By selecting the "I Accept" button and typing my name below, I am signing this consent electronically. I agree that my electronic signature (‘e-signature’) is the legal equivalent of my manual signature and that I am legally bound by the terms and conditions of the consents and agreements I electronically sign.

I further agree that my use of a key pad, mouse or other device to select an item, button, icon or similar act/action, constitutes my “e-signature.”

I agree that no certification authority or other third party verification is necessary to validate my e- signature and that the lack of such certification or third party verification will not in any way affect the enforceability of my e-signature or any resulting contract/agreement between myself and Ocean Partnership for Children.

I understand that I may withdraw my consent to use electronic signatures at any time. In order to withdraw my consent, I will notify Ocean Partnership for Children in writing that I wish to withdraw consent and request that future documents, notices, and disclosures be provided in paper format.

I represent and warrant that:

1. I have the authority to grant this consent; and
2. I am not party to a court order that requires consent for any of this to be agreed to by another person, including but not limited to another parent; and
3. I will inform Ocean Partnership For Children if there is a change to the custodial requirements to the subject of this consent.

The following items are essential to the care of your family while participating with Ocean Partnership For Children, Inc. (OPC By signing this consent form, you acknowledge receipt, understanding and agreement with the following:

CONSENT FOR EMERGENCY MEDICAL TREATMENT: In the event that my child is the victim of an accident, injury or illness while on outings with an Ocean Partnership for Children, Inc. employee and I am unable to be reached I authorize the Care Manager or the Care Manager’s designee to take action and give consent on my behalf as his or her judgment dictates.

CONSENT FOR PARTICIPATION IN SUPERVISED SPORTS & RECREATIONAL ACTIVITIES: I give my consent for my child/children to participate in supervised sports and recreational activities that are scheduled as part of the program, which may be outside of the home and may require transportation outside of Ocean County. I understand and acknowledge that some of the activities may involve unanticipated risks and could result in injury to the child, to property or to third parties. I agree to accept and assume all of the risks involved in activities within and outside of my home. Transportation for activities may be furnished by Ocean Partnership For Children, Inc.

CONSENT/WAIVER OF RESPONSIBILITY FOR PERSONAL INJURY: I give my consent for my children to possess certain items of personal property. I understand that Ocean Partnership For Children, Inc. is not responsible for the loss, theft, or damage of personal property or money.

CONSENT FOR TRANSPORTATION: I hereby give my consent for my child/children to be transported by Ocean Partnership For Children, Inc., as needed.

CONSENT FOR INFORMATION TO BE USED IN RESEARCH: I give my consent for the evaluation of data obtained during my enrollment in Ocean Partnership For Children, Inc. for research to evaluate effectiveness of the program. I understand that this research may be presented at conferences, universities, and in publication. I understand that information collected for this research is part of the usual Ocean Partnership For Children, Inc. evaluation procedures. I understand that my family’s confidentiality will be protected. No information that is presented to the public will contain any identifying information such as name, pictures, address, or telephone number.

CONSENT FOR PARTICIPATION IN OPC PROGRAMS AND SERVICES: 

• I understand and agree that OPC may, from time to time, arrange for and/or coordinate clinical and non-clinical services on my behalf or that of my child/children; and that OPC staff will access my child’s records as needed to support OPC operations.
• I voluntarily agree to accept care management services through the Ocean Partnership for Children, Inc. (OPC I understand that all services through OPC are voluntary and, therefore, I may refuse or terminate those services at any time.
• I understand that OPC operates in compliance with all federal and state statutory and regulatory requirements through New Jersey’s Children’s System of Care.
• I understand that OPC works in partnership with the New Jersey Department of Children and Families (DCF) – Children’s System of Care (CSOC) and its Contract Services Administrator, Perform Care.
• The OPC Care Manager has explained the care management services that are being offered.
• The OPC Care Manager has explained the role and availability of the Ocean Family Support Organization.
• I have received a copy of the OPC Notice of Privacy Practices.

I represent and warrant that:

1. I have the authority to grant this consent; and
2. I am not party to a court order that requires consent for any of this to be agreed to by another person, including but not limited to another parent; and
3. I will inform Ocean Partnership For Children if there is a change to the custodial requirements to the subject of this consent.

I represent and warrant that:

1. I have the authority to grant this consent; and
2. I am not party to a court order that requires consent for any of this to be agreed to by another person, including but not limited to another parent; and
3. I will inform Ocean Partnership For Children if there is a change to the custodial requirements to the subject of this consent.

This notice is about the privacy of the information that has been collected by Ocean Partnership for Children, Inc. (OPC), to assist in planning for services for your child and family. This notice is required by Federal laws for health providers due to dramatic changes in electronic information that have taken place in the past few years. For your information, Ocean Partnership for Children, Inc. maintains all client records – in either electronic and/or hard copy files – in compliance with all federal and state laws and regulations through its partnership with the New Jersey Department of Children and Families (Children’s System of Care) and its designated Contract System Administrator.

