The information presented here is part of the consumer orientation, as
outlined in the client handbook. A review of the item and the signatures below
confirm that each section has been thoroughly explained and comprehended
by the consumer.

✓ Rights and Grievance Procedures
✓ Services offered, operational days and hours, anticipated level of
engagement
✓ Access to emergency services outside regular hours
✓ Code of ethics and conduct
✓ Confidentiality and its limitations
✓ Methods and opportunities for providing feedback
✓ Clarification of financial responsibilities, fees, and financial arrangements
✓ Fire safety and emergency measures
✓ Policy regarding the use of restraints
✓ Policy concerning tobacco products
✓ Policy on the introduction of illicit or legal drugs into the program
✓ Policy on weapons permitted within the program
✓ Identification of the individual accountable for service coordination
✓ Program regulations, including limitations and the process for losing and
regaining rights
✓ Prevention and treatment of AIDS/HIV and Hepatitis
✓ Client grievance process
✓ Objectives and procedures for assessment
✓ Individualized person-centered plan
✓ Criteria and procedures for discharge or transition

✓ To be treated with respect and dignity
✓ To have your privacy safeguarded
✓ To create a care plan with services tailored to your needs
✓ To engage in decisions concerning your care
✓ To inquire about names, locations, phone numbers, and languages of local
agencies
✓ To obtain the quantity and duration of services required
✓ To be free from the use of seclusion or restraints
✓ To receive services that are appropriate for your age and culture
✓ To comprehend the available treatment options and alternatives
✓ To decline any suggested treatment
✓ To receive care that is free from discrimination (e.g., age, race, type of
illness)
✓ To be protected from any form of sexual exploitation or harassment
✓ To receive a comprehensive explanation of all prescribed medications and
their potential side effects
✓ To access treatment, including medical care and habilitation, irrespective of
age or level of MH/DD/SA disability
✓ To submit a request for an administrative (fair) hearing
✓ To request and obtain a copy of your medical records and to request
amendments. You will be informed of the copying costs.

I acknowledge the subsequent points:
a. The process for obtaining a copy of my service plan
b. The fees that are applied and the method of collecting those fees for the
treatment rendered;
c. The procedure for filing a grievance;
d. The conditions under which suspension and expulsion from services may
occur;
e. The protocols regarding the search and seizure of personal belongings

 

I acknowledge that I can reach out to the Governor’s Advocacy Council for
Persons with Disabilities (GACPD).
I recognize the advantages, potential risks, and alternative treatment options
available.
I am aware that I have the right to decline treatment at any moment, yet I
choose to give my consent for treatment at this time. Additionally, I understand
that my refusal will not be the sole reason for the termination of services
unless it is the only viable option available.
I have received a copy of "Your Rights as a Client" and comprehend that I
have the right to be protected from harm, abuse, neglect, and exploitation.
 
By signing below, I confirm that I have read and comprehended my rights and
obligations as a participant in the services provided by Rama Cares Integrated
Services.

 The Consumer and/or Guardian of the aforementioned consumer
hereby grants consent to Rama Cares Integrated Services and/or its
DBA to permit any routine or emergency medical, surgical, psychiatric,
or psychological treatment that, in the judgment of the Clinical Staff at
Rama Cares Integrated Services, is considered essential for the well-
being of the consumer.

 

Rama Cares Integrated Services will notify the Consumer, Parent,
Guardian, or Legal Custodian regarding any forthcoming treatment that
has been chosen and will secure his/her consent, unless it is a life-
threatening emergency, in which case Rama Cares Integrated Services
will proceed based on the guidance of the attending physician or
licensed professional.

Notification will then be made as soon as possible to the guardian of the consumer.

I have read and understand the above statements and do hereby give my consent.

Copy Clause:  I agree that a copy of this form may act as an original.

 

This Consent shall be valid for one year from the signature date of this form.
 

Tele-services refer to the utilization of electronic communication
methods that allow healthcare providers to deliver services to clients,
aimed at enhancing client care. The information gathered may be
utilized for diagnosis, treatment, follow-up, and/or educational purposes.
The electronic systems employed will integrate network and software
security protocols to maintain the confidentiality of client identification
and imaging data, and will implement measures to protect the data and
ensure its integrity against both intentional and unintentional corruption.

