This document is intended to inform you of your rights and responsibilities. 

For parents currently working with a Treatment Counselor and/or Court Ordered Treatment:  This form should be submitted AFTER your treatment counselor has completed the Program Enrollment Form. 

The purpose of the Child Care Assistance Program (CCAP) is to provide you with a licensed child care provider to care for you child/ren while you are attending outpatient and inpatient substance use treatment. This is a voluntary program and you are asked to review the following requirements regarding your participation.

Rights:

• You have the right to quality-licensed child care while attending an outpatient Substance Use Disorder Treatment Agency contracted with Spokane County Regional Behavioral Health Administrative Service Organization, and have it paid for you.
• You have the right to choose a CCAP contracted child care provider.
• You have the right to change child care providers.
• You have the right to discontinue child care at any time and choose not to participate in CCAP.  

Responsibilities:

• You will remain in contact with the CCAP Family Support Specialist to complete the intake process for a list of referrals of child care providers. 
• You and the Family Support Specialist will work collaboratively to find licensed childcare program.
• After selecting a provider, complete their registration process, arrange a date when the child care will begin, and contact the CCAP Family Support Specialist with provider selection and start date.
• You are responsible for picking up and dropping off of your child(ren) at the designated time agreed upon during registration.
• You are responsible for calling the child care provider and CCAP Family Support Specialist for all changes including your contact information, outpatient schedules, change in level of care at treatment facility (ex: completing treatment or entering inpatient).
• You are required to call your child care provider at least 24 hours prior to child’s absence from child care. If this is not possible, you must call as close as possible to the 24-hour notice.
• You must comply with all policies maintained by the child care provider and follow all enrollment procedures. The child care provider will contact CCAP if any difficulty is experienced such as violation of provider’s policies or failure to pick up or drop off at the designated time. If you show signs of substance abuse, the provider is a mandated reporter and will contact CPS.  If a discrepancy situation occurs, CCAP will discuss the situation with you.  The outcome may result in you being responsible for all child care costs not authorized by your treatment counselor and / or discontinuation of services. Frequent disregard of your responsibilities will result in your ineligibility for CCAP.
• If at any time, you no longer wish to have a release of information with the CCAP Program, you will be responsible for your child care bill and must notify CCAP that you choose to no longer receive services from CCAP.
• If a grievance occurs with the CCAP Family Support Specialist, contact Arrianne Maldonado at ArrianneM@community-minded.org.

Information provided to you about a particular childcare provider does not imply and is not an endorsement of the childcare provider by CCAP or the treatment agency. Child care providers are licensed by Washington State. Complaints about a specific child care provider should be made to the Division of Youth, Families & Children (DCYF)

hereby authorize COMMUNITY-MINDED ENTERPRISES to disclose identifying information, admission dates, treatment recommendations, dates and times services rendered to me and discharge information pertaining to substance use disorders to Washington State Health Care Authority, Spokane County Regional Behavioral Health Organization (SCRBHO), Spokane County Behavioral Health Administrative Service Organization (BH-ASO), and applicable Managed Care Organizations (MCO) including Amerigroup, Molina Healthcare, and Community-Health Plan of Washington and Coordinated Care

The purpose of this disclosure is to coordinate care, payments and health care operations for childcare services rendered to me while attending substance use disorder outpatient treatment.

I understand that my substance use disorder records are protected under state and federal law, including federal regulations governing the confidentiality of substance use disorder patient records, 42 CFR Part 2 and the Health Insurance Portability and Accountability Act (HIPAA), 45 CFR Parts 160 and 164, and cannot be disclosed without my consent unless otherwise provided for by the regulations.

I understand that I may revoke this authorization except to the extent that it has been relied upon by COMMUNITY-MINDED ENTERPRISES, by providing a written and dated statement of my intent to revoke this consent.

hereby authorize COMMUNITY-MINDED ENTERPRISES to receive / release or re-release any information regarding the child care arrangements made between myself and my child care provider to my treatment agency / counselor / therapist / physician or any other social or to other service agency associated with my care as listed below. I authorize COMMUNITY-MINDED ENTERPRISES to disclose and release or re-release specific information from my treatment or other records or obtain in any form regarding my evaluation and / or treatment or individuals and / or agencies listed below for the specific purpose of arranging child care.