DISCLOSURES REQUIRING SPECIAL CONSENT
My signature on the signature page specifically authorizes the release of healthcare information relating to the testing, diagnosis, or treatment for HIV/AIDS virus.
The purpose or need for the exchange and disclosure of this information is to facilitate the continuity of behavioral health care and physical health care.
TIME LIMITATION OF RELEASE: This consent is subject to revocation at any time, providing the information has not already been disclosed. Please see our Notice of Privacy Practices for instructions as to how to revoke this authorization.
Prohibition on redisclosure: This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR Part 2 and 45 CFR Parts 160 and 164) and/or KY state law. The Federal rules and/or KY state law prohibit you from making 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 and/or KY state law. 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.
AMOUNT AND KIND OF INFORMATION: The information to be released may include but not be limited to: Patient Demographics, Financial information, Vital Signs, Problems and Diagnoses, Insurance Information, Health Care Providers, Laboratory Results, Medications, Medical Care & HIV/AIDS, Alcohol & Substance Abuse and Mental or Behavioral Health information.
PURPOSE: The information shared will be used to help with my Treatment and Care Coordination.
EFFECTIVE PERIOD: This authorization/consent/permission form will remain in effect until termination of services with Pathways.
PROHIBITION ON REDISCLOSURE: This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR Part 2) and (45 CFR Parts 160 and 164) and/or KY state law. The Federal rules and/or KY state law prohibit you from making 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 and/or KY state law. 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.
You may use this form to allow your healthcare provider to access and use your health information. Your choice on whether to sign this form will not affect your ability to get medical treatment, payment for medical treatment, or health insurance enrollment or eligibility for benefits.
By signing this form, I voluntaryily authorize access, use, abd disclosure of my health information:
AMOUNT AND KIND OF INFORMATION: The information to be released may include but not be limited to: Patient Demographics, Vital Signs, Problems and Diagnoses, Insurance Information, Health Care Providers, Laboratory Results, Medications, Medical Care & HIV/AIDS, Alcohol & Substance Abuse and Mental or Behavioral Health information.4230
PURPOSE: The information shared will be used:
If there is no date entered, the consent will be valid for one year from the date this form is signed.
REVOKING MY PERMISSION: I can revoke my permission at any time by giving written notice to the person or organization named above in “To Whom” or “From Whom” sections except to the extent the disclosure agreed to has been acted on.
“This Health Information Exchange (HIE) consent does not permit use of my protected health information in any criminal or civil investigation or proceeding against me without an express court order granting the disclosure unless otherwise permitted under state law.”
This form is invalid if modified. You are entitled to get a copy of this form after you sign it.
As a consumer of Pathways, Inc., upon admission I have been instructed in or given written materials regarding the following. I understand my therapist will be reviewing this information with me at my first appointment.
● Rights and responsibilities of the person served.
● Notice of Privacy Practices
● Grievance and appeal procedures.
● Ways in which input is given.
● The organization’s:
1. Confidentiality policies.
2. Intent/consent to treat.
3. Behavioral expectations of the person served.
4. Transition criteria and procedures.
5. Discharge criteria.
6. Response to identification of potential risk to the person served.
7. Access to after-hour services.
8. Standards of professional conduct related to services.
9. Requirements for reporting and/or follow-up for the mandated person served, regardless of his or her discharge outcome.
● An explanation of any and all financial obligations, fees, and financial arrangements for services provided by the organization.
● Any and all financial obligations, fees, and financial arrangements for services provided by the organization.
● The program’s health and safety policies regarding:
1. The use of seclusion or restraint.
2. Use of tobacco products.
3. Illegal or legal drugs brought into the program.
4. Prescription medication brought into the program.
5. Weapons brought into the program.
● Missed Appointment Policy
● The program rules and expectations of the person served which identifies the following:
1. Any restrictions the program may place on the person served.
2. Events, behaviors, or attitudes and their likely consequences.
3. Means by which the person served may regain rights or privileges that have been restricted.
● Familiarization with the premises, including emergency exits and/or shelters, fire suppression equipment, and first aid kits.
● Education regarding advance directives, if appropriate.
● Identification of the purpose and process of the assessment.
● A description of:
1. How the person-centered plan will be developed, how a crisis/suicide prevention plan is created, and how a Psychiatric Advance Directive is followed
2. The person’s participation in goal development and achievement.
3. The potential course of treatment/services.
4. How motivational incentives may be used.
5. Expectations for legally required appointments, sanctions, or court notifications.
● Identification of the person(s) responsible for service coordination
PERMISSION FOR TREATMENT
APPOINTMENT REMINDER CALLS: As a courtesy, Pathways places appointment reminder calls to its consumers which includes leaving a message if the consumer is unable to answer the call. If you don’t want to receive appointment reminder calls, please advise the Customer Service Representative prior to signing this Acknowledgement Form.