We have always taken great care to protect confidential information and now government regulations require your rights to be spelled out. That is what you will find in our Notice of Privacy Practices.

We believe that privacy is part of the trust that you have placed in our organization, and we are committed to preserve that trust.

If you have any questions about this notice, please contact your Care Manager or OPC’s Privacy Officer at 732.202.1585. Either party will be sure to answer your questions, or find out the answers and respond back to you in a timely manner.

I represent and warrant that:

1. I have the authority to grant this consent; and
2. I am not party to a court order that requires consent for any of this to be agreed to by another person, including but not limited to another parent; and
3. I will inform Ocean Partnership For Children if there is a change to the custodial requirements to the subject of this consent.

The confidentiality of client records is protected by federal and state laws and regulations. Release of such information is limited and requires a written release from/on behalf of the service recipient, as follows.

I/We understand that by authorizing this release, the above information may be shared, in whole or in part, to the extent necessary to develop and implement an individualized service plan. This information may become a part of a participating agency or individual’s confidential record. The New Jersey Children’s System of Care requires that all participants respect the confidential nature of the records, information and the proceedings of any meetings. Further release or use for any other purpose is prohibited and there may be penalties for any unauthorized disclosure of this information. With this release, I/We understand that this information may appear on electronic records.

I/We understand that I/We may refuse to sign this authorization and that refusal to sign will not affect the above-named youth from obtaining treatment, payment to be made, or the above-named child’s eligibility for benefits or services, however, it may affect determination of appropriate level of care. Subject to applicable law, I/We may inspect or copy any written information used/disclosed under this authorization.

I/We understand that if the person or entity that receives the information is not a healthcare provider or health plan covered by federal privacy regulations, the information described above may be re-disclosed and no longer protected by these regulations. However, the recipient may be prohibited from disclosing substance abuse information under the federal Confidentiality of Alcohol and Drug Abuse Patient Records regulations set forth at 42 CFR Part 2.

I understand that Ocean Partnership for Children is permitted under state and federal laws to charge a fee for photocopies of my records and any applicable mailing/postage fees.

I/We understand that I/We may revoke this authorization in writing at any time, except to the extent that action has been taken in reliance on this authorization. The request to revoke this authorization must be provided to in writing to the Ocean Partnership for Children’s Privacy Officer at the address listed on this form. The revocation will be effective on the date that the Privacy Officer receives the request.

I/We understand that this authorization will automatically expire upon termination of service from Ocean Partnership for Children. I/We can receive a copy of this authorization.

I represent and warrant that:

1. I have the authority to grant this consent; and
2. I am not party to a court order that requires consent for any of this to be agreed to by another person, including but not limited to another parent; and
3. I will inform Ocean Partnership For Children if there is a change to the custodial requirements to the subject of this consent.

(**If disclosure involves HIV/AIDS records, signature of youth age 12 or older is required; for alcohol/substance use disorder records, signature of youth is required, regardless of age)

Notice to Recipient: Participants are required to adhere to the confidentiality and release of information requirements; records are protected under applicable federal and state law and regulations, including but not limited to 42 CFR Part 2 and HIPAA.

Notice to Part 2 Recipient: This information has been disclosed to you from records protected by federal confidentiality rules (42 CFR Part 2 The federal rules prohibit you from making any further disclosure of information in this record that identifies a patient as having or having had a substance use disorder either directly, by reference to publicly available information, or through verification of such identification by another person unless further disclosure is expressly permitted by the written consent of the individual whose information is being disclosed 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 (See 42 CFR § 2.31The federal rules restrict any use of the information to investigate or prosecute with regard to a crime any patient with a substance use disorder, except as provided at §§ 2.12(c5) and 2.65.

I represent and warrant that:

1. I have the authority to grant this consent; and
2. I am not party to a court order that requires consent for any of this to be agreed to by another person, including but not limited to another parent; and
3. I will inform Ocean Partnership For Children if there is a change to the custodial requirements to the subject of this consent.

I hearby consent for my child/self to participate in telehealth services with Ocean Partnership for Children (“OPC”). I understand the following will apply:

