Service Overview

Family Connections’ NJ4S (New Jersey Statewide Student Support Services) provides short-term Individual, Family, and Group Counseling. Services are voluntary, funded by the Department of Children and Families (DCF) and managed by Family Connections with no costs to you or your child. Parental/guardian consent is needed for youth who are not of age to legally consent to services. The purpose of this form is to provide you with information on these services, gather necessary information and obtain approval for your child to participate in program services.

The assessment and counseling services that your child receives are confidential. Family Connections may use your child’s information to carry out treatment, payment, or healthcare operations or for other purposes that are permitted or required by law but will not otherwise share information without your consent. Please see the attached copy of Family Connections’ Notice of Privacy Practices for more information on how we maintain privacy (you may access a copy at
https://www.familyconnectionsnj.org/notice-of-privacy-practices/ ). Your child’s counseling records will be maintained in a Family Connections’ Electronic Health Record. Family Connections has implemented measures to keep this information secure in accordance with applicable state and federal privacy statutes and regulations, including the Health Insurance Portability and Accountability Act of 1996 (HIPAA). You can find more information on how Family Connections secures its data at https://www.familyconnectionsnj.org/privacy-policy/.

All counselors in Family Connections’ programs meet the NJ requirements for licensure. Services may be provided by a licensed master’s level clinician who is under the clinical supervision of a fully licensed supervisor. Prior to counseling services beginning, a comprehensive intake assessment will be completed, by a clinician, to gather information and determine appropriate clinical nterventions. Services will occur in school, via telehealth, or in the community as requested (please see the attached document outlining Family Connections’ Teleservice Practices for more information on our procedures) Changes to service location will be confirmed, with parent/guardian, via phone.

Benefits of services include improved mental health and wellbeing. The risks of services include discussing unpleasant aspects of your life and experiencing uncomfortable feelings. There are no guarantees on the result of services and active participation and compliance with treatment recommendations is necessary to achieve the maximum benefit.

This consent will remain in effect for 1 year. 

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Client Data

 

Parent/Guardian Data

Consent

I have reviewed the services rendered by Family Connections’ NJ4S (NJ Statewide Student Support Services) program and consent to my child’s assessment and/or any recommended counseling services that may be offered. I affirm that my child’s participation in assessment and/or treatment is voluntary, and I understand we may refuse services at any time. I agree that participation in assessment and services does not guarantee that treatment services will be offered. I understand that, with all forms of treatment, there are benefits as well as risks. I acknowledge that no guarantees have been made to me or my child as to the result of my assessment and/or treatment. I understand that compliance with treatment recommendations is necessary to maximize benefit.

I consent to Family Connections using and disclosing my child’s health information for the purposes of treatment, payment, and healthcare operations as outlined in Family Connections’ Notice of Privacy Practices. I understand that my consent to this disclosure is necessary for my child to participate in services. I also understand that Family Connections stores information electronically and has implemented measures to keep this information secure in accordance with applicable state and federal privacy statutes and regulations. I acknowledge that I have been given a copy of Family Connections’ Notice of Privacy Practices and access to Family Connections’ electronic Privacy Policy.

I understand that services will be provided in my child’s school or at a community location; the location of which I will agree to in advance. Please select one:

• I permit my child to participate in sessions only at the child’s school.
• I permit my child to participate in sessions, at school on a secure telehealth platform, and/or in a community location; to which I will pre-approve.

In the event of a medical emergency, if the staff of NJ4S are unable to reach me, I hereby give consent for the program staff to seek, authorize, and obtain medical treatment for the above-named youth. I understand that this consent will remain in effect from the date it is signed by me unless it has been rescinded by written notice signed by me and delivered to NJ4S program staff.

For further information, contact NJ4S at:
Email: infonj4sessex@familyconnectiosnj.org
Family Connections NJ4S-Essex
7 Glenwood Avenue Suite 304, East Orange, NJ 07017
973-323-3451

              Authorization to Disclose Protected Health Information

By signing this form, I authorize Family Connections and

to share the following information regarding the above-named client’s enrollment in the NJ4S program:

• Attendance in NJ4S Services.
• Enrollment Status within the NJ4S Program.
• Reason for Discharge from NJ4S Program.
• NJ4S’ Discharge Recommendations.

