Tele-services involve the use of electronic communications to enable health care providers at to provide services to the client for the purpose of improving client care. The information may be used for diagnosis, therapy, follow-up and/or education. Electronic systems used will incorporate network and software security protocols to protect the confidentiality of client identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.
More efficient evaluation and management.
In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information.
By signing this form, I understand the following:
1. I understand that the laws that protect privacy and the confidentiality of medical information
also apply to telemedicine, and that no information obtained in the use of telemedicine which identifies me will be disclosed to researchers or other entities without my consent.
2. I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment.
3. I understand that I have the right to inspect all information obtained and recorded in the
course of a telemedicine interaction and may receive copies of this information for a reasonable fee.
Consent To The Use of Telemedicine
I have read and understand the information provided and all of my questions have been answered to my satisfaction. I give my informed consent for the use of tele-services in my care.
I have elected to make use of the medication therapy management services providedby Safe Place Counseling. My participation is voluntary. I understand that these services are not a direct substitute for medical care provided by my physician or any other provider.
I authorize Safe Place Counseling to maintain a copy of my health profile and medication related recommendations for the purpose of follow-up and monitoring.
I understand that every effort will be made to maintain the confidential nature of my private health information. Information about this review will not be shared with anyone except my legal representative without my written consent.
Safe Place Counseling’s policy is to protect the rights of each client. During the intake process, the client’s rights are reviewed in a manner that is understandable. The Corporate Compliance Officer responds to questions and grievances pertaining to the client’s rights and ensures compliance with Texas administrative code. Rule §404.154. The client’s rights and responsibilities are reviewed annually as listed below.
To make your mental health treatment successful, we need to work together. The agency asks that all clients provide clear, complete, and truthful information always. We do our part by providing you with information concerning your rights and the services we offer. Your part is to take responsibility for the following:
I acknowledge that I have been provided a copy of the Notice of Privacy Practices for Safe Place Counseling. I understand that the Notice of Privacy Practices discusses how my personal health care information may be used and/or disclosed, my rights with respect to health care information, and how and where I may file a privacy-related complaint.
I may review a copy of the Notice from Safe Place Counseling office.
I may obtain a copy of this from Safe Place Counseling
I understand that the terms of this Notice may be changed in the future, and these changes will be posted in Safe Place Counseling office. I may also request a copy of the new Notice by contacting the Privacy Officer.
I have been informed that Safe Place Counseling has a crisis response line (713-429-5114) available 24hrs /7 days a week, 365 days a year for Recipient to use in crisis situations. A designated on-call qualified professional will be responsible for responding to all crisis calls during and after regular business hours. The on call qualified professional will be responsible for the implementation of Crisis Plan via phone and face to face within two hours. The on call qualified professional will have access to the crisis plan for everyone.
CSC will not deny, interrupt, suspend, reduce, or terminate your services without a good cause. If you are a Medicaid recipient (or eligible to be one) and a decision has been made to deny, reduce, suspend, or terminate services being received, then you have the right to appeal the decision.
A notification of the decision will be sent by your MCO. If you need clarifications on any issues, please contact Safe Place Counseling immediately. We will assist you with the appeal process follow up.
Recipients maybe expelled or suspended from services when the agency can no longer meet the recipient’s needs or guarantee their safety. Safe Place Counseling shall notify recipients once a specific time is determined to restore services. Safe Place Counseling shall make efforts to recommend appropriate services that will meet recipient’s needs and discharge plan if any.
It is your right to be free of harm, abuse, neglect, and exploitation. Safe Place Counseling prohibits any abuse or neglectful conduct on the part of any individual employed or contracted by the agency or serving in a consultative capacity.If for any reason, you have questions, concerns or complaints that involve any kind of abuse, sexual, physical etc. you should call the Texas Department of Family and Protective Service at 1-800-252-5400
I Parent/Legally responsible person do give Safe PlaceCounseling staff the permission to visit my child at school to provide mental health rehabilitation services to my child.
Each client, parent, or legal guardian of a client will be instructed and given written information regarding the following, upon admission to Safe Place Counseling’s program:
· Additional information will be provided throughout the intake process, including but not limited to:
By signing this acknowledgement, I agree to the terms of all contents of the Client Orientation/Intake Process and have received a copy of the Client Handbook.
The provider I choose is:
Safe Place Counseling & Consulting PLLC
By Signing below, I acknowledge that I freely choose to receive services from the above provider, and I acknowledge my responsibility to notify my previous provider to coordinate care.