Expected Benefits: 

More efficient evaluation and management. 

Possible Risks: 

In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information.

By signing this form, I understand the following: 

1. I understand that the laws that protect privacy and the confidentiality of medical information 

also apply to telemedicine, and that no information obtained in the use of telemedicine which 
identifies me will be disclosed to researchers or other entities without my consent. 

2. I understand that I have the right to withhold or withdraw my consent to the use of 
telemedicine in the course of my care at any time, without affecting my right to future care or treatment. 

3. I understand that I have the right to inspect all information obtained and recorded in the 

course of a telemedicine interaction and may receive copies of this information for a 
reasonable fee.  

Consent To The Use of Telemedicine 

I have read and understand the information provided and all of my questions have been answered to my satisfaction.  I give my informed consent for the use of tele-services in my care. 

Crisis Response

My signature below confirms that I have reviewed the Client
Acknowledgement for the 24 Hour On-Call Service.
I have been given the chance to ask questions and have the information
clarified regarding my treatments. I have received the names of the staff
members who will be assisting me or my child and I am aware of the specific
days and times that each staff member will be present to help me achieve my
treatment objectives.
I understand that if there is ever a scheduling conflict, I should contact my
staff member to notify them and arrange for a new appointment date and/or
time. Additionally, I have been provided with a Crisis Telephone number that is
available 24/7/365.

I hereby grant my consent for Rama Cares Integrated Services First to utilize
and disclose my protected health information (PHI) for the purposes of
treatment, payment, and health care operations. (The Notice of Privacy
Practices provided by Rama Cares Integrated Services First offers a more
comprehensive description of these uses and disclosures.) I retain the right to
review the Notice of Privacy Practices before signing this consent.

Rama Cares Integrated Services First retains the authority to amend its Notice
of Privacy Practices at any time. A revised Notice of Privacy Practices can be
acquired by sending a written request to Rama Cares Integrated Services
First.

With this consent, Rama Cares Integrated services First may call my home or other alternative location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any calls pertaining to my clinical care, including laboratory test results, among others.

With this consent, Rama Cares Integrated Services First is permitted to send
to my residence or another designated location any materials that aid the
practice in executing TPO, including appointment reminder cards and patient
statements, provided they are labeled as "Personal and Confidential."

By granting this consent, Rama Cares Integrated Services may send to my
home or any other designated location items that aid the practice in executing
TPO, including appointment reminder cards and patient statements. I retain
the right to ask that Rama Cares Integrated Services First limit its use or
disclosure of my PHI for TPO purposes. While the practice is not obligated to
accept my requested restrictions, should it choose to do so, it will be obligated
to adhere to this agreement.

By signing this form, I am consenting to allow Rama Cares Integrated services First to use and disclose my PHI to carry out TPO.

I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, Rama Cares Integrated services First may decline to provide treatment to me.

 

I have read and understand the transportation rules listed below for Rama Cares Integrated services. and I hereby voluntarily give consent for transportation by Rama Cares Integrated services. staff members.

 Transportation Guidelines/Rules:                                                                                                                                                                            

The consumer or the legally responsible individual is required to read and sign
the Consent for Transportation before any services or transportation are
provided.

No weapons, drugs, alcohol, or smoking are permitted, nor is the use of
profanity, inappropriate touching of others, leaving trash in the vehicle, or
throwing objects from the windows.

Hands and objects must remain inside the vehicle, and the windows and
doors should stay closed unless the driver grants permission to open them.

Do not leave the vehicle until the driver has given permission.
Seat belts must be fastened at all times.
The appropriate child restraint devices and procedures will be utilized in
compliance with North Carolina State law.

**The Emergency Information form is required to be with staff and
consumers during all outings away from the home. The documents must
be stored in a locked device within a locked glove compartment or trunk
of the vehicle.

By signing below, I confirm that I have read and comprehended this
transportation policy and give my consent

In case of an emergency what hospital would you prefer to be taken to?