The purpose of this authorization is to allow these parties to coordinate care, as well as provide referrals and academic support.

I understand that medical records are protected under federal and state law, including the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 45 C.F.R. Parts 160 and 164 and cannot be disclosed without written authorization of the client (or parent or guardian if client is a minor) unless otherwise provided for in those laws and/or regulations. In some cases, federal law, e.g., HIPAA, does not prevent the persons or entities named above from redisclosing the information.

 

I further understand that the information to be shared by Family Connections is limited to the scope outlined above. Should the school request or require additional information, such as diagnosis, records, or other details regarding treatment, a new Release of Information Authorization will need to be signed specifically requesting that information.

This authorization will remain in effect for one year from the date of my signature unless it is revoked sooner. I understand that I may revoke this authorization at any time in writing except to the extent that action has been taken in reliance on it. If I wish to rescind this authorization prior to its expiration, I may submit a request in writing to Family Connections.

Acknowledgement and Signature

I acknowledge that the information to be released was fully explained to me and that this consent is given of my own free will. I have been provided with a copy of this form. I understand that I may also request Family Connections to provide me with a copy.

NOTICE OF PRIVACY PRACTICES

This Notice of Privacy Practices describes how Family Connections may use and disclose your protected health information (PHI) to carry out treatment, payment, or health care operations and for other purposes that are permitted or required by law. This Notice further states the obligations we have to protect your health information. It is our duty to maintain the privacy of PHI, to abide by the terms of the privacy notice currently in effect, and to provide individuals with notice of its legal duties and privacy practices relative to PHI. This Notice also describes your rights regarding the health information we maintain about you and a brief description of how you may exercise these rights. Please review it carefully.

If you have any questions about this Privacy Notice, please discuss them with a Family Connections Program Manager. You may also contact our Privacy Officer at 973-675-3817.

Your Rights
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

• Get A Paper or Electronic Copy of Your Medical Record. You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. You must submit this request in writing, and we will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee. We may deny your request under exceptional circumstances, consistent with federal regulations. You have the right to appeal a denial and can contact our Privacy Officer to discuss the appeal process.
• Request Corrections to Your Records. You can ask us to amend your health and claims records if you think they are incorrect or incomplete. Requests for amendments must be sent in writing to our Privacy Officer and must include a description of why you believe the information is incorrect or inaccurate. We may say “no” to your request, but we’ll tell you why in writing within 60 days.
• Request Confidential Communications. You can ask us to contact you in a specific way (for example, home or work) or to send mail to a different address. Requests for confidential communications, must be made in writing to the staff providing you with services. We will consider all reasonable requests. Should you choose to be contacted by email or text messages, it is important to know that this form of communication is not completely secure. Because of the many internet and e-mail factors beyond our control, we cannot be responsible for misdelivered or interrupted e-mail. While Family Connections has safeguards in place to protect the security of your electronic information when it is stored in our databases, we are not liable for breaches of confidentiality caused by yourself or a third party. If your email is a family address, or you share a phone with other family members, other people may see your messages, therefore, please be aware that you e-mail or text at your own risk. Email and text are best suited for routine matters, such as appointment scheduling, and should not be used for sensitive information.
• Request That We Limit What We Share. You can ask us to limit the health information we use or disclose about you for treatment, payment or health care operations. You may also ask that any part (or all) of your health information not be disclosed to family members or friends who may be involved in your care. Family Connections will carefully consider all requests but may not grant them if they affect your care and are not required to grant your request unless it relates solely to a health care item or service for which Family Connections has been paid out-of-pocket, in full. To request a restriction, you must either complete a "Request for Restrictions on the Use and/or Disclosure of Protected Health Information" form with a Family Connections Manager or send a written request to Family Connections' Privacy Officer.
• Get A List of Those with Whom We Shared Your Information. You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, with whom we shared it, and why. We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months. To get an accounting of disclosures, you must submit your request in writing to our Privacy Officer.
• Get a Copy of This Notice. You can ask for a paper copy of this notice at any time, even if you have received it electronically. We will provide you with a paper copy promptly.
• Choose Someone to Act for You. If you have given someone medical power of attorney or have a legal guardian, that person can exercise your rights and make choices about your health information. We will ensure they have this authority and can act for you before we take any action.
• File a Compliant if You Feel Your Rights are Violated. You can complain if you feel we have violated your rights by contacting Family Connection’s Privacy Officer using the information on the top of this Notice. You can also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/. We will not retaliate against you for filing a complaint.

