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  • CLIENT INTAKE FORM

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  • Emergency Contact Information

  • Client Data Form

  • MEDICAL HISTORY Questionnaire

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  • CONSENT FOR TREATMENT

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    1. I consent to and authorize treatment through First Choice Behavioral
    2. I authorize the collection of necessary administrative dates regarding me. I understand that such data shall be computerized for statistical, programming, and billing purposes.
    3. I understand information regarding me shall be collect responsibility and maintained in a confidential clinical record. Any such records or information shall remain confidential except in the following incidences:
    1. Information required by third party payers and parties giving FCB authorization to provide said services shall be forwarded to them.
    2. Records shall be open to First Choice Behavioral staff as needed and to appropriate state mental health officials.
    3. Information may be exchanged if I sign a written release form indicating the nature of information to be released.
    4. Information, which indicates a severe threat to the life or safety or another person or to self, shall be forwarded to the threatened parties or appropriate agencies to the extent necessary to protect life and safety.
    5. Information will be released if required under a court subpoena.
    6. Suspected abuse or neglect shall be reported to Protective Services as mandated by the Code of Texas and Federal Law.
    7. State and Federal law prohibits the disclosure of any information identifying a Recipient as receiving alcohol/drug services unless the Recipient consents in writing, the disclosure is allowed by court order, disclosure is made to medical personnel in a medical emergency, or to qualified personnel for research, audit, or program evaluations.
    8. Federal Law does not protect any information about a crime committed by a Recipient either at the program or against any person who works for the program or about any threat to commit such a crime
    1. I understand that all services will be provided regardless of gender, color, national origin, sexual orientation, religious preference, and a level of disability.
    2. If there is a medical or psychiatric emergency, I give permission for staff to seek emergency care on my behalf.
    3. First Choice Behavioral staff may share information with my consent with other associated facilities such as group homes, Dept. of Social Services, Court Services, and Area Programs if a Recipient is seen in two or more of these agencies.
    4. I agree to satisfy my financial obligation with First Choice Behavioral. I understand payment is due at the time services are rendered unless payment arrangements are made.
    5. You have the right to accept or refuse any medication, procedure test or treatment. Exception to this right is when there is an emergency, court order or if the recipient is under 18 years old and his/her parent or guardian has given permission.
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  • INFORMED CONSENT FOR TEL-SERVICES

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    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. 

    Expected Benefits: 

    More efficient evaluation and management. 

    Possible Risks: 

    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. 

     

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  • Medication Therapy Management Consent Form

  • I have elected to make use of the medication therapy management services providedby First Choice Behavioral. 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 First Choice Behavioral 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.

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  • CLIENT’S RIGHTS AND RESPONSIBILITIES

  • I authorize First Choice Behavioral 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.

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  • PRIVACY NOTICE ACKNOWLEDGMENT FORM (HIPPA)

  • I acknowledge that I have been provided a copy of the Notice of Privacy Practices for First Choice Behavioral. 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 First Choice Behavioral office.

     

    I may obtain a copy of this from First Choice Behavioral

    I understand that the terms of this Notice may be changed in the future, and these changes will be posted in First Choice Behavioral office. I may also request a copy of the new Notice by contacting the Privacy Officer.

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  •  CRISIS RESPONSE SERVICE

  • I have been informed that First Choice Behavioral has a crisis response line (210-441-7148) 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.

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  • RIGHT OF DETERMINATION APPEAL PROCESS

  • FCB 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 First Choice Behavioral 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. First Choice Behavioral shall notify recipients once a specific time is determined to restore services. First Choice Behavioral shall make efforts to recommend appropriate services that will meet recipient’s needs and discharge plan if any.

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  • ABUSE / NEGLECT PROTOCOL / PROCEDURE

  • It is your right to be free of harm, abuse, neglect, and exploitation. First Choice Behavioral 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

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  • EMERGENCY PREPARDNES QUESTIONNAIRE

    Please provide us with your updated emergency contact information and contact information of your evacuation destination
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  • AUTHORIZATION FOR SCHOOL VISITS

  • I      Parent/Legally responsible person do give First Choice Behavioral staff the permission to visit my child at school to provide mental health rehabilitation services to my child.

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  • Client Orientation Checklist

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    Each client, parent, or legal guardian of a client will be instructed and given written information regarding the following, upon admission to First Choice Behavioral’s program:

     

    • Informed Consent/Freedom of Choice
    • Non-discrimination provisions
    • family involvement.
    • safety.
    • the rules governing individual conduct.
    • authorization to provide treatment.
    • adverse reactions to treatment.
    • the general nature and goals of the program.
    • proposed treatment to include treatment methodology, duration, goals, and services.
    • risks and consequences of non-compliance.
    • treatment alternatives.
    • client’s rights and responsibilities.
    • all other pertinent information, including fees and consequences of non-payment of fees.

