As our valued client, you are entitled to:
- Have your rights explained in a way that is understandable to you, prior to the initiation of services, annually, and available for review and clarification at all times that you are enrolled as a client of
- The right to confidentiality of your records and information.
- The right to be free from mental, physical, sexual or verbal abuse, exploitation, retaliation, humiliation and neglect.
- High quality professional services in a cooperative environment
- Receive services in a non-coercive environment
- Consultation with your assigned JF&CS staff member to discuss the care you or your loved on are receiving
- Request another JF&CS staff member or referral
- Be informed of the consequences of non-compliance with agency recommendations and regulations
- Know how to lodge complaints, grievances or appeals
- Determine disclosure of confidential information as long as such disclosure is not life-threatening or dangerous to others
- Know that your records are protected against unauthorized access and that they can be shared with others only with your legal consent
Your comments are welcomed:
- You may discuss any issues, concerns or questions with your JF&CS staff member
- You may request an appointment with your JF&CS staff member's supervisor
- You may submit concerns in writing to the Department Head
- You may register a complaint by filing a grievance. To file a grievance or receive a copy with instructions about how to file a grievance, please contact Wendy Liverant at firstname.lastname@example.org or by phone at 678.236.6087.
Actively participate in your own treatment/service and work to achieve your goals.
Keep your scheduled appointments. We ask that client's please cancel appointments with JF&CS staff with 24 hours' notice when possible. If cancellation becomes an issue the assigned JF&CS staff member will address this concern with the client and/or that client's personal representative.
Provide accurate insurance information and benefits coverage. Inform your JF&CS staff member of any significant changes in your financial situation, insurance coverage and/or address.
If applicable, pay the agreed upon fee at the time of service, and be responsible for any outstanding balance to be paid within 30 days of a JF&CS staff member requesting payment for services. The agency reserves the right to suspend or terminate treatment if payment has not been collected within 30 days of request from a JF&CS staff member. This form has been fully explained to me and I certify that I understand its contents. I also understand that it is my sole responsibility to ask any questions or obtain any clarification necessary to my understanding this form fully.