Our Responsibilities

Federal and state laws and regulations require Family Connections to maintain the privacy and security of your PHI. Therefore, in general, we may use or disclose PHI only when (1) you give us your written authorization on a form that complies with federal and state laws; or (2) there is an exception as described in this Notice, such as, but not limited to, uses and disclosures made pursuant to a court order or medical emergency. When we need to use or disclose it, we will comply with the full terms of this Notice. Anytime we are permitted to or required to share your PHI with others, we only provide the minimum amount of data necessary to respond to the need or request unless otherwise permitted by law.

All locations comprising Family Connections will follow this notice. In addition, these sites, or locations may share health information with each other for treatment, payment, or health care operation purposes, as permitted by law.

Breach Notification Requirements. We take very seriously the confidentiality of our patients’ information, and we are required by law to protect the privacy and security of your PHI through appropriate safeguards. We will notify you in the event a breach occurs involving or potentially involving your unsecured PHI and inform you of what steps you may need to take to protect yourself.

Confidentiality of Substance Abuse Records. For individuals who have received treatment, diagnosis, or referral for treatment from our drug or alcohol abuse programs, the confidentiality of drug or alcohol abuse records is protected by federal law and regulations. As a general rule, we may not disclose any information identifying you as having a substance use disorder, unless:

• you authorize the disclosure in writing; or
  
• the disclosure is permitted by a court order; or
  
• the disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit or program evaluation purposes; or
• you commit or threaten to commit a crime either at the drug abuse or alcohol program or against any person who works for our drug abuse or alcohol programs.

Federal law and regulations governing confidentiality of drug or alcohol abuse permit us to report suspected child abuse or neglect under state law to appropriate state or local authorities. Violation of federal law and regulations governing drug or alcohol records is a crime. Suspected violations may be reported to: United States District Attorney’s Office, Newark, NJ, 973-645-2700 OR Substance Abuse and Mental Health Service Administration Center for Substance Abuse Treatment 240-276-2700. Please see 42 U.S.C. § 290dd-2 for federal law and 42 C.F.R., Part 2 for federal regulations governing confidentiality of alcohol and drug abuse patient records.

How We Use and Disclose Your Information

We may typically use or share your information without your consent or authorization in the ways outlined as follows. For each category, a general description is provided, but does not describe all specific uses or disclosures of health information. Note for Mental Health and Substance Abuse Services: We are prohibited from releasing information specific to your mental health and/or substance use disorder to outside persons / entities in many of these circumstances without your written consent unless specified, or in response to a court order, in an emergency, or otherwise required or allowed by law.

• To Provide Treatment. We may use your health information and share it with professionals who are providing you with medical, mental health, or substance use treatment or services for treatment purposes. We may use and disclose your health information, including your mental health information, within Family Connections among our staff to provide and coordinate your health care and any related services. We will obtain your written consent to share your substance use information for treatment purposes.
  
• For Healthcare Operations. We may use and disclose your health information, including your mental health information, for our operations. These uses and disclosures are necessary to run our organization and ensure that our consumers receive quality care. These activities may include, by way of example, quality assessment and improvement, reviewing the performance of our clinicians, training students in clinical activities, licensing, accreditation, and general administrative activities. We may also use and disclose your health information to contact you regarding your services with us. We will obtain your written authorization to share your substance use information for healthcare operations. There may be instances where services or functions are provided to Family Connections through third-party Qualified Service Organizations or Business Associates, who create, receive, store, or transmit PHI on Family
  Connections’ behalf. Family Connections maintains formal agreements with these entities, and they are subject to the same privacy standards.
  
