DePaul Community Based Services Enrollment and Treatment Consent Information

To be completed/submitted by the client, legal guardian, or authorized representative ONLY. A Referral for Service is also required, if not already submitted. Services cannot begin until this information is submitted.
Client Name:
First*
Last*
Client Date of Birth*
Person Providing Information*
First Last
Relationship to Client*
Email*
Phone*
Medical Information
Put N/A if not applicable.
Client's Physician*
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
List Medications and Dosages (to include current or previous use of birth control)*
Allergies (medications, seasonal, bee stings, etc.)*
Recent Medical / Physical Complaints.*
Chronic Conditions*
Communicable Diseases (Hepatitis, HIV, Tuberculosis, etc.).*
Alcohol or Drug Use History.*
Developmental or Mental Health History (Developmental delays, disabilities, mental health conditions, etc.)*
Emergency Contact Information
Put N/A if not applicable.
First Name*
Last Name*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone*
Email*
Relationship to Client*
Insurance Information
In the event of a medical emergency, I hereby authorize the staff of DePaul Community Resources to apply basic first aid measures, to call the personal physician, and/or the local rescue squad if this is indicated. I further give my consent for DePaul Community Resources staff to provide transportation of myself or my child to receive emergency medical services in the event that it is necessary and to authorize emergency treatment when the legal guardian is unable to be contacted. In addition, staff may supply pertinent medical history information on my behalf to emergency health professionals to assist in my or my child’s treatment. This consent is valid for one year from date and may be revoked in writing at any time.*
In the event of a medical emergency, I hereby authorize the staff of DePaul Community Resources to apply basic first aid measures, to call the personal physician, and/or the local rescue squad if this is indicated. I further give my consent for DePaul Community Resources staff to provide transportation of myself or my child to receive emergency medical services in the event that it is necessary and to authorize emergency treatment when the legal guardian is unable to be contacted. In addition, staff may supply pertinent medical history information on my behalf to emergency health professionals to assist in my or my child’s treatment.

This consent is valid for one year from date and may be revoked in writing at any time.

I agree to the privacy policy.
Authorization to Release Protected Health Information
Types of Release*
- One-Time exchange of Information
- Ongoing Exchange of Information
Name of Person Completing Form / Authorizing Release*
First Last
Relationship to Client*
Client Address*
Street Address Address Line 2 City State ZIP Code
Client Phone Number*
Client Date of Birth*
Information May Be (Check All That Apply)*
- Received from Primary Care Physician (PCP)
- Released to Primary Care Physician (PCP)
Information To Be Sent/Shared (Check All That Apply)*
- Intake/ Assessment Information
- Progress Notes
- Medical Records
- Psychological Records
- Mental Health Diagnoses
- Social History
- Educational Records
- Psychiatry Records
- Substance Abuse Information
- Discharge Summary Information
- Other
Other*
Purpose of Disclosure (Check All That Apply)*
- Service Provision/ Service Coordination
- Client Request
- Eligibility Determination
- Other
Other*
Authorization Consent*
I understand that:
• Different agencies provide different services and benefits, and that each agency must have specific information in order to provide services and benefits. By consenting and authorizing this form I am allowing agencies to exchange certain information, including potential confidential health information, so it will be easier for them to work together more effectively to provide or coordinate services.
•I can withdrawal this authorization at any time by notifying DePaul in writing.
• Withdrawal of this authorization does not affect any disclosure of Protected Health Information made prior to the receipt of written notice of revocation.
• I have the right to see and receive copies of the information described in this authorization if I request it in writing.
• My provision of services, payment, enrollment, or eligibility for benefits will not be conditioned on signing this authorization.
• There is a potential that information disclosed may be re-disclosed by the recipient and no longer protected by law (see note below regarding 42 CFR Part 2)
• A copy of this authorization and a notation concerning the person or agencies to which disclosure was made shall be included with the original health records and I have a right to a copy of this authorization at my written request.
• This authorization will automatically expire one year after the date of acknowledgement for an ongoing release/90 day for one-time release, unless otherwise revoked in writing.

