Information Included:
Description of Services & Support
Expected Outcomes, Benefits & Risks
Confidentiality Statement
Authorization for Audiovisual Recording
Suicide Prevention Policy
Fee Agreement
Individual Rights
Grievance Procedure
Acknowledgment & Consent to Services
Your Protected Health Information Rights
Description of Services & Support
There are several things you may wish to know about the services and support offered by Oregon Community Programs (OCP). If your questions are not answered in the following document, please feel free to ask your therapist/case manager, or telephone OCP’s Outpatient Program Director, Evyan Stuart at: (541) 743-4340.
Oregon Community Programs (OCP) is a non-profit treatment center dedicated to finding ways to help children and parents. It is our mission to provide therapy and counseling services that have been proven to be effective through research to families. Through our connection with current research and our treatment programs, we work to identify and promote those factors that contribute to healthy social adjustment for children , adolescents, and families.
Most children who participate in our treatment programs are living with their families and seeking services to improve family functioning. Some clients have been referred for services by the Oregon Youth Authority (OYA) or the Department of Human Services Child Welfare (DHS). Services are individualized to fit each child’s needs, and may be informed by a specific treatment model such as Parent Management Training Oregon, Trauma Focused Cognitive Behavioral Therapy, Parent Child Interaction Therapy, Treatment Foster Care Oregon, or another model that research has proven to be effective for children and families. You may be working with a single staff member or have several people working together and sharing information about your family in addition to your lead clinician. This may include a separate family therapist/counselor working with you, an individual therapist/counselor and/or skills trainer working with your child. The lead clinician coordinates services and helps the child’s family and/or foster parents construct and implement the plan to manage and improve the child's behavioral and emotional problems. The family therapist/counselor helps the child’s family learn ways to manage and help the child in their home. The individual therapist/counselor or skills trainer helps the child learn new skills and problem solve. We provide intensive, comprehensive treatment services and support. This includes 24-hour access by phone, supporting visits with family members, assistance with obtaining appropriate educational services, and coordination with community agencies.
You will be asked to participate in the development of your child’s treatment plan (Individual Services & Support Plan or Master Service Plan), provide information about yourself and your family, and to work between therapy/counseling sessions. Your child’s success in treatment is affected by your efforts, input, and candidness. It is important for us that we work together as a team throughout the treatment process.
Expected Outcomes, Benefits & Possible Risks of Service
Benefits often include a reduction in child problem behaviors, family conflict, and communication problems, as well as an increase in self-esteem, better performance in school, and improved relationships and coping skills. While we make every effort to help our clients, we cannot guarantee success. If we determine that we cannot provide effective services and support, we will provide a referral to another mental health provider.
Risks can include behavior problems and emotional difficulties getting worse before they get better. Discussing certain issues and trying to change behaviors may be stressful and difficult. Additionally, parents may not agree with some of the rules of our program. We will be asking you to contribute information throughout treatment that will help to determine whether improvements are being made among the ups and downs of daily life.
There are also risks to not receiving services and support. Problem behaviors often do not change without treatment and sometimes they get worse Not treating problem behaviors or mental health symptoms can put you at risk for the issues to become harder to treat over time, for the development of other mental health or physical health symptoms, decreased quality of personal relationships, decreased quality of life issues, increased risk of victimization, accidents, substance use or self-harm or suicidal behavior.
For treatment foster care clients: Often children make positive changes while living in foster care, and parental involvement during treatment is essential to maintaining these changes when their children return home. We work with the client’s family to reduce these stresses and believe the potential benefits outweigh the risks.
Confidentiality
Information we obtain about you and your family is confidential. If anyone other than you or a legal guardian asks us to discuss your child’s case, they will not be told anything unless you have signed a release giving your permission for us to do so. If there is someone with whom you believe we should speak, please tell us as soon as possible. After a release is signed, you have the right to withdraw that permission at any time. Everyone at OCP is a mandated reporter. By law, we must release information in situations where someone is at risk of being seriously harmed or where someone is suspected of having been abused or neglected. There may be other individuals who have rights to access our records (for example, officers of the court under subpoena, non-custodial parents, DHS, OYA, legal representatives), and we will outline for you who we know to be involved in your situation. For the purposes of payment, OCP will also be releasing information about your treatment including diagnoses, sessions and attendance. To ensure confidentiality, all files and records pertaining to your child’s case are kept locked in our file room or on a secure data server. OCP uses a team-based approach to confidentiality, while you may be working with multiple OCP staff members, these staff members will be sharing all aspects of your treatment internally. No one outside of OCP staff has access to these records. You have the right to review your records. If you wish to do so, contact your lead clinician who will offer to arrange an appointment within two working days. All staff members and foster parents sign confidentiality agreements. While this can be confusing, it is recommended that you retain a copy of this information, and any OCP staff person would be happy to review and explain these rules and how they apply to you at any time.
Authorization for Audiovisual Recording
Audiovisual recording of sessions helps OCP clinical staff provide the highest quality services. We typically record treatment sessions for the purpose of case supervision and coordination. At any time, you may request that videos made of you and your family members be erased, and we will do so.
