Health Solutions Consents and Agreements

Client Name*

First NameLast Name

Client Date of Birth*

MonthDayYear

Client ID

By selecting “Accept” you are acknowledging that you consent to and understand the item selected. Please ask a Health Solutions team member if you are unsure of any item below:

Acknowledgement Of Privacy Notice

I have read, received a copy of and understand my rights related to the privacy of my healthcare information.*

Acknowledged

Acknowledgement Of Privacy Notice for Substance Use Disorder Information

The confidentiality of alcohol and drug abuse client records maintained by this program are protected by Federal laws and regulations. Because this agency completes a co-occurring assessment to evaluate the need for substance use and mental health treatment, I have been made aware of my rights associated with Federal Statute 42 CFR Part 2 and have received a summary of the federal law and regulation.*

Acknowledged

Photographs

I understand that I have the right to refuse to be photographed except for facility identification and the administrative purposes of the facility. Photographs and/or video recordings shall be confidential and shall not be released by the facility except pursuant to court order. No other non-medical photographs and/or video recordings shall be taken or used without appropriate consent or authorization. (Section 27-65-117(4), C.R.S.).*

Acknowledged

Acknowledgment of Third-Party Forms and Letters Policy

Health Solutions is committed to providing the best possible customer service to our clients. At times some clients have asked us to certify, determine their level of disability, orestablish a level of competency for them. Health Solutions cannot provide these sorts of documents or comment on one's ability to perform job duties or predict one's behavior in the future, thus we are unable to fulfill these types of requests.

The following are forms that Health Solutions staff members are able to complete for our clients:

•Diagnosis and/or Compliance Letters
•Medicaid Transportation
•Victim Compensation
•Med-9 (all clients must be active and compliant with recommended treatment at
Health Solutions for a minimum of 90 days prior to the request of a Med-9 in order to have the form revied for approval)

Request for completion of forms not on the above list will be reviewed for approval or denial on a case-by-case basis per Health Solutions policy.
We apologize for any inconvenience this may cause you. All requests for forms and letters will be filtered through the Medical Records Department
at the location you receive services to assure necessary releases are on file as required by State and Federal laws.

If you need a form completed that is against our policy, we recommend that you contact your Primary Care Provider (PCP) for assistance, who can also help you with referrals to specific types of providers, if needed.*

Acknowledged

Acknowledgement Of Care Coordination

I understand that as part of best practice, Health Solutions offers holistic care to ensure that all of my health care needs are met so that I can reach my treatment goals and live a healthy life. A care coordinator can assist me with facilitating access to proper medical care and coordinating my mental health treatment with my other medical providers. I also understand that the care coordinator will only provide the minimum necessary information to allow for this process to take place and does not require a release of information.

Treatment Agreements

In order for me to reach my goals in treatment I must attend my treatment appointment(s) regularly and actively participate in the development of my treatment plan.

I am committing to regular attendance and being on time for all of my appointments. It is my responsibility to inform Health Solutions of any need to cancel, reschedule, or delay a scheduled appointment within 24 hours of my appointment time.

It is also my responsibility to notify Health Solutions of changes in my telephone number, address, and my insurance coverage.

Failure to make changes to appointments within 24 hours of my appointment may result in cancelation of future appointments and possible discharge from services.

Per Health Solutions’ policy, a pattern of habitual non-attendance may result in discharge from services and the closing of my chart.

If my chart is closed, I will have emergency/crisis services available to me 24 hours a day, 7 days a week. These services do not include medication refills. If my case has been terminated and I wish to continue to seek services with Health Solutions, I am always welcome to return and re-enroll.*

AcceptsDeclinesN/A

Psychiatric/Medical Advance Directives

An advance directive is a legal document written by a currently competent person who lives with a mental illness or medical issues. An advance directive allows a person to beprepared if a mental health or medical crisis prevents them from being able to make decisions. An advanced directive describes treatment preferences, or names a person to maketreatment decisions, should the person with a mental health or medical condition be unable to make decisions. I understand that I may speak to my clinician or the consumer orfamily advocate to help me develop my advanced directive or obtain further information about Health Solutions’ policies regarding advance directives.

I UNDERSTAND THAT ADVANCE DIRECTIVES ARE NOT REQUIRED IN ORDER TO RECEIVE TREATMENT AT HEALTH SOLUTIONS.*

AcceptsDeclines

Follow Up Contact Surveys and Research

I understand that Health Solutions or its representatives may contact me during or after my treatment to obtain follow-up information, clinical outcomes information, or ask about my satisfaction with treatment or services. Such information is confidential and will be used for quality assessment. I may choose to participate in these surveys or not, without jeopardizing my care. I further understand that Health Solutions or its representatives may conduct research and publish that research using information that is non-identifiable.

This means that my confidentiality will remain fully intact and that no information will be included that can be linked back to me.*

AcceptsDeclinesN/A

Consent to Treat

Having reviewed all of the above as well as my client rights, I am willing and freely consenting to begin treatment with Health Solutions. If at any time I have concerns about my treatment, I am aware I can contact the client advocate or a supervisor/director to discuss my concerns.*

AcceptsDeclines

Intern/Student Consent

By accepting, I give consent for an intern/student to observe and/or conduct my mental health session for the purposes of education and training. I understand the following:

This is voluntary and I may refuse to allow the intern/student to observe sessions at any time;
This consent will have no impact on my current treatment;
I may revoke this consent in writing at any time;

This consent will remain valid until I no longer participate in treatment or until I revoke this consent.*

AcceptsDeclinesN/A

Telemedicine / Teletherapy Consent

All Health Solutions Center clients receiving telemedicine/tele-therapy services maintain the following rights.

•All clients retain the option to refuse the delivery of health care services via telemedicine/tele-therapy at any time without affecting the client's right to future care or treatment and without risking the loss or withdrawal of any program benefits to which the client would otherwise be entitled.

•All applicable confidentiality protections shall apply to the services.

•The client shall have access to all medical information resulting from the telemedicine/tele-therapy services as provided by applicable law for client access to his or her medical records.

These requirements do not apply in an emergency. [C. R. S. 2006, 25.5-5-320 (4) & (5)].

I give verbal consent to receive telemedicine/teletherapy services.*

AcceptsDeclines

By signing your name electronically on this document, you are agreeing that the signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability and admissibility.*

AgreeDisagree

Client / Guardian Signature