• For Payment. We can use and disclose your health information to bill and get payment from health plans or other entities. We may disclose your health information to permit your health plan to take certain actions before it approves or pays for your services. We will obtain your written authorization prior to sharing PHI related to mental health or substance use for payment purposes.

Your Choices

For certain health information, you can tell us your choices about what we share.

• Communication with Family, Friends, or Others Involved in Your Care. Unless you object, we may, using our best judgment, disclose to a family member, other relative, close personal friend or any other person you identify, health information relevant to that person’s involvement in your care or payment related to your care; in emergency or similar types of situations, we may use or disclose information to notify or assist in notifying a family member, personal representative, or another person responsible for your care, your location, and general condition. If you are not
  able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.  Disaster Relief. Unless you object, we may share your information in a disaster relief situation. If you are not able to tell us your preference, for example if you are unconscious or we cannot reach you, we may go ahead and share your information if we believe it is in your best interest.
  
• Appointment Reminders. Unless you object, we may use and disclose health information to contact you as a reminder that you have an appointment for treatment or services.
  
• Treatment Alternatives. Unless you object, we may use and disclose health information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.
  
• Health-Related Benefits and Services. Unless you object, we may use and disclose health information to tell you about health-related benefits or services that maybe of interest to you.
  
• Fundraising. We may contact you for fundraising efforts, but you can tell us not to contact you again.
  
• Research. Family Connections does not routinely participate in research studies. Any disclosure for research purposes shall be based on your written, informed consent, and assurances that the researchers shall comply with ethical standards for ensuring the confidentiality of your information.
  
• Participation in Health Information Exchange Organizations (HIE). We may partner with one or more HIEs to access and disclose your health information for the purposes described in this notice, including treatment, payment, or health care operations. HIEs allow participating physicians, healthcare facilities, or other authorized users to share your information electronically, to the extent permitted by law, which can reduce medical errors, eliminate redundant care, and reduce unnecessary costs. You have a right to decline participation in an HIE. If you decline participation in an HIE, your information will not be accessible from the exchange networks, however, all other typical uses and releases of your information will continue in accordance with this Notice and applicable laws. Upon request, we will provide you with additional information about the uses and disclosures of your Protected Health Information in connection with each HIE in which we participate. If you are receiving treatment for a substance use disorder, we will not share your information with an HIE without your prior written authorization.
  

 

Disclosures Permitted Without Your Authorization or Opportunity to Object

We are allowed or required to share your information in other ways. We have to meet many conditions in the law before we can share your information for these purposes. For more information see www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

 

• Emergencies. We may disclose your health information in an emergency treatment situation.
  
• Help With Public Health and Safety Issues. We can share health information about you for certain situations such as: Preventing disease; Helping with product recalls; Reporting adverse reactions to medications; Reporting suspected abuse, neglect, or domestic violence; Preventing or reducing a serious threat to anyone’s health or safety.
  
• As Required by Law. We will disclose health information about you when required to do so by federal, state, or local law, including the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.
• Health Oversight Activities. We may disclose health information to a health oversight agency for activities authorized by law, including audits, investigations, inspections and licensure.
  
• Disclosures in Legal Proceedings. We may disclose health information about you when we are court ordered to do so by a judge.
  
• Law Enforcement Activities. We may disclose health information to a law enforcement official for law enforcement purposes when: We report criminal conduct occurring on the premises of our facility or against our staff; We determine that the law enforcement purpose is to respond to a threat of an imminently dangerous activity by you against yourself or another person; The disclosure is otherwise required by law.
  
• Coroners, Medical Examiners and Funeral Directors. We may be required to disclose health information to a Corner or Medical Examiner. We may also disclose health information to funeral directors consistent with applicable law to carry out their duties.
  
• Correctional Institutions. As required by law, should you be an inmate of a correctional institution, we may disclose to the institution or agents thereof health information necessary for your health and the health and safety of other individuals.
  
• Organ Procurement Organizations. Consistent with applicable law, we may disclose health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant.
  
• Workers’ Compensation. We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law.
  
