UNIVERSAL COMMUNITY SERVICES
3908 W 12TH AVE HIALEAH, FLORIDA 33012
office@universalcommunityservices.com
universalcommunityservices.com
phone# 305-400-8904
fax# 786-703-3924

I, hereby authorize Universal Community Services Inc and its designated staff to provide comprehensive Mental Health services for the individual named above

I understand that i may revoke this consent for services at any time by written or verbal request.

I agree to participate in the development of an individualized Service Plan.

I auhtorize the use of any medical or mental Protected Health Information (PHI) necessary to process a reimbursement for Mental Health services and request payment of Medicare/Medicaid (or any other third party agency, public or private, for wich I may be eligible)

I understand that Universal Community Services Inc uses electronic records, and these records are shared within staff providing services. 

I authorize the use of my electronic signature (e-signature) on all applicable documents required for Mental Health services.

   I, hereby consent to participate in telemental health as part of my psychotherapy. I understand that telemental health is the practice of delivering clinical health care services via technology-assisted media.
1. I understand that I have the right to withdraw consent at any time without affecting my right to future care, services, or program benefits to which I would otherwise be entitled.
2. I understand and agree to receive telemental health services from my therapist through a live interactive video connection, meet for scheduled psychotherapy sessions under the conditions outlined in this document.
3. I understand that there are risks, benefits, and consequences associated with telemental health, including but not limited to, a) the video connection may not work, or it may stop working during a session; b) the video or audio transmission may not be clear, and c) I may be asked to go to my therapist’s office in person if telemental health is not an appropriate modality of treatment for me.
4. I recognize the benefits of telemental health, which may include the following: a) reduced cost and time commitment for treatment due to the elimination of travel; b) ability to receive services near my home or from my home; and c) access to services that are not available in my geographic area.
5. I understand that my therapist uses HIPAA-compliant technology to transmit and receive video and audio and stores allnotes and information related to my treatment in a manner that is compliant with state and federal laws. I understandthat it is my responsibility toensure that my physical location during video conferencing is free of other people to ensuremy confidentiality.Furthermore, I agree that recording my online sessions is prohibited.
6. I understand that I have the option to request in-person treatment at any time, and my therapist will assist in scheduling this or make a referral if travel to the therapist’s office is not feasible for me. I understand that closerproviders may not be available, depending on my location.
7. I understand the limitations to confidentiality with my therapist include the reasonable belief that I am a danger to myself or others. I understand that if my therapist reasonably believes that I plan to harm myself or some one else, my
therapist will contact local emergency services to come to my location and ensure my safety.

Level 1:

We encourage you to discuss any complaints or issues about your Mental Health services with your therapist or counselor. If we are unable to resolve your complaint immediately or within five (5) business days of receipt, please proceed to Level 2 below. You do have the right to take your complaint straight to Level 2, but we believe the simplest way to resolve your concerns is to do this at Level 1.
Level 2:

If you disagree with the outcome of the Level 1 determination, you may
request either verbally or in writing a review of your complaint by the therapist supervisor. You will recieve a notification from the supervisor of the grievance outcome once a determination has been made, or within five (5) business days of receipt.

Level 3:

If you disagree with our Level 2 determination, you have the right to send a
written grievance to the Director of the Agency:

Agency - Universal Community Services

Address - 3908 W 12th Ave Hialeah, FL 33012

Phone Number - 3054008904

A mental health advance directive is a legal document that lets you name
another individual as your agent to make mental health treatment decisions for you, if you become incapable of making your own decisions, or if you want someone else to make those decisions for you now, even though you are still capable of making your own decisions. Universal Community Services will honor any mental health advance directives that you may have executed within the scope of the law. Advance directives are not required to receive services in Universal Community Services. Please choose one of the following statements:

Yo, certifico que todos los documentos, formularios y la información que ha (Nombre del Cliente/Nombre del Custodio Legal)sido proporcionada por la agencia Universal Community Services referente a mi caso, fue explicada totalmente en mi idioma primario y que entiendo y apruebo todo su contenido. Yo he firmado todos los documentos voluntariamente y todas mis preguntas acerca de ellos han sido contestadas en mi idioma primario.

I, certify that all documents, forms, and information that has been provided (Client/Legal Guardian's Name ) by the agency Universal Community Services regarding my case, was fully explained in my primary language and that I understand and approve all of its contents. I have voluntarily signed all the documents, and my questions about them have been answered in my primary language.

I, hereby acknowledge that i will not harm myself in any way, attempt suicide, or die by suicide. 

Furthermore, I agree that i will take the following actions if I am ever suicidal: 

1. I will remind myself that i can never, under any circumstances, harm myself in any way, attempt suicide, or die by suicide.
2. I will call 911 if I believe that I am in immediate danger of harming myself.
3. I will call any or all the following numbers if I am not in immediate danger of harming myself but have suicidal thoughts (please list additional names, phone numbers, and any other relevant contact information below):

1. 1-800-SUICIDE (1-800-784-2433) ethics is a 24-hour suicide prevention line that can be called from anywhere in the U.S
2. 211-Crisis Line

     4. I will continue talking on the phone with as many people as necessary for as long as necessary until the suicidal thoughts have subsided.