1. I understand that telehealth is the practice of delivering care management services via technology-assisted media or other electronic means between an OPC staff member and a youth/family who are located in two (2) different locations. The benefits of telehealth may include removing transportation and travel barriers; minimizing time constraints; and providing greater access to sessions.
2. I understand that I have the right to withdraw this consent for myself/child to participate in telehealth at any time without affecting my child’s/my right to future care or treatment or risking the loss or withdrawal of any program benefits at OPC to which would otherwise be provided.
3. I understand that there are risks and consequences associated with telehealth. These include but are not limited to technology limitations and failures; interruptions and/or confidentiality issues because other persons may be present during the telehealth session; limited ability to see or hear things that are crucial to the session; and/or the limited ability for OPC to respond to an emergency that they are made aware of during a telehealth session. I also understand that telehealth may not be as effective as in-person health services.
4. I understand that recording, taking screenshots, etc., of any kind during any telehealth session is strictly prohibited.
5. I understand that all laws relating to confidentiality of records; all provisions of the OPC Notice of Privacy Practices that I received; and all provisions of the Consent for Participation & Services and the Rights of Children & their Families will apply to the telehealth process. All information disclosed during sessions and all information that OPC places in its records will be kept confidential in accordance with applicable law, except where I have authorized the disclosure pursuant to a separate authorization or as otherwise required by law.
6. I understand that to conduct the telehealth session, OPC will use a third party platform and that platform has represented that it is compliant with the Health Insurance Portability and Accountability Act of 1996 and its implementing regulations, as amended (“HIPAA” OPC assumes no liability or responsibility for the failure of the platform to be HIPAA-compliant or to safeguard and/or protect my confidentiality. I will advise my Care Manager immediately if I wish to use a different third party platform to conduct the telehealth session and in extenuating circumstances OPC may grant such request. I understand and acknowledge that there may be risks associated with the use of any other third party platform and I agree to hold OPC harmless for all losses resulting from the use of any other third party platform. OPC reserves the right to deny requests to use any other third party platform. In the event that OPC denies my request to use any other third party platform, OPC will let me know why it is denying the request and offer other alternatives to conduct the session (i.e., telephone conference
7. I understand that I and/or my child is/are expected to be available, focused and engaged in telehealth s session(s).
8. I understand that in order to protect confidentiality, we cannot share the links to any telehealth sessions and that the session needs to occur in a private location where we can speak openly without being overheard or i interrupted by others. If someone comes into the room during a session or if confidentiality is somehow affected, we agree to advise OPC immediately so that we can discuss the best way to handle. OPC assumes no responsibility for breaches of confidentiality that may occur due to the failure to participate in a telehealth session in a private location or to failure to safeguard any telehealth links.
9. I understand that if OPC believes that I or my child would be better served by another form of communication, telehealth will no longer be used.
10. I agree to call 911 or to go to my local emergency room immediately if my child is in crisis during a telehealth session.
    
11. I understand that the time for any meeting is specifically reserved for me/my child and we are responsible for joining the meeting on-time. If I/my child is late, the appointment will still end at the scheduled end time. If we need to cancel or reschedule a session, I will contact the Care Manager prior to the scheduled meeting time.
12. I understand that OPC assumes no responsibility for my/my child’s failure to participate in a session, in whole or in part, due to issues caused by us, including but not limited to dead or uncharged equipment batteries; malfunctioning equipment; poor reception due to location; or failure to obtain a confidential place to participate in the session.
13. 13. I understand that during a telehealth session, technical difficulties beyond both OPC’s and our control could result in service interruptions. If this occurs, we will end and restart the session. If we are unable to reconnect within ten minutes following any service interruption, the meeting organizer will reach out to us to discuss or to reschedule, if need be.
14. I understand that telehealth may or may not be authorized by the Department of Children and Families and the Center for Medicaid Services. If these entities do not approve the use of telehealth for the provision of Care Management services, OPC may be unable to continue to utilize telehealth.
15. I will hold OPC harmless for any technical failures during the telehealth encounter beyond the control of OPC, including any resulting delays in evaluation or for information lost due to such technical failures.
16. I understand that I need to inform OPC of my child’s location at the start of any session in case of an emergency and to provide the name of a contact person who OPC can communicate with on my/my child’s behalf in case of a life-threatening emergency that arises during a session.

I represent and warrant that:

1. I have the authority to grant this consent; and
2. I am not party to a court order that requires consent for any of this to be agreed to by another person, including but not limited to another parent; and
3. I will inform Ocean Partnership For Children if there is a change to the custodial requirements to the subject of this consent.

• I understand no individual involved with Ocean Partnership for Children may record a conversation or meeting without full knowledge and consent of all parties present.
• I understand Recordings are permitted by way of audio and/or video monitoring/recording in appropriate circumstances, as permitted by applicable law, regulations, and guidance, provided all of the following criteria met:
  • There is a legitimate purpose for the recording.
  • The recording device is in plain view.
  • Written authorization has been obtained from ALL parties.
• I understand if a request to record/monitor a conversation is made, OPC’s ‘Procedures for Audio/Video Recording, Monitoring, & Photography’ must be followed.
• I understand photographs may not be taken without consent of all parties included in the photograph. If a request to photograph an individual is made, OPC’s Procedures for Audio/Video Recording, Monitoring & Photography must be followed.”
• I understand if anyone revokes authorization to record at any time, the recording will be stopped, and no portion of the recording will be utilized.
• I understand a violation of this policy by an individual may result in immediate transition from Ocean Partnership for Children’s services, immediate termination of a Memorandum of Understanding, and/or disciplinary action, including termination of employment.

I represent and warrant that:

1. I have the authority to grant this consent; and
2. I am not party to a court order that requires consent for any of this to be agreed to by another person, including but not limited to another parent; and
3. I will inform Ocean Partnership For Children if there is a change to the custodial requirements to the subject of this consent.