• Special Government Functions. If you are a member of the armed forces, we may be required by law to disclose health information about you as required by military command. We may disclose health information about you to authorize federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations or intelligence, counterintelligence, and other national security activities authorized by law.

Disclosures That Require Your Written Authorization

In general, we will need your specific written authorization to use or disclose your PHI for any purpose other than those listed above. We will seek your written authorization for at least the following information unless the use or disclosure would be otherwise permitted or required by law as described above.

- Marketing Purposes. We must obtain your specific written authorization to use your PHI to send you marketing materials. However, we may provide you with marketing materials face-to-face without obtaining authorization, in addition to communicating with you about services or products that relate to your treatment, case management, or care coordination, alternative treatments, therapists, providers, or care settings.

• Activities Where We Receive Money for Exchanging PHI. For certain activities in which we would receive money (remuneration) directly or indirectly from a third party in exchange for your PHI, we must obtain your specific written authorization prior to doing so. However, we would not require your authorization for activities related to payment for services provided.
  
• Tuberculosis Information. We must obtain your specific written authorization prior to disclosing any information that would identify you as having or being suspected of having tuberculosis (TB). We may use and disclose TB information where authorized by law, to the New Jersey Department of Health, or otherwise authorized by court order.
  
• Sexually Transmitted Infection Information. In most cases, we must obtain your specific authorization prior to disclosing information that would identify you as having or being suspected of having a sexually transmitted infection (STI). We may use and disclose information related to STIs without obtaining your authorization only where permitted by law, including to the New Jersey Department of Health and Senior Services and only under limited circumstances.
• HIV/AIDS Information. In most cases, we will not release any of your HIV/AIDS related information unless your authorization expressly states that we may do so. There are certain purposes, however, for which we may be permitted to release your HIV/AIDS information without obtaining your express authorization, such as to comply with a court order or, when otherwise required by law, to the New Jersey Department of Health or other governmental entity.
  
• Genetic Information. We must obtain your specific written authorization prior to obtaining or retaining your genetic information, or using or disclosing it for treatment, payment or health care operations purposes. We may use or disclose your genetic information without your written authorization only where it would be permitted by law or otherwise authorized by a court order.
  
• Mental Health Information. We must obtain your specific written authorization prior to disclosing certain mental health information unless otherwise permitted by law.
  
• Psychotherapy Notes. We must obtain your specific written authorization prior to disclosing any psychotherapy notes unless otherwise permitted by law. Where the psychotherapy notes involve family therapy and the records for all participants have been integrated, no single family member shall have access to those records unless all adult participants and the guardians of any minor participants agree through a signed authorization form.
  
• Substance Use Information. We must obtain your specific written authorization prior to disclosing your substance use treatment records unless otherwise permitted by law.
  
• Minors. Individuals ages 13 and over receiving Substance Use Treatment and individuals ages 14 and over receiving Mental Health Treatment must provide written authorization prior to their information being disclosed, unless otherwise permitted by law.

- Right to Revoke Authorization. You may revoke your authorization, in writing, at any time. Any revocation will be granted except to the extent we may have taken action in reliance upon your authorization.
Changes to this Notice

• We reserve the right to change the terms of our Notice of Privacy Practices. We also reserve the right to make the revised or changed Notice of Privacy Practices effective for all health information we already have about you as well as any health information we receive in the future. We will post a copy of the current Notice of Privacy Practices at each site where we provide care. You may also obtain a copy of the current Notice by accessing our website at www.familyconnectionsnj.org or by asking our staff for a copy.

Family Connections Teleservice Practices

Teleservice is the use of technology to provide services when a provider and client are in different locations. Any of Family Connections’ services can be provided via teleservice, as permitted by the entity paying for the service (e.g., insurance, government funding, etc.) and/or federal or state laws regulating the service. Family Connections offers teleservices via secure, HIPAA-compliant software platforms that can be accessed through your PC, tablet, or smartphone. Our staff takes all steps reasonably necessary to maximize your privacy and confidentiality. Your services cannot be seen or overheard by others at staff’s location.

Teleservice Benefits include:
• The ability to connect with Family Connections and receive services from a distant location.
• Added time and convenience of not having to travel to or from an appointment.
• Ability to give staff more context in describing your home environment.