I understand
Date*
MM slash DD slash YYYY
Note: This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR Part 2). The Federal rules prohibit you from making any further disclosure of this information unless further disclosure if expressly permitted by this written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2.
Community Based Services Consent for Treatment Agreement
I acknowledge that I give consent for treatment by DePaul Community Resources staff for services for which I am requesting/referring. In the case of the client being a minor, I cite that I am the legal guardian/authorized representative, and hereby give consent for treatment. I agree to a needs assessment and participation in the therapeutic services aimed at meeting needs that are agreed upon with the treatment provider. I understand that the therapeutic process is a cooperative effort between the client and service provider(s) and the intensity and duration of services will be based on client need, participation, and the availability of funding. I understand that I will be involved in decision-making regarding the course of services.*
I acknowledge that I give consent for treatment by DePaul Community Resources staff for services for which I am requesting/referring. In the case of the client being a minor, I cite that I am the legal guardian/authorized representative, and hereby give consent for treatment. I agree to a needs assessment and participation in the therapeutic services aimed at meeting needs that are agreed upon with the treatment provider. I understand that the therapeutic process is a cooperative effort between the client and service provider(s) and the intensity and duration of services will be based on client need, participation, and the availability of funding. I understand that I will be involved in decision-making regarding the course of services.
Acknowledgement
Grievance Procedure
Your input regarding the direction of your (or your child’s) treatment is important. If you are not satisfied with your services, it is important to talk to your service provider about your concerns. You may also contact the Director of Community Based Services or the Vice President of Child and Family Services if you feel your concerns are not being addressed. Contact information for these individuals can be found on our website (www.depaulcr.org) or by calling 1-888-233-7285.*
Your input regarding the direction of your (or your child’s) treatment is important. If you are not satisfied with your services, it is important to talk to your service provider about your concerns. You may also contact the Director of Community Based Services or the Vice President of Child and Family Services if you feel your concerns are not being addressed. Contact information for these individuals can be found on our website (www.depaulcr.org) or by calling 1-888-233-7285.
Acknowledgement
Confidentiality
Protecting your confidentiality is of the utmost importance to DePaul Community Resources. All client information is kept confidential. Written permission is required by law to facilitate the release of client-related information to outside parties, except in the following situations: 1. Mandated reporting of suspected or confirmed abuse, neglect, self-harm, harm to others, duty to warn of threats to harm others, or inability to care for self. 2. Medical emergencies, for the purpose of preventing injury to, or death of, client or other persons. 3. Subpoena for records, legal counsel, hearings, reviews, appeals, or investigation under the regulations of Licensing, Human Rights, or certification or accreditation (12 VAC 35-115-80).*
Protecting your confidentiality is of the utmost importance to DePaul Community Resources. All client information is kept confidential. Written permission is required by law to facilitate the release of client-related information to outside parties, except in the following situations:
1. Mandated reporting of suspected or confirmed abuse, neglect, self-harm, harm to others, duty to warn of threats to harm others, or inability to care for self.
2. Medical emergencies, for the purpose of preventing injury to, or death of, client or other persons.
3. Subpoena for records, legal counsel, hearings, reviews, appeals, or investigation under the regulations of Licensing, Human Rights, or certification or accreditation (12 VAC 35-115-80).

Acknowledgement
Health Insurance Portability and Accountability Act (HIPAA)
Client Rights*
It Is Your Right…
• To be treated with dignity and respect.
• To be told about your treatment.
• To have a say in your treatment.
• To speak to others in private
• To have your complaints resolved.
• To say what you prefer.
• To ask questions and be told about your rights.
• To get help with your rights.

I acknowledge that I read and understand these rights and that I may be provided with a Human Rights sheet listing my rights and indicating my area Human Rights Advocate and contact information at any time, at my request.

Acknowledgement
Orientation
As part of the DePaul Community Resources client orientation process, I acknowledge that upon enrollment in services, I will be provided with either electronic or paper copies of the following information: • Local office hours • Office layout information • Emergency procedures (how to contact crisis services after hours) • Appointment management (no show and cancellation policies) • Grievance Procedures • HIPAA information • Confidentiality information • Course of treatment/services • Client Rights • Emergency Medical Information*
As part of the DePaul Community Resources client orientation process, I acknowledge that upon enrollment in services, I will be provided with either electronic or paper copies of the following information:
• Local office hours
• Office layout information
• Emergency procedures (how to contact crisis services after hours)
• Appointment management (no show and cancellation policies)
• Grievance Procedures
• HIPAA information
• Confidentiality information
• Course of treatment/services
• Client Rights
• Emergency Medical Information

