Connext Care, LLC Consent, Authorization & Acknowledgment Form

Connext Care, LLC Consent, Authorization & Acknowledgment Form

Please complete all sections.
SECTION 1: Consumer Information

Please provide your personal details.
Consumer Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number*
Please enter a valid phone number.
Email
example@example.com
SECTION 2: Notice of Privacy Practices (HIPAA Acknowledgment)

Please review and acknowledge our privacy practices.
Connext Care may use and disclose your protected health information (PHI) for treatment, payment, and healthcare operations. Additional disclosures require your written authorization. You have the right to request restrictions, receive confidential communications, inspect and copy your records, request amendments, obtain an accounting of disclosures, and file complaints without retaliation.
I acknowledge that I have received or been offered a copy of the Notice of Privacy Practices.*

I acknowledge that I have received or been offered a copy of the Notice of Privacy Practices.
SECTION 3: Rights & Responsibilities

Understand your rights and responsibilities as a consumer.
Your rights include: choice of services, confidentiality, dignity and respect, freedom from abuse or neglect, the ability to deny services, review your records, and file grievances.
Your responsibilities include: participating in services, attending meetings, maintaining confidentiality of others, and refraining from violence, drugs, alcohol, or weapons during services.
I understand my rights and responsibilities.*

I understand my rights and responsibilities.
SECTION 4: Grievance Procedure Acknowledgment

Grievance procedure steps and acknowledgment.
If you have a grievance, please speak with your provider first. If unresolved, request assistance or escalate to the appropriate state agency. You will receive a written response within 30 days. There will be no retaliation for filing a grievance.
I understand the grievance procedure.*

I understand the grievance procedure.
SECTION 5: Consent to Release Confidential Information

Authorize Connext Care to release and obtain records for coordination of services.
I authorize Connext Care to release and obtain records including medical, psychological, ISP, social service, educational, and vocational records for the purpose of coordinating services.
Entities authorized for release (select all that apply):

Vocational RehabilitationDepartment of Children & FamiliesAgency for Persons with DisabilitiesMedical ProvidersOther
Release Start Date

MonthDayYear
Date
Release End Date

MonthDayYear
Date
I understand I may revoke this authorization in writing at any time.*

I understand I may revoke this authorization in writing at any time.
SECTION 6: Person-Centered Services Acknowledgment

Person-centered services policy acknowledgment.
Services are person-centered, based on your expressed wishes, reviewed annually or upon request, focused on independence and dignity of risk, and developed with your participation.
I acknowledge receipt of the Person-Centered Approach Policy.*

I acknowledge receipt of the Person-Centered Approach Policy.
SECTION 7: Transportation Authorization

Authorization for transportation by Connext Care staff.
I authorize Connext Care staff to transport me for work-related activities, medical appointments, Social Security/Vocational Rehabilitation, social outings, emergency services, and community connections.
I authorize transportation as described above.*

I authorize transportation as described above.
SECTION 8: Consent to Services

Voluntary consent to receive services.
Services are voluntary. Consent may be withdrawn at any time. All questions have been answered to your satisfaction.
I voluntarily consent to receive services from Connext Care, LLC.*

I voluntarily consent to receive services from Connext Care, LLC.
SIGNATURE SECTION

Sign and date to complete this form.
Consumer/Guardian Name*
Relationship to Consumer
Consumer/Guardian Signature*

Powered by Jotform SignClear
Date*

MonthDayYear
Date
Agency Representative Name
Agency Representative Signature

Powered by Jotform SignClear
Date

MonthDayYear
Date
Should be Empty:

Connext Care, LLC Consent, Authorization & Acknowledgment Form

SECTION 1: Consumer Information

SECTION 2: Notice of Privacy Practices (HIPAA Acknowledgment)

SECTION 3: Rights & Responsibilities

SECTION 4: Grievance Procedure Acknowledgment

SECTION 5: Consent to Release Confidential Information

SECTION 6: Person-Centered Services Acknowledgment

SECTION 7: Transportation Authorization

SECTION 8: Consent to Services

SIGNATURE SECTION