ALP CLIENT CONSENT AND REFERRAL

Primary Care Solutions Client Consent and Referral
Client Full Name
Client Date of Birth

MonthDayYear
Date
Client 12-Digit Medicaid Insurance Billing Number
Consent for Services

I agree to get the medical and mental health services suggested by the staff at Primary Care Solutions, like tests and counseling I agree to cooperate in the implementation of the services. I know that some information about my treatment will be shared with the insurance company to help keep track of care across the state.

Family Involvement Consent/Denial

I consent to have the family members listed below involved in the planning and delivery of the services that I shall be receiving during this period of service. I understand that, without this consent, the agency's employees will not be allowed to acknowledge to any family member that I am a consumer of their services.

Family members to be involved:
Name
Phone
Relationship
Name
Phone
Relationship
Select one below:

I Do Not consent to have family members involved in the planning or delivery of the services I shall be receiving during this period of service.I Do Consent to have family members involved in the planning or delivery of the services I shall be receiving during this period of service.
Follow-Up Contact Consent

I consent to have the staff of Primary Care Solutions contacting me within 90 days after the termination of this period of service to collect information on the outcomes of that service.I do not consent to follow-up contact.I consent to give 24-hour notice of cancellation if not participating in planned services and understand that if I do not show up for planned services, the treatment plan may be reviewed by treatment staff to determine the appropriateness of continued treatment or discharge.
CONFIDENTIALITY POLICY

It is the policy of Primary Care Solutions of Ohio to ensure that all verbal and written information of consumers served is released in a manner that protects the individual's right to confidentiality and adheres to all HIPAA requirements. Information may not be released without the individual's written permission, except as the law permits or requires. Primary Care Solutions of Ohio will make reasonable efforts to limit the use, disclosure, and requests for private health information to the minimum necessary to accomplish the intended purpose.

FIRE, SAFETY, AND LIABILITY POLICY

Policy Statement:

Primary Care Solutions of Ohio ensure that all employees are aware of safety and liability issues related to providing services. All programs comply with state and local fire, health, and safety codes.

Inspections and Compliance:

Programs are inspected and approved annually by local and/or state fire, health, and safety agencies. Written records of these inspections are maintained at each site.

Any citations noted by fire and health authorities must be corrected, and documentation of these corrections must be available at each location.

Programs with existing sprinkler systems must have annual inspections conducted by licensed companies or local fire authorities, with documentation retained at the site.

A systematic pest control program will be implemented, with documentation maintained at each site.
FIRE, SAFETY, AND LIABILITY POLICY
Policy Statement: continued

Scheduled fire equipment inspections will be conducted, which include:

Annual inspections by an outside source (e.g., fire marshal, fire department representative) with a dated tag

Monthly inspections by staff to verify equipment readiness, documented in a log or on the equipment.

Fire Extinguishers:

Facilities will have operable 2A-108:C multi-purpose fire extinguishers in accessible locations. Maintenance records must show that extinguishers are properly serviced and recharged as needed, at least once every six years.

Fire extinguishers that cannot be recharged must be replaced immediately.

Safety Equipment:

Each facility is equipped with fire extinguishing equipment and alarms/detectors in areas where necessary (e.g., flammable storage, kitchens, laundry rooms, garages)

Carbon monoxide detectors are required in any building with natural gas or open flames, with at least one detector per 1,000 square feet.

Emergency Exits:

Clear diagrams of escape routes will be posted in visible locations throughout the facility, clearly indicating

All exits will be adequately marked with lighted signs that remain visible at all times, with emergency lighting equipped with battery backup.

Windows that are part of the emergency exit must be operable from the inside without tools and provide a minimum opening of 20 inches wide by 24 inches high.

Access and Safety Measures:

No exit door will be locked when the building is occupied, unless an emergency system is in place that allows it to unlock during emergencies.

Exterior doors may have key-operated locks, provided a visible sign that states, "THIS DOOR MUST REMAIN UNLOCKED WHEN THE BUILDING IS OCCUPIED."
Facility Maintenance:

The interior and exterior of each facility must be maintained safely and sanitarily, with furnishings kept clean and in good repair.

Facilities providing direct services will ensure operable hot water with temperatures set between 100- and 120-degrees Fahrenheit, measured quarterly.

Emergency lighting systems will be tested monthly for at least 30 seconds and annually for 90 minutes, with records of these tests maintained.

Utilities and Emergency Planning:

Facilities will have operational utilities (water, sewer, air conditioning, heat, electricity) and must maintain a written emergency action plan should utilities fail. This plan will be available for review.

GRIEVANCE PROCEDURES

1. Resolution of Issues

Day-to-day concerns should be addressed informally between the consumer and their assigned staff member. If the issue is not resolved satisfactorily, the Owners will follow the guidelines in this policy to facilitate access to formal resolution procedures.

2. Contact Information

If a client is uncomfortable discussing issues with PCS staff, they may call (888) 380-9990 for assistance.