I CONSENT TO RELEASE OR OBTAIN INFORMATIONto obtain healthcare information or release healthcare information of the recipient named above from/to:
This consent is subject to written revocation at any time except to the extent that action has already been taken in reliance upon this consent. This authorization shall expire on Date (date or event). I understand that if I do not specify an expiration date/event, this authorization shall expire one year from the date of consent.I understand that the treatment/services are not contingent upon my signing or not signing this authorization. I freely and voluntarily give my authorization for the release of information from my health record. I also understand and authorize that this information may be sent via facsimile transmission.TO PARTIES RECEIVING THIS INFORMATION: This information has been disclosed to you from records whose confidentiality is protected by federal law. Federal regulations (42 CFR, Part 2) prohibit you from making further disclosures of it without specific written consent of the person to whom it pertains. A general authorization for the release of health or other information is not sufficient for this purpose.
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
This notice describes how medical information about a recipient may be used and disclosed and how to gain access to the above information. Please review it carefully.
All information that is provided during the screening, admission, and treatment/rehabilitation process is considered confidential by the employees, interns, and volunteers of Comcare. We are required to protect the privacy of health information of a recipient, and the disclosure of protected health information will be governed by the Health Insurance Portability and Accountability Act of 1996, as well as any other applicable federal or state laws.
Exchange and use of protected health information between Safe Place Counseling staff and/or Safe Place Counseling programs for the purpose of treatment, payment, or healthcare operations will be permitted and based on “need to know” guidelines, and positional authority. For example:
Disclosure of protected health information outside of Safe Place Counseling is permitted when recipient or their legal representative signs a written authorization or gives verbal authorization in an emergency. Any authorization for disclosure may be revoked at any time, except to the extent that action has been taken in reliance on it.
Recipients have the right to request restriction of the disclosure of their health information, except
when Safe Place Counseling is required to do so. Even without recipient specific consent, Safe Place Counseling may disclose information to someone outside of Safe Place Counseling(and in some cases Safe Place Counseling may even be required by law or professional ethics to disclose recipient information), in the following situations:
Recipients also have other rights related to the use and disclosure of health information in their medical record.
These rights include:
Right to request recipient medical record be designated as secured
All medical records are secure and confidential. Recipient may restrict the disclosure of their medical records only for the purpose of treatment, payment, or healthcare operations. Safe Place Counseling will make every effort to accommodate recipient request, but we are not required to do so. For example, if the information is the subject of a lawsuit or legal claim or if release of the information may present a danger to you or someone else.
Right to inspect and request a copy of recipient medical record.
If recipients would like to inspect or receive a copy of their health information, please contact Safe Place Counseling for instructions on how to submit a written request. The agency may deny recipient request in limited circumstances. If request is denied, Safe Place Counseling will respond to the recipient in writing, stating why the request was not granted and describing any rights to request a review for denial. If recipient request is approved, the agency may charge a reasonable fee for the costs of copying, mailing or other supplies associated with any request for copies.
Right to request amendment of any section of recipient medical record.
If recipients feel that the agency has information that is inaccurate or incomplete, recipients have the right to request amendments of record. If request is denied, the agency will notify recipient in writing of the reason and will describe recipient rights to provide a written statement disagreeing with the denial.
Right to receive an accounting of disclosures that have occurred.
Each disclosure of protected health information will be documented in the medical record. Recipients have the right to request an accounting of the disclosures of previous years, if any.
Right to request an alternative method of contact.
Safe Place Counseling may call recipients or mail information regarding appointment reminders, billing information, or other information about treatment alternatives or services that might be of interest. If
recipients would like to request an alternative method of contact, please notify the agency. Safe Place Counseling will accommodate reasonable requests, but may condition our accommodation on recipients providing, information regarding how payment, if any, will be handled.
Right to a copy of this Notice.
Recipients have the right to receive a paper copy of this Notice. Safe Place Counseling reserves the right to change this notice and to make the new notice effective for all protected health information that is maintained in hard copy or electronic format. Revisions to the
NOTICE OF PRIVACY PRACTICES will be made available at each facility for distribution to all recipients.
Safe Place Counseling recognizes the importance of confidentiality, and recipient’s right to be fully informed of all regulations regarding protected health information.
If recipients feel that their privacy rights have been violated, they may contact:
Safe Place Counseling
Office of Consumer Services and Rights Protection
Phone: (800) 252.8154