RECORD REQUEST FORM

• I understand that incomplete request forms will be returned and not acted upon until they are complete. 
• I understand that I will receive a copy of this form and my request will be processed within thirty (30) days, or I will be informed of the need for an extension of not more than thirty (30) additional days to process the request.
• I understand if I checked “Inspection Only,” I will need to schedule an appointment through my Care Manager to review only the information specified above.
• I understand that I may be responsible for paying a reasonable cost-based fee for supplies, labor, copying, and/or mailing, and that the requested information will either be mailed to me via U.S. Postal Mail at the address indicated above, or I can arrange to pick up the records myself.
• I understand that my request may be denied for either of the reasons stated below. If I am denied access for either of these reasons, I understand that I may submit a written request for an administrative review of the basis for denial.
  
  • If a licensed healthcare professional has determined, in the exercise of professional judgment, that the provision of access is reasonably likely to endanger the life or physical safety of any individual, or likely to cause substantial harm to the individual or another person;
  • If the PHI makes reference to another person (unless the other person is a healthcare provider) and a licensed healthcare professional has determined, by exercising professional judgment, that the access request is likely to cause substantial harm to such person, or violate such person’s right to privacy.
• I understand that the following types of information are exempted from the right of access, and denial of access is not subject to appeal or review:
  • Psychotherapy notes.
  • Information compiled in reasonable anticipation of, or for use in, a civil, criminal or administrative action or proceeding.
  • Information that is not part of the Designated Record Set (DRS)

I also understand that I have the right to file a formal complaint with either or both of the following:

• New Jersey Department of Children and Families; PO Box 717; Trenton, NJ 08625-0717
• Office for Civil Rights; U.S. Department of Health and Human Services; 26 Federal Plaza - Suite 3312 New York, NY 10278. [Voice Phone: 800-368-1019; FAX: 212-264-3039; TDD: 800- 537-7697]

Note: If you have any questions about this process, please contact our Privacy Officer, at 732-202 1585.

The confidentiality of my records is protected by Federal law, including 42 CFR Part 2 and HIPAA and the applicable regulations, as well as any applicable State law and regulations.  My treatment records can only be used or disclosed with my written consent, except as permitted by 42 CFR Part 2, HIPAA, and applicable state law.

I understand that I have the right not to sign this form.  OPC cannot provide care management without a signed authorization, as services depend on the ability to coordinate care with other agencies and providers. Refusal to sign may result in ineligibility for services. 

By my signature on this form, I hereby authorize Ocean Partnership for Children (OPC) to RELEASE, OBTAIN, and DISCUSS my protected health information under HIPAA, including my substance use disorder (SUD) records under 42 CFR Part 2, for the purposes of treatment, payment, and health care operations (TPO), as defined under HIPAA and 42 CFR Part 2 with:

This information may be shared with individuals and agencies involved in the development and delivery of services and may become part of their confidential records. All parties are expected to protect the privacy and confidentiality of this information in accordance with federal and state law, including the New Jersey Department of Children and Families.

This authorization has been explained to me in a language that I understand.  I understand that information released to organizations covered by HIPAA may be redisclosed in accordance with HIPAA privacy regulations, except for uses and disclosure for civil, criminal, administrative or legislative proceedings against me. I acknowledge that there is a potential for the records used or disclosed pursuant to this authorization to be subject to redisclosure by the recipient and no longer protected by 42 CFR Part 2. 

I understand that:

• I may revoke all or part of this authorization at any time in writing, except to the extent that action has already been taken based on it. Revocation requests must be submitted to your assigned Care Manager.
• I have the right to request limits on the type of information shared or the individuals or agencies who may receive it. If I would like to place any limitations on this authorization, I understand that I should discuss my request with my Care Manager before signing. Any agreed-upon limitations will be documented and honored to the extent permitted by law and program requirements.
• This authorization will expire automatically at the time of transition from OPC, unless continued use is permitted by law for quality improvement, evaluation, or as otherwise authorized by me.
• OPC may contact me/us after services have ended to request feedback or input for internal quality improvement or program evaluation purposes. I authorize such contact by phone, email, or mail, using the contact information I have provided. I understand that participation in any post-discharge feedback is voluntary and does not affect eligibility for future services.
• I may request a copy of this signed authorization.
• I understand that I have the right to request access to or copies of my or my child’s records, in accordance with federal and state law. A reasonable fee may be charged for copies of records or for mailing, as allowed by law.

By signing below, I acknowledge that I have read and understand the above information. I understand that by signing, I accept and consent to the above terms. I understand that I may revoke or cancel any part of this consent at any time by providing written notice. I understand that revocation may affect OPC’s ability to deliver services.

42 CFR PART 2 PROHIBITS UNAUTHORIZED USE OR DISCLOSURE OF THESE RECORDS.