ADDITIONAL CONSENT FORMS

  • CONSENT FOR SERVICES

  • Carolina Therapeutic Services First provides services to individuals who have behavioral health and/or substance abuse problems. The staff members are trained to provide appropriate services as needed to help the individual. This may include Outpatient Therapy, Residential Services, and Community Support Team.
  • Who is this for?

  • REQUIRED REPORTING

  • Carolina Therapeutic Services First is required by state and federal regulations to report non-identifying client information for the purpose of evaluation and funding purposes. It will also be necessary for Carolina Therapeutic Services First is to use and disclose certain information about myself in order to carry out treatment, payment and health care operations.

  • REPORTING OF SUSPECTED ABUSE/NEGLECT

  • Carolina Therapeutic Services First professionals are required by state laws to report suspected abuse or neglect to the appropriate authorities. If you have any questions about this, please feel free to ask for a better understanding before you sign this document. Your signature below acknowledges receipt of this information.

  • PERMISSION FOR TRANSPORTING AND OFF SITE ACTIVITIES

  • EMERGENCY TREATMENT / EMERGENCY INFORMATION / EMERGENCY RESTRICTIVE INTERVENTION

  • In case of sudden illness/accident/emergency, I hereby give permission to the staff of Carolina Therapeutic Services First to seek emergency treatment on behalf of the below named client should the need arise. It is understood that a qualified medical professional, physician, and/or hospital emergency room personnel will provide this treatment. In addition, a copy of current medications and known medical conditions and allergies may be released. Efforts will be made to contact person named below prior to treatment, should this be possible. I also will hold harmless Carolina Therapeutic Services First against any liability caused by they're taking of any emergency procedures and/or contacts.
  • Date Information Collected
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
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  • Carolina Therapeutic
    Service First
  • CONSENT FOR RELEASE OF CONFIDENTIAL INFORMATION

  • I         authorize a mutual exchange of information between Carolina Therapeutic Services First and TCL Housing.

  • The purpose of these disclosures is: Assessment, service planning, treatment, monitoring of progress
  • Specific information to be disclosed: PCP, CCA, Assessment, Psychiatric evaluation, Medication Management notes, Progress Notes, Diagnoses, Treatment Plans
  • I understand that my records are protected under the federal regulations governing Confidentiality of Alcohol And Drug Abuse Records, 42 CFR Part 2, and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I understand that the recipient of my confidential information may not re-disclose such information without my further written authorization unless otherwise provided for by State of Federal law.
  • I understand that I may revoke this consent at any time. I understand that revocation will not apply information that has ready already been released. If I do not revoke this consent, it expires one year from the date this consent is signed or opens the closing of my case with Carolina Therapeutic Services First, whichever comes first.
  • I understand that the information in my records may include information relating to HIV infections, AIDS, Substance abuse and or psychological or psychiatric conditions and that any disclosure may include this information.
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  • Expiration Date (1 year)
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  • Carolina Therapeutic Service

  • CONSENT FOR RELEASE OF CONFIDENTIAL INFORMATION

  • I         authorize a mutual exchange of information between Carolina Therapeutic Services First and Crisis Contact.

  • The purpose of these disclosures is: Assessment, service planning, treatment, monitoring of progress
  • Specific information to be disclosed: PCP, CCA, Assessment, Psychiatric evaluation, Medication Management notes, Progress Notes, Diagnoses, Treatment Plans
  • I understand that my records are protected under the federal regulations governing Confidentiality of Alcohol And Drug Abuse Records, 42 CFR Part 2, and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I understand that the recipient of my confidential information may not re-disclose such information without my further written authorization unless otherwise provided for by State of Federal law.
  • I understand that I may revoke this consent at any time. I understand that revocation will not apply information that has ready already been released. If I do not revoke this consent, it expires one year from the date this consent is signed or opens the closing of my case with Carolina Therapeutic Services First, whichever comes first.
  • I understand that the information in my records may include information relating to HIV infections, AIDS, Substance abuse and or psychological or psychiatric conditions and that any disclosure may include this information.
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  • Expiration Date (1 year)
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  • CONSENT FOR RELEASE OF CONFIDENTIAL INFORMATION

  • I         authorize a mutual exchange of information between Carolina Therapeutic Services First and Pharmacy.

  • The purpose of these disclosures is: Assessment, service planning, treatment, monitoring of progress
  • Specific information to be disclosed: PCP, CCA, Assessment, Psychiatric evaluation, Medication Management notes, Progress Notes, Diagnoses, Treatment Plans
  • I understand that my records are protected under the federal regulations governing Confidentiality of Alcohol And Drug Abuse Records, 42 CFR Part 2, and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I understand that the recipient of my confidential information may not re-disclose such information without my further written authorization unless otherwise provided for by State of Federal law.
  • I understand that I may revoke this consent at any time. I understand that revocation will not apply information that has ready already been released. If I do not revoke this consent, it expires one year from the date this consent is signed or opens the closing of my case with Carolina Therapeutic Services First, whichever comes first.
  • I understand that the information in my records may include information relating to HIV infections, AIDS, Substance abuse and or psychological or psychiatric conditions and that any disclosure may include this information.
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  • Expiration Date (1 year)
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  • Client ID#:
  • Carolina Therapeutic
    Service First

  • CONSENT FOR RELEASE OF CONFIDENTIAL INFORMATION

  • I         authorize a mutual exchange of information between Carolina Therapeutic Services First and Housing.