3. Consumer Rights:

Consumers have the right to due process regarding grievances, and the organization will provide every reasonable opportunity for informal and formal resolution.

4. Who Can File a Grievance:

Consumers who may file grievances include:

The individual receiving services

The guardian of the individual

An authorized attorney or representative from a rights protection or advocacy agency
5. Protection Against Retaliation:

No individual will face disciplinary action or reprisal, including service denial or loss of privileges, because of filing a grievance.

o Notices explaining the right to due process and how to file grievances will be available at each facility.

o Each individual will be informed of their right to file a grievance and to receive assistance from a representative of their choice in an understandable manner.

7. Formal Grievance Rights:

During a formal grievance procedure, the individual has the right to:

o Assistance from their chosen representative

o Review information used in the grievance process, except information violating confidentiality

o Present evidence and witness testimony relevant to the grievance

o Receive complete findings and recommendations, except those violating confidentiality

8. The Burden of Proof:

The organization must demonstrate compliance with policies and procedures protecting consumer rights.

9. Filing and Responding to a Grievance:

o Formal grievances must be submitted in writing to the supervisor or director of the relevant service unit or

o The grievance will also be forwarded to the administrative head.

o The supervisor will meet with the grievant and/or their representative to discuss potential resolutions promptly.

o A formal written response will be provided within five working days, excluding weekends and holidays.
10. Grievance Details

Each grievance must include:

The date

The approximate time of the incident

A description of the incident and the names of individuals involved

11. Appealing a Grievance Decision:

If a grievant is not satisfied with the response, they may appeal to the Owner/CEO within five days, excluding weekends and holidays. The Owner/CEO will respond within the same time frame.

12. Referral to Third Parties:

If the grievant remains unsatisfied with the findings, they may be referred to external organizations for advocacy, such as protective services or professional licensing boards.

13. Training and Confidentiality:

All staff will receive training on these procedures during orientation and ongoing training as needed. Grievances related to staff actions will follow personnel rules and contract provisions.

A Grievance Log will be maintained to record the nature of complaints, the investigation process, and outcomes, ensuring participant confidentiality.

Record Retention

All grievances will be kept for a minimum of two years, including:

1. A copy of the original grievance.

2. Documentation of the process and resolution.

3. Documentation of any circumstances extending resolution beyond 21 days.
DISCHARGE INFORMATION

We encourage discussions about your discharge to begin as early as possible. It is important for you to be actively involved in this process and to understand the timeframe of the services provided.

You will be scheduled for an assessment appointment. Based on your needs following the assessment, you may receive one or more of the following services:

1. Therapy

2. Case Management

3. Substance Abuse Treatment

4. Other

Typically, you will be engaged in services for at least 3 months, but it may extend beyond 18 months, depending on your progress in achieving your goals.

If you choose not to continue services or if you transition out of services and need assistance during a crisis, please refer to the information below for additional services or contact your Primary Care Physician.

Nearest Local Hospital: The Christ Hospital - 2139 Auburn Ave, Cincinnati OH 45219

Nearest Local Crisis Center: Hamilton County Mental Health and Recovery Services - Mobile Crisis Team - 513- 584-5098 University of Cincinnati Medical Center Psych Emergency Room - 3188 Bellevue Ave, Cincinnati, OH 45219
Authorization to Disclose Information to Primary Care Physician

Effective communication between those who care for your mental health and those who care for your physical health (Primary Care Physician) is essential.

By signing this form, you are giving Primary Care Solutions (PCS) permission to share information related to your mental health services and treatment with your primary care physician. This information may include your diagnosis, treatment plan, and progress.

We will not release any information without your written consent.

I authorize Primary Care Solutions to release and/or communicate with the physician listed below regarding
Physician Name
Phone
Address
Client Rights

You may revoke this authorization (permission to use or disclose information) at any time by contacting PCS. If you request to end this authorization, it will not affect any information that has already been used or disclosed based on your prior consent.

Signing this form is not a requirement for treatment, enrollment, or eligibility for benefits.

Please be aware that the information disclosed because of this authorization may be re-disclosed by the recipient and may no longer be protected by law.

Patient Authorization

I, the undersigned, understand that I may revoke this consent at any time, except to the extent that action has already been taken based on it. This consent will expire one year from the date of signature unless another date is specified. I have read and understand the information provided above and give my authorization.
CLIENT PLEASE CHECK ONE

I DO give authorization to release mental health information to my primary care physician.I DO NOT give my authorization to release any information to my primary care physician.
CLIENT CHOICE OF SERVICES AND PROVIDERS
Primary Care Solutions is committed to ensuring that consumers have the right to choose the services they qualify for and to select their preferred providers.

By signing this form, you acknowledge that you, as a consumer, have the right to choose relevant services and which provider delivers those services. You also confirm that no employees of Primary Care Solutions have influenced your choice of services or providers in any way.