Acknowledgement
Assignment of Benefits
I authorize the release of any information, to include protected health/medical/substance abuse information, that is deemed necessary to process claims to third-party payors (i.e. Medicaid, HMO’s, CSA, etc.) as needed. I also authorize payment of any medical benefits to be made to DePaul Community Resources (DCR) on my behalf. If any payments are made directly to me as reimbursement for services that I have not yet paid to DCR, I will immediately notify DCR of such payments and arrange payment to DCR. I agree to pay all co-payments and deductibles, if applicable, and understand that if fees are not paid when due, services may be delayed or discontinued. I agree to notify DePaul Community Resources of any changes to my healthcare benefits, as needed, and will provide up-to-date benefit information, as necessary. I understand that my insurance may require me to supply certain information directly to ensure payment, and it is my responsibility to comply with their request. I understand the balance of my claim is my responsibility, whether or not the insurance company pays my claim, as my insurance benefit is a contract between myself and my insurance company, and DePaul is not party to that contract.*
I authorize the release of any information, to include protected health/medical/substance abuse information, that is deemed necessary to process claims to third-party payors (i.e. Medicaid, HMO’s, CSA, etc.) as needed. I also authorize payment of any medical benefits to be made to DePaul Community Resources (DCR) on my behalf. If any payments are made directly to me as reimbursement for services that I have not yet paid to DCR, I will immediately notify DCR of such payments and arrange payment to DCR.

I agree to pay all co-payments and deductibles, if applicable, and understand that if fees are not paid when due, services may be delayed or discontinued. I agree to notify DePaul Community Resources of any changes to my healthcare benefits, as needed, and will provide up-to-date benefit information, as necessary. I understand that my insurance may require me to supply certain information directly to ensure payment, and it is my responsibility to comply with their request. I understand the balance of my claim is my responsibility, whether or not the insurance company pays my claim, as my insurance benefit is a contract between myself and my insurance company, and DePaul is not party to that contract.
Acknowledgement
Party Responsible for Payment*
*
Acknowledgement
Choice of Provider Information
I understand that I have the right to choose my service provider, and acknowledge that I am choosing to receive community-based treatment services at DePaul Community Resources. I am aware that I may receive a list of local area providers with similar services at my request.*
I understand that I have the right to choose my service provider, and acknowledge that I am choosing to receive community-based treatment services at DePaul Community Resources. I am aware that I may receive a list of local area providers with similar services at my request.
Acknowledgement
Notice of Appeal
I acknowledge that have the right to request an appeal or review of any actions as it relates to eligibility determination, change in services, continuance in services, or termination from services. Requests for appeal/review must be made in writing, and include the actions with which you disagree or are contesting, within 30 days of receipt of the agency’s notice of action taken. You may write a letter or complete an Appeal Request Form. These forms are available online at www.dmas.virginia.gov. Please mail Appeal/Review Requests to: Appeals Division Department of Medical Assistance Services 600 E. Broad Street Richmond, VA 23219 Appeal/Review Requests may also be faxed to: 804-371-8491 The Department of Medical Assistance Services may be contacted by phone at: 804-371-8488*
I acknowledge that have the right to request an appeal or review of any actions as it relates to eligibility determination, change in services, continuance in services, or termination from services.

Requests for appeal/review must be made in writing, and include the actions with which you disagree or are contesting, within 30 days of receipt of the agency’s notice of action taken. You may write a letter or complete an Appeal Request Form. These forms are available online at www.dmas.virginia.gov.

Please mail Appeal/Review Requests to:

Appeals Division
Department of Medical Assistance Services
600 E. Broad Street Richmond, VA 23219

Appeal/Review Requests may also be faxed to:
804-371-8491

The Department of Medical Assistance Services may be contacted by phone at: 804-371-8488

Acknowledgement
Name
First Last
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DePaul Community Based Services Enrollment and Treatment Consent Information

Medical Information

Emergency Contact Information

Insurance Information

Authorization to Release Protected Health Information

Community Based Services Consent for Treatment Agreement

Grievance Procedure

Confidentiality

Health Insurance Portability and Accountability Act (HIPAA)

Orientation

Assignment of Benefits

Choice of Provider Information

Notice of Appeal