Teleservice Risks include:
• Technology interruptions (e.g., dropped calls, poor internet service, etc.)
• Potential privacy and security risks resulting from services being provided remotely (e.g., an unintended third party intercepting electronic communication, the conversation being overheard by others at your location).
• Planned services may need to be rescheduled due to technology issues or if you are receiving services at a location, or in the presence of others, that may be detrimental to your care.
• Services involving multiple people at different locations (e.g., group or family services) pose additional privacy and security risks as others participating may not have taken all of the steps needed to maximize privacy and security and minimize risks. Family Connections cannot guarantee that everyone attending is participating from a private and secure location.
• Services involving multiple people at different locations (e.g., group or family services) may involve interruptions if any privacy or security risks are discovered.

To minimize these risks, Family Connections has established procedures to maximize security and confidentiality, as well as provide you with optimal care. Staff take all steps reasonably necessary to maximize security and confidentiality, including enabling all security features available on the agreed-upon communication platform and ensuring that your conversation cannot be seen or overheard by others at their location. You are encouraged to take similar precautions as part of receiving services. Staff will discuss procedures for informing you of upcoming appointments and communicating between appointments. At the start of each teleservice session, staff will discuss a technology interruption plan with you and also obtain your physical location and a contact phone number so that we can direct any services that may be needed in the event of an emergency.

To minimize technology disrupting your services, Family Connections has established the following technology interruption plans:
• Individual and Family Services: All parties will attempt to reconnect to the appointment using the same technology. If all parties cannot connect after 5 minutes, Family Connections staff will call you at the phone number you provided at the start of the appointment.
• Group Services: You will attempt to reconnect to the appointment using the same technology for at least 5 minutes. If you are unable to reconnect, Family Connections staff will contact you via phone, email, or text within 2 hours with information on your next group session.

By consenting to receive teleservices, you:

• Agree to participate in Family Connections services through the technology that provides the most security to protect your privacy and is mutually available to you and Family Connections.
• Understand that Family Connections staff will review how you will be informed of upcoming appointments and procedures for communicating between appointments. If you need assistance between appointments, you may contact Family Connections staff during their office hours but understand that staff may not be immediately available due to their schedule. You further agree to contact 911 or your nearest emergency room should you experience a true emergency between appointments.
• Agree to provide Family Connections staff with your location and a contact phone number at the start of each appointment in the event of an emergency.
• Understand that you have a responsibility to take the privacy and security precautions similar to those outlined above and, if you are unable to do so, we may reschedule a service if proceeding with the service could be detrimental to you.
• Understand that the privacy laws that protect the confidentiality of your Protected Health Information (PHI) also apply to teleservice, unless an exception applies as outlined in Family Connections’ Notice of Privacy Practices.
• Acknowledge that Family Connections’ staff can only control technology security settings on their side of the communication, can only manage privacy in their environment, and are not responsible if your Protected Health Information is seen/overheard by others at your location, or if you have not maximized the security features of our agreed-upon communications.
• Understand that if participation includes group services or services involving multiple people at different locations, this poses additional privacy and security risks as other participants may not have taken the full steps necessary to help ensure confidentiality. Family Connections’ staff will review group privacy and security requirements with all participants at the start of each group session and remove members who cannot adhere to these requirements if this information becomes known. However, staff may not know of all potential risks at each group member’s location.
• Understand that teleservices may only be permissible as determined by the entity paying for your services (e.g., insurance, government funding, etc.) and/or federal or state laws regulating your services. You further understand that services may transition to in-person as authorized or required by any of these entities.