The doctors and providers from Universal Community Services charge fees for the service they provide. These fees can be different from previous estimations, this includes deductibles and coinsurances. The copayments should be paid at the moment of service. You are responsible for any deductible and coinsurance from your insurance plan.

In case the Insurance Company that provides your health insurance denies payment of the total amount charged from Universal Community Services, you (patient or guardian) will be responsible to pay to Universal Community Services the total amount denied by the Insurance Company.

If the information you provide to Universal Community Services related to your Insurance Company is wrong, then you will be charged the fees for the service.

If you do not have health insurance, then you should be charged the fees for the service provided.

Medicare will only pay for the services accepted and estimated as necessity according to Section 19862(a)(1) of the Medicare Law. By signing this form, you certify that the information you provide to Universal Community Services about the payment under the Tittle XVIII and XIX of the Social Security Law are correct.

By signing this Form, you consent Universal Community Services to charge your Health Insurance Company for every service provided in their institution. Every payment will be charged by Universal Community Services under your name.  

I hereby acknowledge that I have received or read a copy of Universal Community Services HIPAA Notice of Privacy Practices.

This HIPPA Notice of Privacy Practices describes how Universal Community Services may use and disclose your Protected Health information (PHI) following applicable law. It also describes your rights regarding how you may again access to and control your PHI. You have the right to request restrictions on uses and disclosures of your PHI for treatment, payment, or health care operations.

I understand that Universal Community Services HIPAA Notice of Privacy Practices may change periodically and that I am entitled to recieve a copy of any revised HIPAA Notice of Privacy Practices upon request. 

I hereby grant permission to Universal Community Services to obtain and use photographs and/or videotape as needed, including upon admission to program for identification.

I also grand permission to Universal Community Services to videotape therapy sessions to be used for therapist's supervision, and to assist in treatment. I also grant the right it gives to transfer and exhibit photographs or videotapes to any responsible individual, business or others as deemed necessary and in my best interests. 

Universal Community Services agrees to maintain my con fidentiality rights by using photographs and/or videotapes only as required, and not for commercial orother business gains. Access to photographs adn/or video is limited to only those persons approved by the administration.

TRANSPORTATION POLICY

It is the policy of Universal Community Services that all clients transported by Universal Community Services must always wear seat-belts. If you fail to follow this policy, you agree that you do so at your own risk.

If an injury occurs as a result of failure to follow this policy, you agree that you will be fully responsible for any injuries sustained as a result of your failure to wear a seat-belt and you release Universal Community Services from any liability whatsoever, resulting from the injury. 

 

FOOD SAFETY POLICY

It is the policy of Universal Community Services from time to time, to distribute snacks and prepared food, including breakfast and lunch, to clients attending the program. 

I hereby release Universal Community Services from any liability, in the rare event that a possible ill effect may occur, as the result of our organization's food distribution. This release of liability also applies to lunches that I may choose to take home to enjoy following the program.

We, at Univeral Community Services strive to provide the best quality of services to our clients, and, as such, have implemented strict controls to closely monitor our food service process in order to prevent ill effects from ocurring.

In the event of an emergency, recipients will request assistance from a 24-hour staff member, all of whom are trained in Universal Community Services emergency procedures and would help them evacuate the building. The following events would constitute an emergency that would require the recipient to report immediately to a staff member:

1. Smelling or seeing smore or fire
2. Smelling of gas
3. Flooding water
4. Apparent illness of another person or staff member
5. Unlawful entry of a person into the facility
6. Accidents or injuries of another recipient or staff member
7. Violence or altercations
8. Finding drugs on premises

Recipients or staff may call 911 in an emergency. In the event of a fire, all staff is trained during bi-annual fire drills to meet at a predesignated area.

Recipients who are experiencing an emergency in their home would access immediate services by dialing 911 and then contacting their case maager for support.

The above written policy has been explained to me and I understand what i need to do in the event of an emergency. 

  I certify to the best of my knowledge that I am not currently receiving Mental Health services from another agency. I understand that receiving duplicate Mental Health services constitute Medicaid fraud, and I understand its consequences.

 

  Yo certifico desde el mejor de mis conocimientos que actualmente no estoy recibiendo servicios de salud mental de otra agencia. Yo entiendo que recibir servicios de salud mental duplicados constituye un fraude a Medicaid y entiendo sus consecuencias.

I hereby authorize the request, use or disclosure of preotected health confidential information about the individual named above ("Client" or "you")

The protected health information may be released and or requested by:

• Name (individual/organization): Universal Community Services 
• Address: 3908 w 12th Ave, Hialeah, FL 33012
• Phone Number: 305-400-8904
• Fax Number: 786-703-3924

The protected health information may be received from/disclosed to: Emergency Contanct

I understand that i have the right to revoke this authorization in writing at any time. I know that the information disclosed based on this authorization may be re-disclosed by the recipient and may no longer be protected by federal or state privacy laws. I understand that my eligibility for services will not be affected if I refuse to sign this authorization. I understand that I have the right to receive a copy of this authorization form.