FINANCIAL RELEASE
I understand that Enduring The Course Inc Therapeutic Service and Support and its respective cliniciansmay use confidential information about me to bill and be paid for provided services. I have been given theopportunity to ask any questions regarding the services offered and have received satisfactory answers tomy questions. I hereby consent Enduring The Course Inc Therapeutic Service and Support and itsrespective clinicians to release confidential information to the billing agent, Integrity Support, Inc. and itscontracted clearinghouse, and/or to the funding source(s), and for the funding source to releaseconfidential information to Enduring The Course Inc Therapeutic Service and Support and its respectiveclinicians for this Purpose.PERMISSION TO TRANSPORTI hereby grant permission for Enduring The Course Inc Therapeutic Service and Support and its respectiveclinicians to provide transportation to myself and/or my child and agree to hold Enduring The Course IncTherapeutic Service and Support and its respective clinicians harmless for any accident/injury that resultsfrom the provision of transportation.If my child does not meet the height and weight requirements of the State of Ohio to ride without a childrestraint system, I am aware that I must provide such a system for transport and failure to do so will resultin no transportation for my child.PERMISSION TO SEEK EMERGENCY MEDICAL CAREI hereby give consent for Enduring The Course Inc Therapeutic Service and Support and its respectiveclinicians to seek and sign consent for emergency medical care formyself and/or my child in the event that I am unable to do so for myself for my child.It is understood that Enduring The Course Inc Therapeutic Service and Support and its respectiveclinicians will attempt to locate me, or another legally responsible adult, as quickly as possible in the eventof an emergency situation.CLIENT RIGHTS/GRIEVANCE POLICIESI have received and had explained to me the Client Rights and Grievance Policies handout. I have beengiven the opportunity to ask any questions regarding the services offered and have received satisfactoryanswers to my questions. Enduring The Course Inc Therapeutic Service and Support and its respectivecliniciansprovided me with this handout and verbally explained the rights that myself and/or my child has as a clientat Enduring The Course Inc Therapeutic Service and Support.Privacy PracticesEnduring The Course Inc Therapeutic Service and Support and its respective clinicians have provided mewith the Privacy Rights handout and verbally explained my rights/the rights of my child as a client atEnduring The Course Inc Therapeutic Service and Support. I have been given the opportunity to ask anyquestions regarding the services offered and have received satisfactory answers to my questions. Iunderstand these rights are designed to protect my privacy and that no information will be released byEnduring The Course Inc Therapeutic Service and Support or its respective clinicians without mypermission, except in cases where abuse or neglect are reported, or myself/my child becomes a danger toself or others.
NOTICE OF PRIVACY PRACTICES
As an agency, we have a legal duty to protect private information about you/your child.The agency is required to protect the privacy of heath information about you or your child. The agency isrequired to follow the procedures in this Notice.THE AGENCY MAY USE AND DISCLOSE INFORMATION UNDER THE FOLLOWING CONDITIONS:
1. THE AGENCY MAY USE AND DISCLOSE INFORMATION ABOUT YOU TO PROVIDE SERVICES.This may include communicating with other health care providers regarding your treatment. For example,the agency may use and disclose information if you need a referral for other health care services, or toreceive authorization to begin services.
2. THE AGENCY MAY USE AND DISCLOSE INFORMATION ABOUT YOU TO OBTAIN PAYMENT FORSERVICES.Generally, the agency may use and give your medical information to others to bill and collect payment forthe treatment and services provided to you. Before you receive scheduled services, the agency may shareinformation about these services with your insurer to assure that services are covered.
3. THE AGENCY MAY USE AND DISCLOSE YOUR INFORMATION FOR HEALTH CARE OPERATIONS. The agency may use and disclose information about you in performing business activities, which arecalled "health care operations". These "health care operations" allow the agency to improve the quality ofcare we provide and reduce health care costs. Examples of the way the agency may use or discloseinformation about you for "health care operations" include the following:Reviewing and improving the quality, efficiency, and cost of care that we provide to you.Reviewing and evaluating the skills, qualifications, and performance of health care providers taking care ofyou.Cooperating with outside organizations that assess the quality of the care that the agencies and othersprovide. These organizations might include the Ohio Department of Mental Health and Addictions Servicesand the county Addictions and Mental Health Services Board.Resolving complaints and grievances.Reviewing activities and using or disclosing information in the event that control of the agency changessignificantly.