Teleservice is the use of technology to provide services when a provider and client are in different locations. Any of Family Connections’ services can be provided via teleservice, as permitted by the entity paying for the service (e.g., insurance, government funding, etc.) and/or federal or state laws regulating the service. Family Connections offers teleservices via secure, HIPAA-compliant software platforms that can be accessed through your PC, tablet, or smartphone. Our staff takes all steps reasonably necessary to maximize your privacy and confidentiality. Your services cannot be seen or overheard by others at staff’s location. In addition to the service benefits and risks described for each service outlined above, there are additional risks and benefits associated with receiving teleservice. Teleservice Benefits include: • The ability to connect with Family Connections and receive services from a distanced location. • Added time and convenience of not having to travel to or from an appointment. • Ability to give staff more context in describing your home environment. Teleservice Risks include: • Technology interruptions (e.g., dropped calls, poor internet service, etc.) • Potential privacy and security risks resulting from services being provided remotely (e.g., an unintended third party intercepting electronic communication, the conversation being overheard by others at your location). • Planned services may need to be rescheduled due to technology issues or if you are receiving services at a location, or in the presence of others, that may be detrimental to your care. • Services involving multiple people at different locations (e.g., group or family services) pose additional privacy and security risks as others participating may not have taken all of the steps needed to maximize privacy and security and minimize risks. Family Connections cannot guarantee that everyone attending is participating from a private and secure location. • Services involving multiple people at different locations (e.g., group or family services) may involve interruptions if any privacy or security risks are discovered. To minimize these risks, Family Connections has established procedures to maximize security and confidentiality, as well as provide you with optimal care. Staff take all steps reasonably necessary to maximize security and confidentiality, including enabling all security features available on the agreed-upon communication platform and ensuring that your conversation cannot be seen or overheard by others at their location. You are encouraged to take similar precautions as part of receiving services. Staff will discuss procedures for informing you of upcoming appointments and communicating between appointments. At the start of each teleservice session, staff will discuss a technology interruption plan with you and also obtain your physical location and a contact phone number so that we can direct any services that may be needed in the event of an emergency. To minimize technology disrupting your services, Family Connections has established the following technology interruption plans: • Individual and Family Services: All parties will attempt to reconnect to the appointment using the same technology. If all parties cannot connect after 5 minutes, Family Connections staff will call you at the phone number you provided at the start of the appointment. 3 7 FAMILY CONNEC TIONS' CONSUMER GUIDE • Group Services: You will attempt to reconnect to the appointment using the same technology for at least 5 minutes. If you are unable to reconnect, Family Connections staff will contact you via phone, email, or text within 2 hours with information on your next group session. By consenting to receive teleservices, you: • Agree to participate in Family Connections services through the technology that provides the most security to protect your privacy and is mutually available to you and Family Connections. • Understand that Family Connections staff will review how you will be informed of upcoming appointments and procedures for communicating between appointments. If you need assistance between appointments, you may contact Family Connections staff during their office hours but understand that staff may not be immediately available due to their schedule. You further agree to contact 911 or your nearest emergency room should you experience a true emergency between appointments. • Agree to provide Family Connections staff with your location and a contact phone number at the start of each appointment in the event of an emergency. • Understand that you have a responsibility to take the privacy and security precautions similar to those outlined above and, if you are unable to do so, we may reschedule a service if proceeding with the service could be detrimental to you. • Understand that the privacy laws that protect the confidentiality of your Protected Health Information (PHI) also apply to teleservice, unless an exception applies as outlined in Family Connections’ Notice of Privacy Practices. • Acknowledge that Family Connections’ staff can only control technology security settings on their side of the communication, can only manage privacy in their environment, and are not responsible if your Protected Health Information is seen/overheard by others at your location, or if you have not maximized the security features of our agreed-upon communications. • Understand that if participation includes group services or services involving multiple people at different locations, this poses additional privacy and security risks as other participants may not have taken the full steps necessary to help ensure confidentiality. Family Connections’ staff will review group privacy and security requirements with all participants at the start of each group session and remove members who cannot adhere to these requirements if this information becomes known. However, staff may not know of all potential risks at each group member’s location. • Understand that teleservices may only be permissible as determined by the entity paying for your services (e.g., insurance, government funding, etc.) and/or federal or state laws regulating your services. You further understand that services may transition to in-person as authorized or required by any of these entities. Teleservices