• Rama Cares Integrated services

    4216 McKinley Dr, Charlotte,NC-28208
  • CONSENT FOR LIMITED RELEASE OF INFORMATION

  • I grant permission to Rama Cares Integrated Services to disclose the
    specified information

  • Consumer's Date of Birth
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  • Format: (000) 000-0000.
  • Consumer/Guardian must click each category to be disclosed.
  • Information to be Received, Released and/or Discussed:

  • Reason
  • Date
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  • Date
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  • Authorization to Release without Consent

    § 122C-53. Exceptions; client.

    (b) A facility is permitted to reveal the admission or discharge status of a client to
    the client's next of kin when the responsible professional concludes that such
    disclosure serves the best interest of the client.

    (g) An internal client advocate shall be permitted access to routine reports and
    other confidential information essential for carrying out his monitoring and
    advocacy duties, without requiring the consent of the client or their legally
    responsible representative.

    (h) In accordance with G.S. 122C-205, the facility shall notify the appropriate individuals upon the escape from and subsequent return of clients to a 24-hour facility.

    § 122C-54. Exceptions; abuse reports and court proceedings.

    (a) A facility is required to reveal confidential information if a court with
    appropriate authority issues an order mandating such disclosure.

    (a1)For the purpose of submitting a petition for the involuntary commitment of a
    client in accordance with Article 5 of this Chapter, or for the purpose of filing a
    petition for the determination of incompetency

    (b) If a person is a defendant in a criminal case and the court has mandated a
    mental examination of the defendant in accordance with G.S. 15A-1002, the
    facility is required to forward the results or the report of the mental
    examination to the clerk of court, the district attorney or prosecuting officer,
    and the attorney of record representing the defendant as stipulated in G.S.
    15A-1002(d).

    (g) A facility is permitted to share confidential information with an attorney
    representing either the facility itself or an employee of the facility, provided
    that such information pertains to litigation, the facility's operations, or the
    services offered by the facility.

    (h) A facility is required to disclose confidential information in order to comply with
    Article 3 of Chapter 7B of the General Statutes and Article 6 of Chapter 108A
    of the General Statutes, or as mandated by other State or federal legislation.

    § 122C-55. Exceptions; care and treatment.

    (a) Any facility is permitted to disclose confidential information pertaining to any
    client of that facility to another facility when it is essential for the coordination
    of suitable and effective care, treatment, or habilitation of the client.

    (a1)Any facility is permitted to disclose confidential information pertaining to any
    client of that facility to the Secretary. Furthermore, the Secretary is authorized
    to share confidential information about any client with a facility when it is
    essential for conducting quality assessment and improvement activities, or for
    coordinating suitable and effective care, treatment, or habilitation of the client.

    (b) An institution, physician, or any other person tasked with the assessment,
    management, oversight, or care of individuals evaluated or admitted for
    outpatient treatment in accordance with Article 5 of this Chapter is permitted
    to request, obtain, and share confidential information as required to effectively
    carry out their duties.

    (c) A facility is permitted to provide confidential information it holds to the Division
    of Adult Correction within the Department of Public Safety upon request from
    that department concerning any client of the facility, provided that the inmate
    has been assessed by the Division of Adult Correction of the Department of
    Public Safety as requiring treatment for mental illness, developmental
    disabilities, or substance abuse.

    (d) A diligent professional may reveal confidential information if he believes there
    is an immediate threat to the health or safety of the client or another person,
    or if there is a possibility of a felony or violent misdemeanor being committed.

    (e) A diligent professional may share confidential information with a physician or
    another health care provider who is delivering emergency medical services to
    a client.

    The sharing of information is restricted to what is essential for addressing the
    emergency, as assessed by the qualified professional.

    (e2) A diligent professional may reveal prior directives regarding mental health
    treatment or confidential details from such directives to a physician,
    psychologist, or another qualified expert when the diligent professional
    concludes that such disclosure is essential to implement or facilitate treatment
    in line with the advance instruction.

    (f) A facility is permitted to share confidential information with a support services
    provider when the facility has established a written contract with an individual
    to deliver support services. This contract must contain a clause in which the
    support services provider agrees to protect and refrain from further disclosing
    any confidential information received, stored, processed, or otherwise
    handled.

    (g) In instances where there is justification to assume that the client qualifies for
    financial assistance from a governmental agency, a facility is permitted to
    share confidential information with state, local, or federal government entities

    (g2) In instances where there is justification to assume that the client qualifies for
    educational services provided by a governmental agency, a facility is required
    to share client identifying information with the Department of Public
    Instruction.

    (i)Upon a specific request, a qualified professional may disclose confidential
    information to a physician or psychologist who has referred the client to the
    facility.

    (k)At the request of the next of kin or another family member who has a valid role
    in the therapeutic services provided, or any individual appointed by the client
    or their legally accountable representative, the responsible professional is
    obligated to inform the next of kin, family member, or designated individual
    about the client's admission to the facility, transfer to a different facility,
    decision to depart from the facility against medical advice, discharge from the
    facility, as well as referrals and appointment details for post-discharge
    treatment, following the notification to the client that such information has
    been requested.

    § 122C-56. Exceptions; research and planning.

    (b) The Secretary may obtain access to confidential information from both private
    and public agencies or representatives for the purposes of research and
    assessment in the fields of mental health, developmental disabilities, and
    substance abuse.

    (c) A facility is permitted to share confidential information with individuals tasked
    with performing general research or conducting clinical, financial, or
    administrative audits, provided there is a valid and documented necessity for
    such information.

  • Consent shall remain valid for a period of one (1) year from the date of signature on this form. 

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