EMERGENCY MEDICAL AUTHORIZATION: I, the undersigned, do hereby authorize Pathways, Inc. and its agents or representatives to consent, on my behalf, to any emergency medical/hospital care or treatment to be rendered upon the advice of any licensed physician. I agree to be responsible for all necessary charges incurred by any hospitalization or treatment rendered pursuant to this authorization.
CONSUMER CONFIDENTIALITY STATEMENT: As a consumer of services provided by Pathways, Inc., I understand that the identity of other consumers is confidential. I understand that Federal Law and regulations protect the confidentiality of each individual who receives services from Pathways, Inc.
I will respect other consumers’ confidentiality. I understand that if I obtain information regarding another consumer, including but not limited to, the fact that an individual is being treated at Pathways; and/or, if while attending a group service, should I learn any additional information regarding an individual, I cannot discuss this outside of the program.
I understand that there could be penalties for failure to comply with the above statements, including possible civil penalties.
PATHWAYS CONFIDENTIALITY STATEMENT: In general, the privacy of all communications between a consumer and Pathways is protected by law, and Pathways can only release information about our work to others with written permission; however, there are a few exceptions.
FEE ASSESSMENT: I agree to pay Pathways the amount of fees that my third party guarantor reports I am responsible for paying. In the event I do not have a third party guarantor, or my third party guarantor does not cover the particular service I may receive, I agree to pay the fees listed in Pathways' Sliding Fee Scale. These fees are subject to change when either: (1) there is a change in my ability to pay such as employment status or third party coverage or, (2) on the annual anniversary date of my current Fee Agreement or, (3) when Pathways determines that current Fee Agreement conflicts with the agency's fee policy and/or fee scale. I also understand that payment is due at the time of service unless I have made arrangements with the office staff. Furthermore, I certify that all financial information provided is true, complete, and accurate, to the best of my knowledge. I understand that should it be determined that such information is not true; I will be responsible for paying Pathways' full fee for all services rendered from the date of this agreement. I understand that this agreement replaces any previous fee agreements. I have received a copy of the Fee Scale.
SUBSCRIBER'S ASSIGNMENT OF BENEFITS: I hereby authorize my insurance company to pay directly to Pathways, Inc. for services rendered any and all sums of money otherwise payable to me under the terms and conditions of said insurance contracts. In the event that such payment is insufficient to meet the total charges for my account, I understand I am financially responsible and obligated to pay all charges not covered by this assignment.
CONSUMER'S RELEASE OF INFORMATION FOR INSURANCE BILLING PURPOSES: I authorize Pathways, Inc. to release my medical records, including any alcohol or drug abuse data protected by Federal Regulation (42 CFR Part 2) or otherwise, together with any information relating to mental or emotional conditions, to any agency, insurance company, or other entity which might require them to process any claim on my behalf. I understand such information will NOT be released for any other purpose without my written consent. I understand I may revoke this authorization at any time in writing. If I do not, it will remain in effect for 24 months from the date I sign it.
AUTHORIZATION FOR PATHWAYS TO ASSIST IN APPEALS OR REQUESTS WITH MANAGED CARE ORGANIZATION: In the event that I have Medicaid coverage through a Medicaid Managed Care Organization (MCO) and that MCO denies a service authorization or approves less than what has been requested, I authorize Pathways to file an appeal.
I request Pathways, Inc. to use electronic mail (e-mail) to communicate clinical information to me pertaining to health care services that I have received. I acknowledge and understand that e-mail communication may contain my personal and private medical information including, but not limited to, my name, address, date of birth, types and dates of health care services received, medication, insurance coverage information, and/or test results.
I understand that, although Pathways, Inc. may attempt to protect the privacy of the contents of email sent to me and will take reasonable measures to protect my privacy, the e-mail messages sent to me are not encrypted and travel over the Internet. As a result, there is a risk that the e-mail will be intercepted and read by unauthorized third parties. In allowing Pathways to send me e-mail, I assume this risk.
I also acknowledge and understand the following as it relates to this e-mail communication
Pathways, Inc. is authorized to respond to and/or send medical information to my e-mail address listed above.
IF YOU ARE EXPERIENCING A MENTAL HEALTH CRISIS OR FEELING SUICIDAL, DO NOT USE EMAIL TO COMMUNICATE.
CALL OUR 24/7 HELP LINE AT 1-800-562-8909
Pathways provides a multitude of behavioral health services, one of which is an evaluation for medication by a prescriber. Medication is often helpful in the treatment of behavioral health problems. It is important to note Pathways is not a medication-only clinic.
I recognize and agree to receive prescriber services from Pathways under the terms outlined herein and hereby agree to follow these terms in order to receive prescriber services from Pathways. I further recognize that prescriber services will not be provided and/or cancelled in the event that I do not follow the terms of service.
Typing my name below indicates I have read and agree to the terms of the forms listed:
Authorization for Release and Exchange of Confidential Information with Primary Care Provider