Peer Recover Support Services Intake, Consent, & Referral

Peer Recovery Support Services Referral, Intake, & Consent Form

The purpose of this disclosure authorized herein is to enable you to stay connected with Peoria Recovery Support Services to facilitate intervention or recovery coaching services, as needed. This will also inform you of your rights as a participant.
I am...*

requesting services for myself.requesting services for someone else.
Which are you seeking services for?*

Requesting Services for Myself
Full Name*
Date of Birth*

MonthDayYear
Date
Reason for contacting us?*
What is your gender?*
What is your sexual orientation?*
What is your race and ethnicity?*

Contact Information
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Alt. Phone Number
Email Address
example@example.com
Best time to contact you?*
Case Manager Phone Number, If Applicable

Area CodePhone Number
Case Manager Email, If Applicable
example@example.com
Do you need the Peoria Tribe to provide attendance records to a third party? (probation, pretrial, etc.)*

HIPAA Statement & Participant Rights

I understand that my alcohol and/or drug treatment records are protected under the Federal Regulations governing the Health Insurance Portability and Accountability Act, HIPAA, of 1996 and Confidentiality of Alcohol and Drug Abuse Patient Records, 42 CFR, Part 2, and 45 CFR, Pts. 160 & 164 and cannot be disclosed without my written consent unless otherwise provided for in the regulation. I also understand that I may revoke this consent at any time except, to the extent that action has been taken in reliance on it, and that in any event this consent expires automatically one year from date of signing or on date specified below. If there is a difference between 42 CFR, Part 2, 45 CFR, or HIPAA, which ever regulation is stricter will apply.A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient. I understand I may be denied services if I refuse to consent to a disclosure for purposes of treatment payment. I will not be denied services if I refuse to consent to a disclosure for other purposes. I further understand that when information is disclosed, this information is protected by Federal Law and may not be re-disclosed except with my consent or under other authorization (42 CFR Part 2.32). Disclosed information may be verbal or in writing and the prohibition on re-disclosure pertains to both.
Name*

First NameLast Name
Please Check One:*

I AgreeI Disagree
Participant Rights

Please read the following carefully.
You have the right to accept or refuse intervention and recovery support services at any time. If you decline services, you have the right to re-enroll at any time.

You have the right to a humane environment that provides reasonable protection from harm and appropriate privacy for your personal needs.

You have the right to be free from abuse, neglect, and exploitation.

You have the right to be treated with dignity and respect.

You have the right to appropriate intervention and recovery services that meet your needs.

You have the right to be told before receiving support services, in a language that you can understand, about the program rules and regulations.

You have the right to get a copy of these rights (attached here) before you are accepted into the program.

You have the right to a service plan designed to meet your needs, and you have the right to take part in developing that plan.

You have the right to meet with staff to review and update the plan as needed.

You have the right to refuse to take part in research without affecting the services you are receiving.

You have the right to have information about you kept private and to be told the time when information can be released without your permission.

Your private information will not be disclosed without your written consent, except as permitted by law.

Your services are paid in full by the Tribal Opioid Response project with no additional charges to you.

You have a right not to be restrained or placed in a locked room.

You have the right to make a complaint and receive a response from the Tribal Opioid Response Project within a reasonable amount of time.

You have the right to complain directly to the Consumer Protection Division by contacting: Oklahoma State Department of Health, Consumer Health Service, PO Box 268815, Oklahoma City, OK 73126-8815 or 405.426.8250.
Date (Consent will expire one year from this date)*

MonthDayYear
Date
Signature*

Clear

Referring for Someone Else...
Your Name
Name of Person Referred*
Email Address
example@example.com
Phone Number
Alt. Phone Number
Reason for contacting us*
What is your role?*
If other, please specify
What type of services or programs are you requesting?
Signature*

Clear
Date*

MonthDayYear
Date

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Peer Recovery Support Services Referral, Intake, & Consent Form

Requesting Services for Myself

Contact Information

HIPAA Statement & Participant Rights

Participant Rights

Referring for Someone Else...

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