4. THE AGENCY MAY DISCLOSE INFORMATION TO PERSONS INVOLVED IN YOUR CARE.The agency may disclose information about you to a relative, or any other person you identify if thatperson is involved in your care and the information is relevant to your care. When the client is a minor, forinstance, the agency may disclose information about the minor to a parent, guardian, or other personinvolved in your care if there is an emergency situation, and someone needs to be notified of your locationor condition.You may request that the agency not disclose information to persons involved in your care. The agencywill generally comply with your request, unless there is an emergency, or the client is a minor. If the clientis a minor, the agency may or may not be able to comply with your request.
5. OTHER CIRCUMSTANCES IN WHICH THE AGENCY MAY USE AND DISCLOSE INFORMATION ABOUTYOU.The agency may use and/or disclose information about you for a number of circumstances in which youdo not have to consent, give authorization, or otherwise have an opportunity to agree or object. Theseinstances include:When the use and/or disclosure is required by law. For example, when a disclosure is required by federal,state, or local law or other judicial or administrative proceedings, or when the disclosure related to victimof abuse, neglect, or domestic violence.When the use and/or disclosure is for health oversight activities. For example, the agency may discloseinformation about you to a state or federal health oversight agency which is authorize by law to overseeagency operations or to assure the health of the public.When the disclosure is for law enforcement purposes. For example, the agency may disclose informationabout you in order to comply with laws that require the reporting of certain types of wounds or otherphysical injuries, or in reporting of missing persons.When the use and/or disclosure is to have a serious threat to health or safety. For example, the agencymay disclose information about you to prevent or lessen a serious and imminent threat to the health orsafety of a person or the public.When the use and/or disclosure involves correctional institutions and in other law enforcement custodialsituations. For example, in certain circumstances, the agency may disclose information about you to acorrectional institution having lawful custody of you.
6. THE AGENCY MAY USE OR DISCLOSE INFORMATION ABOUT YOU WITH YOUR AUTHORIZATION.Under any circumstances other than those listed above in #5, the agency will ask for your writtenauthorization before the use or disclosure of information about you. If you sign a written authorizationallowing the agency to disclose information about you in a specific situation, you can later cancel yourauthorization in writing. If you cancel in writing, the agency will not disclose information after receipt ofyour cancellation, except for disclosures which were being processed before the cancellation wasreceived.
YOU HAVE SEVERAL RIGHTS REGARDING PROTECTED HEALTH INFORMATION (PHI) ABOUT YOU. YOUHAVE THE RIGHT TO REQUEST RESTRICTIONS ON USES AND DISCLOSURES OF INFORMATION ABOUT YOU. The agency is not required to agree to your requested restrictions. However, even if the agencyagrees to your request, in certain situations, your restrictions may not be followed. These situationsinclude emergency treatment, disclosures to the Department of Health and Human Services, and uses anddisclosures described in the previous section of this Notice.
YOU HAVE THE RIGHT TO REQUEST DIFFERENT WAYS TO COMMUNICATE WITH YOU. You have the rightto request how and where the agency contacts you. For example, you may request that the agency contactyou at your work number or by email.
YOU HAVE THE RIGHT TO REQUEST TO SEE AND RECEIVE A COPY OF INFORMATION IN YOUR CLINICAL RECORD. There are certain situations in which the agency is not required to comply with your request.Under these circumstances, the agency will respond to you in writing, stating why your request is not beinggranted and describing any rights you may have to request a review of the denial.YOU HAVE THE RIGHT TO REQUEST AMENDMENTS OR CHANGES TO CLINICAL, BILLING, AND OTHERRECORDS USED TO MAKE DECISIONS ABOUT YOU. If you believe that the agency has information that iseither inaccurate or incomplete, information may be added to indicate the problem and notify others whohave copies of the inaccurate or incomplete information.