  • The purpose of these disclosures is: Assessment, service planning, treatment, monitoring of progress
  • Specific information to be disclosed: PCP, CCA, Assessment, Psychiatric evaluation, Medication Management notes, Progress Notes, Diagnoses, Treatment Plans
  • I understand that my records are protected under the federal regulations governing Confidentiality of Alcohol And Drug Abuse Records, 42 CFR Part 2, and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I understand that the recipient of my confidential information may not re-disclose such information without my further written authorization unless otherwise provided for by State of Federal law.
  • I understand that I may revoke this consent at any time. I understand that revocation will not apply information that has ready already been released. If I do not revoke this consent, it expires one year from the date this consent is signed or opens the closing of my case with Carolina Therapeutic Services First, whichever comes first.
  • I understand that the information in my records may include information relating to HIV infections, AIDS, Substance abuse and or psychological or psychiatric conditions and that any disclosure may include this information.
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  • Expiration Date (1 year)
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  • Carolina Therapeutic Service First
  • CONSENT FOR RELEASE OF CONFIDENTIAL INFORMATION

  • I         authorize a mutual exchange of information between Carolina Therapeutic Services First and NCTOPPS.

  • The purpose of these disclosures is: NCTOPPS- To provide reliable information that is used to measure the impact of treatment and improve service.
  • Specific information to be disclosed: NC-TOPPS is a web-based system to gather outcome and performance data on behalf of consumers with mental health and substance use disorders in North Carolina public system of treatment services.
  • I understand that my records are protected under the federal regulations governing Confidentiality of Alcohol And Drug Abuse Records, 42 CFR Part 2, and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I understand that the recipient of my confidential information may not re-disclose such information without my further written authorization unless otherwise provided for by State of Federal law.
  • I understand that I may revoke this consent at any time. I understand that revocation will not apply information that has ready already been released. If I do not revoke this consent, it expires one year from the date this consent is signed or opens the closing of my case with Carolina Therapeutic Services First, whichever comes first.
  • I understand that the information in my records may include information relating to HIV infections, AIDS, Substance abuse and or psychological or psychiatric conditions and that any disclosure may include this information.
  • Date
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  • Expiration Date (1 year)
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  • Carolina Therapeutic
    Service First

  • CONSENT FOR RELEASE OF CONFIDENTIAL INFORMATION

  • I         authorize a mutual exchange of information between Carolina Therapeutic Services First and Medication Management Provider.

  • The purpose of these disclosures is: Assessment, service planning, treatment, monitoring of progress
  • Specific information to be disclosed: PCP, CCA, Assessment, Psychiatric evaluation, Medication Management notes, Progress Notes, Diagnoses, Treatment Plans
  • I understand that my records are protected under the federal regulations governing Confidentiality of Alcohol And Drug Abuse Records, 42 CFR Part 2, and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I understand that the recipient of my confidential information may not re-disclose such information without my further written authorization unless otherwise provided for by State of Federal law.
  • I understand that I may revoke this consent at any time. I understand that revocation will not apply information that has ready already been released. If I do not revoke this consent, it expires one year from the date this consent is signed or opens the closing of my case with Carolina Therapeutic Services First, whichever comes first.
  • I understand that the information in my records may include information relating to HIV infections, AIDS, Substance abuse and or psychological or psychiatric conditions and that any disclosure may include this information.
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  • Expiration Date (1 year)
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  • Carolina Therapeutic
    Service First

  • CONSENT FOR RELEASE OF CONFIDENTIAL INFORMATION

  • I         authorize a mutual exchange of information between Carolina Therapeutic Services First and Medicaid Transportation System.
    Ph: 704.336.4547 Fax: 704.353.1881

  • The purpose of these disclosures is: Assessment, service planning, treatment, monitoring of progress
  • Specific information to be disclosed: PCP, CCA, Assessment, Psychiatric evaluation, Medication Management notes, Progress Notes, Diagnoses, Treatment Plans
  • I understand that my records are protected under the federal regulations governing Confidentiality of Alcohol And Drug Abuse Records, 42 CFR Part 2, and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I understand that the recipient of my confidential information may not re-disclose such information without my further written authorization unless otherwise provided for by State of Federal law.
  • I understand that I may revoke this consent at any time. I understand that revocation will not apply information that has ready already been released. If I do not revoke this consent, it expires one year from the date this consent is signed or opens the closing of my case with Carolina Therapeutic Services First, whichever comes first.
  • I understand that the information in my records may include information relating to HIV infections, AIDS, Substance abuse and or psychological or psychiatric conditions and that any disclosure may include this information.
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  • Expiration Date (1 year)
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  • Carolina Therapeutic
    Service First

  • CONFIDENTIALITY OF ALCOHOL AND DRUG ABUSE PATIENT RECORDS WRITTENNOTICE OF REGULATIONS

  • The confidentiality of alcohol and drug abuse client records maintained by Carolina Therapeutic Services First. Program is protected by Federal law and regulations. Generally, Carolina Therapeutic Services First may not say to the person outside the program that a consumer attends the program or disclose any information identifying a consumer as an alcohol or drug abuser UNLESS:
    1. The consumer consents in writing
    2. If a court order is received
    3. If there is a medical emergency
    4. To qualified personnel for research, audit, and program, evaluation
    5. If we believe that you are likely to commit a crime at the program or against program personnel
    6. To report child abuse or neglect
    7. For the purpose of internal communications
    Violation of the Federal Law and regulations by Carolina Therapeutic Services First. is a crime. Suspected violations may be reported to appropriate authorities in accordance with Federal regulations.
    Federal; Law and regulations do not protect any information about a crime committed by a consumer or against any person who works for Carolina Therapeutic Services First, Inc. or about any threat to commit such a crime. Federal Laws and regulations do not protect any information about suspected child abuse or neglect from being reported under State Law to appropriate State Law to appropriate State or local authorities. (See 42 USC 290dd-3 and 42 USC 29ee-3 for Federal Laws and 42 CFR Part 2 for Federal regulations.)
    My signature below acknowledges that these regulations have been explained to me: that I have read them and understand the content.
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