    ·         Additional information will be provided throughout the intake process, including but not limited to:

     

    1. Grievance and Appeal Procedures
    2. Communication/input policies regarding
      1.  Quality of Care
      2. Outcome Achievement
      3. Client Satisfaction
    1. Explanation of the agency’s
    • Mission/Philosophy/General nature and goals of the program
    • Services, activities, and therapeutic interventions
    • Family Participation/Involvement
    • Hours of Operation
    • 24-Hour on Call Policy
    • Code of Ethics
    • Confidentiality Policy and HIPPA Privacy Rights
    • Requirements for follow-up for mandated clients, regardless of his/her discharge outcome.
    1. Explanation of all financial obligations, fees, and arrangements for services provided by the organization (There are no out of pocket fees associated with services provided to Medicaid recipient’s).
    2. Orientation with the agency facilities, including emergency exits, fire suppression equipment, and first aid kits.
    3. The agency policies regarding safety and:
    1. Seclusion, restraints, or physical holds
    2. Smoking and Tabaco
    3. Illicit or licit drugs
    4. Weapons
    5. Abuse and neglect
    1. Identification of direct care worker.
    2. Program rules that identify:
      1. Any restrictions the program may place on clients.
      2. Events, behaviors, or attitudes that may lead to the loss of rights or privileges for the client.
      3. Means by which the client may regain rights or privileges that have been restricted.
    3. Identification of the purpose and process of assessment.
      1. Smoking and Tabaco
      2. Illicit or licit drugs
      3. Weapons
      4. Abuse and neglect and exploitation
    4. Program rules governing individual conduct, risk, and consequences of non-compliance
    5. Education regarding Advanced Directives, where appropriate.
    6. Authorization to provide treatment and adverse reactions to treatment.
    7. A description of how the Treatment Plan will be developed, treatment methodology, duration, goals, and services
    8. Information regarding transition, transfer and discharge criteria and procedures.
    9. Treatment alternatives/Treatment approaches.
    10. Non- payment fee, all client must maintain Medicaid eligible to avoid disruption of services.
    11. Health and Safety concerns inclusive of physical and Environmental safety, Waste Management, and Infection Control Factors.

    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.

     

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  • Member’s Freedom of Choice Form

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    The provider I choose is:

     

    First Choice Behavioral Health Services LLC

    210-441-7148

    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.

     

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  • CONSENT TO RELEASE OR OBTAIN INFORMATION

  • I   *   CONSENT TO RELEASE OR OBTAIN INFORMATION
    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   Pick a 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.

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  • FIRST CHOICE BEHAVIRAL HEALTH SERVICES LLC

    NOTICE OF PRIVACY PRACTICES
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    THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

     

     

     PLEASE REVIEW IT CAREFULLY.
     If you have any questions about this Notice, please contact: Privacy Office
     
    First Choice Behavioral Health Services

     

     
    Location




    Phone: 210-441-7148


    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 First Choice Behavioral staff and/or First Choice Behavioral 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:


     

     

    • Information obtained about a recipient by a psychiatrist, therapist, case manager, nurse or other member of the treatment team will be recorded in recipient’s record and used to determine the course of treatment that should work best for the recipient.
    • Treatment team members will also be expected to discuss recipient progress with treatment on a routine basis.
    • Information about the services received will be submitted and processed by the billing department so that the Agency can be paid, or the recipient can be reimbursed.
    • Recipient medical record may also be pulled for review by the Quality Improvement department in preparation for an audit or for other internal reviews to improve the quality and effectiveness of the services being provided.

     

    Disclosure of protected health information outside of First Choice Behavioral 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 First Choice Behavioral is required to do so. Even without recipient specific consent, First Choice Behavioral may disclose information to someone outside of First Choice Behavioral (and in some cases First Choice Behavioral may even be required by law or professional ethics to disclose recipient information), in the following situations:

     

    • When there is a medical or psychiatric emergency involving recipient health or safety or safety of others.
    • When First Choice Behavioral is required by law to report instances of neglect or abuse of a child or disabled adult.
    • Disclosure in a legal proceeding, where First Choice Behavioral is responding to an order of a court or administrative tribunal.
    • When First Choice Behavioral is required by Texas Administrative Code to disclose to the physician, information due to an incident which would cause health risk to other persons.
    • When First Choice Behavioral authorizes research for the purpose of program planning and evaluation of services using statistical information that cannot be linked to the recipient as an individual.

     

    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. First Choice Behavioral 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 First Choice Behavioral for instructions on how to submit a written request. The agency may deny recipient request in limited circumstances. If request is denied, First Choice Behavioral 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.

    First Choice Behavioral 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. First Choice Behavioral 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. First Choice Behavioral 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.

     

    First Choice Behavioral 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:

     

     

    First Choice Behavioral

     

    210-441-7148

     

     

     

    OR

     

    Office of Consumer Services and Rights Protection

     

    Phone: (800) 252.8154

     Fax:(512) 706-7353
     1106 Clayton Lane
     Austin, Texas 78723 Mail Code: H700
     

     

           OR  

    Texas Department of Family and Protective Service 

     

    Call: 1-800-252-5400

    If you cannot use the Texas Abuse Hotline you can. Report online a
    www.TxAbuseHotline.orgExternal Link
    Provision of services will not be affected by the filing of any complaint

     

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