5. YOU HAVE THE RIGHT TO RECEIVE A WRITTEN LIST OF DISCLOSURES ABOUT YOU.You may ask for disclosures made up to six (6) years before your request (not including disclosures madeprior to April 14, 2003). We are not required to include disclosures: For your treatment.For billing and collection of payment for your treatment.For health care operations. Authorized by you, or which are made to individuals involved in your care.Allowed or required by law when the use and/or disclosures related to certain specialized governmentfunctions. As part of a limited set of information which does not contain certain information which would identifyyou.The list will include the date of the disclosure, the name (and address, if available) of the person ororganization receiving the information, a brief description of the information disclosed, and the purpose ofthe disclosure.
YOU HAVE THE RIGHT TO REQUEST ADDITIONAL PAPER COPIES OF THIS NOTICE AT ANY TIME.YOU HAVE THE RIGHT TO REQUEST RESTRICTIONS ON USES AND DISCLOSURES.You have the right to request that we limit the use and disclosure of information about you for treatment,payment, and health care purposes.
YOU MAY FILE A COMPLAINT ABOUT THE AGENCY'S PRIVACY PRACTICES. THIS WILL NOT AFFECT THESERVICES OR TREATMENT YOU RECEIVE.
CLIENT RIGHTS AND GRIEVANCE POLICY /PROCEDURE
Enduring The Course Inc Therapeutic Service and Support ensures that quality services are provided on aconsistent basis to each individual client to allow for the resolution of grievances as presented by clientsin a fair and timely fashion to provide a mechanism of reviewing decisions made by others within theagency. Each client at Enduring The Course Inc Therapeutic Service and Support has all of the following rights: The right to be treated with consideration and respect for personal dignity, autonomy and privacy.The right not to be discriminated against for receiving services on the basis of race, ethnicity, age, color,religion, gender, national origin, sexual orientation, physical or mental handicap, developmental disability,genetic information, human immunodeficiency virus status, or in any manner prohibited by local, state, orfederal laws. The right to reasonable protection from physical, sexual, or emotional abuse and inhumane treatment. The right to receive services in the least restrictive, feasible environment.The right to give informed consent to or refuse any service, treatment, or therapy, including medication,except in an emergency.The right to be informed of one's own condition. The right to participate in the development, review, and revision of one's own individualized treatment planand to receive a copy of it. The right to participate in any appropriate and available service that is consistent with an individual serviceplan (ISP), regardless of the refusal of any other service, unless that service is a necessity for cleartreatment reasons and requires the person's participation.The right to be informed of and the right to refuse any unusual or hazardous treatment procedures. The right to freedom from unnecessary or excessive medication, and to be free from restraint or seclusionunless there is an immediate risk of physical harm to self or others.The right to be advised and the right to reuse observation by others and by techniques such as one-wayvision mirrors, tape recorders, video recorders, television, movies, photographs, or any other audio andvisual technology. This right does not prohibit an agency from usingclosed-circuit monitoring to observe seclusion rooms or shared areas, which do not include bathrooms orsleeping areas.The right to confidentiality of communications and person identifying information within the limitationsand requirements for disclosure of client information under state and federal laws and regulations.
The right to have access to one's own client record, unless access to certain information is restricted for clear treatment reasons. If access is restricted, the treatment plan shall, I include the reason for therestriction, a goal to remove the restriction, and the treatment being offered to remove the restriction. The right to be informed, in a reasonable amount of time in advance, of the reason for terminatingparticipation in a service, and to be provided a referral, unless the service is unavailable or not necessary. The right to be informed of the reason for denial of a service. The right to know the cost of services,The right to consult with an independent treatment specialist or legal counsel at one's own expensive; The right to be verbally informed of all client rights, and to receive a written copy upon request. The right to exercise one's own rights without reprisal, except that no right extends so far as to supersedehealth and safety considerations. The right to file a grievance. The right to have oral and written instructions concerning the procedure for filing a grievance, and toassistance in filing a grievance if requested; and The right to contact the Client's Rights Officer who can assist in lodging a grievance/complaint.If any client or guardian feels their rights are not being fulfilled, or if they have any problem or complain,clients or guardians of clients of Enduring The Course Inc Therapeutic Service and Support can voice anyproblems with any member of their care team, a supervisor, the Executive Directors, or the Client's Rights Officer.