Teleservice is the use of technology to provide services when a provider and client are in different locations. Any of Family Connections’ services can be provided via teleservice, as permitted by the entity paying for the service (e.g., insurance, government funding, etc.) and/or federal or state laws regulating the service. Family Connections offers teleservices via secure, HIPAA-compliant software platforms that can be accessed through your PC, tablet, or smartphone. Our staff takes all steps reasonably necessary to maximize your privacy and confidentiality. Your services cannot be seen or overheard by others at staff’s location. In addition to the service benefits and risks described for each service outlined above, there are additional risks and benefits associated with receiving teleservice. Teleservice Benefits include: • The ability to connect with Family Connections and receive services from a distanced location. • Added time and convenience of not having to travel to or from an appointment. • Ability to give staff more context in describing your home environment. Teleservice Risks include: • Technology interruptions (e.g., dropped calls, poor internet service, etc.) • Potential privacy and security risks resulting from services being provided remotely (e.g., an unintended third party intercepting electronic communication, the conversation being overheard by others at your location). • Planned services may need to be rescheduled due to technology issues or if you are receiving services at a location, or in the presence of others, that may be detrimental to your care. • Services involving multiple people at different locations (e.g., group or family services) pose additional privacy and security risks as others participating may not have taken all of the steps needed to maximize privacy and security and minimize risks. Family Connections cannot guarantee that everyone attending is participating from a private and secure location. • Services involving multiple people at different locations (e.g., group or family services) may involve interruptions if any privacy or security risks are discovered. To minimize these risks, Family Connections has established procedures to maximize security and confidentiality, as well as provide you with optimal care. Staff take all steps reasonably necessary to maximize security and confidentiality, including enabling all security features available on the agreed-upon communication platform and ensuring that your conversation cannot be seen or overheard by others at their location. You are encouraged to take similar precautions as part of receiving services. Staff will discuss procedures for informing you of upcoming appointments and communicating between appointments. At the start of each teleservice session, staff will discuss a technology interruption plan with you and also obtain your physical location and a contact phone number so that we can direct any services that may be needed in the event of an emergency. To minimize technology disrupting your services, Family Connections has established the following technology interruption plans: • Individual and Family Services: All parties will attempt to reconnect to the appointment using the same technology. If all parties cannot connect after 5 minutes, Family Connections staff will call you at the phone number you provided at the start of the appointment. 3 7 FAMILY CONNEC TIONS' CONSUMER GUIDE • Group Services: You will attempt to reconnect to the appointment using the same technology for at least 5 minutes. If you are unable to reconnect, Family Connections staff will contact you via phone, email, or text within 2 hours with information on your next group session. By consenting to receive teleservices, you: • Agree to participate in Family Connections services through the technology that provides the most security to protect your privacy and is mutually available to you and Family Connections. • Understand that Family Connections staff will review how you will be informed of upcoming appointments and procedures for communicating between appointments. If you need assistance between appointments, you may contact Family Connections staff during their office hours but understand that staff may not be immediately available due to their schedule. You further agree to contact 911 or your nearest emergency room should you experience a true emergency between appointments. • Agree to provide Family Connections staff with your location and a contact phone number at the start of each appointment in the event of an emergency. • Understand that you have a responsibility to take the privacy and security precautions similar to those outlined above and, if you are unable to do so, we may reschedule a service if proceeding with the service could be detrimental to you. • Understand that the privacy laws that protect the confidentiality of your Protected Health Information (PHI) also apply to teleservice, unless an exception applies as outlined in Family Connections’ Notice of Privacy Practices. • Acknowledge that Family Connections’ staff can only control technology security settings on their side of the communication, can only manage privacy in their environment, and are not responsible if your Protected Health Information is seen/overheard by others at your location, or if you have not maximized the security features of our agreed-upon communications. • Understand that if participation includes group services or services involving multiple people at different locations, this poses additional privacy and security risks as other participants may not have taken the full steps necessary to help ensure confidentiality. Family Connections’ staff will review group privacy and security requirements with all participants at the start of each group session and remove members who cannot adhere to these requirements if this information becomes known. However, staff may not know of all potential risks at each group member’s location. • Understand that teleservices may only be permissible as determined by the entity paying for your services (e.g., insurance, government funding, etc.) and/or federal or state laws regulating your services. You further understand that services may transition to in-person as authorized or required by any of these entities.