New Gateways, Inc. General Information, Your Rights & Consent to Services/Treatment/Health

 

General Information and Your Rights

 

I have been advised of my rights, under law, as a client of New Gateways, Inc. services including an explanation of my rights.

 

I have received the following: general and rights information, consent to services, new client information packet, and procedures.

 

I have been advised that my records may be destroyed after seven (7) years following termination of services or for minors seven (7) years after attaining the age of eighteen.

 

I have received and reviewed the "Your Rights" booklet included in the Orientation Packet mailed/given to me and other information including program brochure, Person-Centered Planning handout, and privacy notice.

 

I am interested in Rights Training. (The office of Recipient Rights provides education, monitoring, and complaint resolution to OCCMHA customers The Rights training provides the basic understanding of the Rights you have as a customer and other options outside the Rights Office for complaint resolution. You get an opportunity to learn about advocacy groups and network with others

 

I have read and authorize the following:

 

That the professionals and other workers assigned to me provide services and/or recommendations for services and supports including treatment, as considered necessary and proper. I realize that this does require a mutually agreed-upon Person Centered Plan of Service. This plan, developed with my participation, shall define a vision for my future or that of my child and my/our goals, roles and responsibilities. My records will be kept confidential, and agree that my records and progress may be revieued for quality of care by the treatment team. The goals of the New Gateways program and are for improved mental health and physical well being to be mutually established by myself/my child/my ward, funding source, and the PCP team. It has been explained to me that the outcome of such treatment cannot be guaranteed. The type and nature of the evaluation and treatment maybe discussed with the PCP team. All records are confidential and can be released only as allowed by law under state and federal statutes. If my treatment is paid for by a third party payor either partially or fully, it has been explained to me that the payor has the right to examine the record. It has been explained to me that client/consumer records may be reviewed by organizations as part of an accreditation process It has been explained to me that I can request a PCP Meeting at any time. I understand that my signature gives authorization and indicates I have read all of the above.