, to resolve any grievances through NHPTC internal process. Otherwise, patients should report all alleged misconduct to the above listed state Board. The specific Board should be specified in the report.
In addition, the Office of Behavioral Health has the general responsibility for regulating practices of licensed substance use treatment programs in the state of Colorado. Questions and Complaints may be directed to:
The Colorado Department of Human Services
Office of Behavioral Health
3824 W. Princeton Circle, Denver, Colorado 80236
In the event of death of the patient and under certain circumstances, it may be the right of the Spouse and/or Parents and/or Children to access the records of the deceased patient. This right is not guaranteed.
Amendments: This Consent to Treatment may be amended in writing from time to time and signed by both parties.
Contact Method: NHS uses a variety of ways to contact patients related to their care such as phone, text and/or email about their healthcare, to include visit information, reminders, account balance notifications and other services. Patient has the right to select to be contacted by phone, text and/or email during and upon discharge from the program. Please be aware there is a risk that an unintended third-party may access information shared through electronic transmissions such as email and/or text. By allowing NHPTC to contact you by email you are consenting to receive electronic communications and understand the risks involved. NHPTC cannot guarantee that confidential information shared using electronic communications will remain confidential. If select to be contacted by telephone I give my permission to NHPTC to leave phone messages and to identify themselves either by staff name and/or by the program name. I understand that message and data rates may apply to messages sent through NHS to my cell phone or email. I know that I am under no obligation to authorize NHS to send me text messages or emails as part of this program. If at any time, a patient wishes to revoke any authorization it will be done in writing notifying NHS and specified the type of contact method no longer valid.
I have read and understand the consent for treatment. I understand its content and do voluntarily agree to its provisions. This authorization is applicable for the period of one year, effective upon signing.