The Client's Rights Officer is:
Armintha Caywood
Office Location: 27801 Euclid Ave. Suite 600 Euclid, Ohio 44132
Office Phone: {216) 337-1411 Cell Phone: {216) 337-1411
E-mail: Arminthaetcinc@gmail.com
Availability: Monday through Friday, 9 am to 5 pm Friday: 9 am to 4 pm
Additional hours available by appointment
If the client's problem or complaint is not resolved informally by speaking with any member of their careteam, a supervisor, the Executive Directors, or the Client's Rights Officer, then the Client's Rights Officershould explain the formal grievance process to the client/guardian and allow him/her to file a clientgrievance/complaint form. The grievance/complaint must be put into writing. The Client's Rights Officer is available to assist a client/guardian in the filing of a grievance/complaint. If the client/guardian cannot write the grievance/complaint on their own, they should request to speakwith the Client's Rights Officer who will help them write it; or, if necessary, listen to the verbal grievance/complaint and transfer it to writing on the grievance/complaint form. The written grievance/complaint must be dated and signed by the client, the individual filing the grievance on behalf of the client (if applicable) or have an attestation by the Client's Rights Officer that the written grievance is a true and accurate representation a/the client's grievance. It is required that the grievance include, if available, the date, approximate time, description of the incident and names of individualsinvolved in the incident or situation being grieved.The completed grievance/complaint form should be given to the Client's Rights Officer. It is thenforwarded to the Director of Compliance, Quality Assurance, and Training.
The Director of Compliance, Quality Assurance, and Training will then conduct an investigation regardingthe grievance/complaint ad make the decision that is in the best interest of the client's health and medicaltreatment.Should the client/guardian disagree with this decision, he/she should request a meeting with the ExecutiveDirector(s) or his designee. All information will be reviewed in the meeting with the Executive Director(s) ortheir designee. The Executive Director(s) or designee shall make a decision after the meeting anddocument his/her decision. The decision of the Executive Director(s) is final.
Enduring The Course Inc Therapeutic Service and Support will make a resolution or decision on allgrievances within twenty (20) business days of receipt of the grievance. If there are any extenuatingcircumstances that indicate that this time period will need to be extended, these circumstances must be documented in writing in the grievance file and written notification of the extension given to the client orclient's guardian.Clients or their guardians must receive a written acknowledgement of receipt of the grievance within three(3) business days from receipt of the grievance.
The written acknowledgement shall include, but not belimited to, the following:Date the grievance was received.A summary of the grievanceAn overview of the grievance process a timetable for completion of an investigation and notification of resolution, andThe Client's Rights Officer's contact name, address, telephone number, and email Clients or their guardians also have the option to file a grievance with outside organizations that include,but are not limited to, the following:
.
Cuyahoga County Board of Alcohol, Drug Addiction, and Mental Health Services
2012 w. 25th St.6th FloorCleveland, OH 44113
(216) 241-3400adamhscc.org
Ohio Department of Mental Health and Addiction Services
30 E. Broad St.36th FloorColumbus, OH 43215
(614) 466-2596
mha.ohio.gov
Disability Rights Ohio
200 Civic Center Dr. Suite 300Columbus, OH 43215
(614) 466-7264
disabilityrightsohio.org
U.S. Department of Health and Human Services Civil Rights Regional Office - Midwest233 N. Michigan Ave.Suite 240Chicago, IL 60601
(800) 368-1019
hhs.gov
If you think your privacy rights have been violated, you may send a written complaint to the
Department o fHealth and Human Services at:
Office for Civil Rights US Department of Health and Human Services
200 Independence Ave, SWRoom 509F, HHH Building Washington, DC 20201
IF YOU FILE A COMPLAINT, WE WILL NOT TAKE ANY ACTION AGAINST YOU OR CHANGE YOURTREATMENT IN ANY WAY.