Our services have been explained in clear, non-technical language, including the risks, benefits, and alternatives to the proposed treatment. My signature below indicates my consent to treatment for services provided.

Chosen Provider: Primary Care Solutions of Ohio

I understand that Primary Care Solutions has not influenced my decision in any way.
Signature Of ClientLegal Guardian

Clear
Date

MonthDayYear
Date
Primary Care Solutions Client Referral
REFERRAL INFORMATION
Date of Referral

MonthDayYear
Date
Referral Agency Organization
Full Name of Referring Person
Referring Person Phone Number
CLIENT INFORMATION
Client Name*
Is client a Minor?*

YesNo
If Filling Out For a Minor, Provide Parent/Guardian Information below: (Required)
Date of Birth

MonthDayYear
Date
Email Address
example@example.com
Home Address*
Phone Number*
CHILD-SPECIFIC INFORMATION (If Applicable)
Who does the child live with
Name of School
Grade Level
PARENT/GUARDIAN INFORMATION
Full Name
Email Address
example@example.com
Home Address
Phone Number
Cell Number
Please select one of the following options:*
CLIENT CHILD-SPECIFIC INFORMATION
Does your child have an IEP?

YesNo
If yes, please list their diagnosis
Does your child have a Section 504 Plan?

YesNo
If yes, please list their diagnosis
Is your child currently experiencing behavioral or emotional challenges, or receiving mental health services?

YesNoN/A
If yes please describe diagnosis triggers strategies that help etc
Please Provides Reason(s) for Referral Below for the Client: Adult or Child

REASON(S) FOR REFERRAL - CONCERN(S) RELATED TO: (Check all that apply)
Do you or Minor that you are filling out the referral form for experience SOCIAL issues listed below? If so, select all that apply.
Social

Teased/dislikedSuspected gang memberIsolated/withdrawnNegative Leader
Do you or Minor that you are filling out the referral form for experience EMOTIONAL issues listed below? If so, select all that apply.
Emotional

Feels worthlessMood swingsFeels unlovedGriefWorriesSadnessFamily Concerns
REASON(S) FOR REFERRAL - CONCERN(S) RELATED TO: (Check all that apply)
Do you or Minor that you are filling out the referral form for experience SCHOOL / WORK PERFORMANCE issues listed below? If so, select all that apply.
School/Work Performance:

Does Not Complete AssignmentsFrequent TardinessShort Attention SpanLeaves Class/School/WorkLacks Motivation/Uninterested in School/WorkPoor AttendanceMoves ConstantlyEasily DistractedDestruction of PropertyPoor Peer RelationshipsCompletion of AssignmentsFrequent Trips to School NurseAcademics: Low Scores/Failing GradesWork Habits/OrganizationPoor Employee PerformanceDrop-out Risk (H.S)
Do you or Minor that you are filling out the referral form for experience BEHAVIORAL issues listed below? If so, select all that apply.
Behavior

DefiantNot Using ToiletStealsDramatic Changes in BehaviorAlways TiredWithdrawnSelf-image/ConfidenceAnxious/NervousSwearingLyingDisrespectfulImpulsiveSelf-harmInattentiveCries easilyNon-touchable/Pulls AwayChews Paper/Clothes/HairStealingSexual Acting OutLack of Social SkillsOutburstsMakes Odd Sounds
Do you or Minor that you are filling out the referral form for have a PREVIOUS OR CURRENT DIAGNOSIS listed below? If so, select all that apply.
Previous or Current Diagnosis

ADHDAutism (ASD)Generalized Anxiety DisorderMajor Depressive DisorderPanic DisorderSchizophreniaSubstance Abuse DisorderEating DisorderBipolar DisorderOppositional Defiant Disorder (ODD)Specific Learning Disability (SLD)Conduct DisorderObsessive Compulsive Disorder (SLD)Learning DisabilitiesPost Traumatic Stress Disorder (PTSD)Sensory Processing Disorder (SPD)Other
Do you or Minor that you are filling out the referral form for have a MEDICAL / PHYSICAL issue listed below? If so, select all that apply.
Medical / Physical

Personal HygieneHealth Care Needs: Dental/Vision/PhysicianPhysically Struggling/Unable to CompleteWeight
Have you or Minor that you are filling out the referral form for experienced a TRAUMA / LOSS related issue listed below? If so, select all that apply.
Trauma / Loss

Victim of violenceTraumatic experienceWitness to violenceDeath/injury of family member or friendSchool/Workplace Violence/Shooting
Other Reason / Concern (Please Explain)
Please submit this form to Primary Care Solutions and contact us via email at info@alternatelifepath.com if you have any questions or need additional information. We will contact you if we have any questions or need additional information.
Should be Empty:

FIRE, SAFETY, AND LIABILITY POLICY

CLIENT CHOICE OF SERVICES AND PROVIDERS

REFERRAL INFORMATION

CLIENT INFORMATION

PARENT/GUARDIAN INFORMATION