By signing this agreement, you authorize OCP to use any audiovisual recording made of you and of your family for internal supervision, training, . Upon written notice you may have all of the audiovisual recordings erased and/or restrict their use. Any audiovisual recording will be destroyed after its use has been completed. Recordings are not considered part of the clinical record and are not ever intended to be saved, except for those used for ongoing training purposes for OCP staff Clients may revoke or restrict authorization for videos to be used for training or any other purpose at anytime by alerting their lead clinician or a Program Director.
Special circumstances for some interventions: With your separate written approval, some video recordings may be securely uploaded to a web-portal for review by trainers outside of OCP for the purpose of ensuring that the interventions you are receiving are high quality and to provide training to your therapist or counselor in improving their delivery of the service. You will have a separate opportunity to approve or decline use of your video recordings in this way. However, declining may mean that you cannot receive that particular service, if video consultation is a requirement for your therapist. In that case, we will work with you to identify another treatment option at OCP that meets your needs or refer you to another provider.
Suicide Prevention Policy
Staff are trained to identify suicidal behavior, as well as the subtle differences between suicidal behavior and self-harming behaviors. Any OCP staff who hears or observes a youth verbalize self-injurious or suicidal behavior will immediately respond in a manner that protects youth safety. Staff will promptly consult with the lead clinician, who will determine if youth is in immediate need of community mental health crisis team assessment or if other measures to protect safety should be taken. All recommendations will be documented and shared with clinical staff and guardian. For more information, please ask to see OCP’s Suicide Prevention Policy.
Fees
OCP services are funded through several sources, including Oregon Health Plan (OHP), private insurance, or contracts with the state or county such as Behavioral Rehabilitative Services (BRS). Trillium Community Health Plan (Trillium) and Pacific Source will be the Coordinated Care Organizations (CCO) responsible for managing OHP’s mental health system in Lane County. Other counties have other CCOs who manage OHP benefits. OHP clients will receive treatment free of payment for services covered by OHP. If you have both private health insurance and OHP that covers your child, we are required to bill your insurance company prior to billing OHP. OHP will be billed for the charges not covered by your private insurance company. OCP is an out-of-network provider for all private insurance companies, and we will collect co-pays at the time of service if your treatment is funded by private insurance only. Your private insurance company may require that we provide them with the information about your child’s diagnosis and treatment. Representatives from a CCO and community representatives will review files of enrolled clients for the purpose of utilization management, authorizing services, quality assurance, and site review. Services funded by state or county contracts are typically provided at no cost to the individual or family. OCP can also bill some out-of-county Coordinated Care Organizations (CCOs) for youth who are co-enrolled in Behavioral Rehabilitative Services through our Treatment Foster Care Oregon programs.
Rights
All children and families who participate in services at OCP have rights including:
The right to privacy protection & confidentiality
The right to be treated with dignity & respect
The right to not be discriminated against for race, color, creed, or sexual orientation.
The right to be provided with information about participating in services & support, including information contained in their clinical record, upon request
The right to be involved in the development of their services and support plans
The right to have information regarding the potential risks and benefits of service
The right to refuse services and support at any time
The right to call your attorney, caseworker, CASA, therapist, counselor, or case manager
The right to file a verbal complaint or written grievance
Individuals also have rights in accordance with OAR 309-019-0115, these include the right to:
(a) Choose from services and supports that are consistent with the assessment and service plan, culturally competent, provided in the most integrated setting in the community and under conditions that are least restrictive to the individual’s liberty, that are least intrusive to the individual, and that provide for the greatest degree of independence;
(b) Be treated with dignity and respect;
(c) Participate in the development of a written service plan, receive services consistent with that plan and participate in periodic review and reassessment of service and support needs, assist in the development of the plan, and receive a copy of the written service plan;
(d) Have all services explained, including expected outcomes and possible risks;
(e) Confidentiality and the right to consent to disclosure in accordance with ORS 107.154, 179.505, 179.507, 192.515, 192.507, 42 CFR Part 2 and 45 CFR Part 205.50;
(f) Give informed consent in writing prior to the start of services, except in a medical emergency or as otherwise permitted by law. Minor children may give informed consent to services in the following circumstances:
(A) Under age 18 and lawfully married;
(B) Age 16 or older and legally emancipated by the court; or
(C) Age 14 or older for outpatient services only. For purposes of informed consent, outpatient service does not include service provided in residential programs or in day or partial hospitalization programs.
(g) Inspect their service record in accordance with ORS 179.505;
(h) Refuse participation in experimentation;
(i) Receive medication specific to the individual’s diagnosed clinical needs, including medications used to treat opioid dependence;
(j) Receive prior notice of transfer, unless the circumstances necessitating transfer pose a threat to health and safety;
(k) Be free from abuse or neglect and to report any incident of abuse or neglect without being subject to retaliation;
(l) Have religious freedom;
(m) Be free from seclusion and restraint;
(n) Be informed at the start of services and periodically thereafter of the rights guaranteed by this rule;
(o) Be informed of the policies and procedures, service agreements and fees applicable to the services provided, and to have a custodial parent, guardian, or representative assist with understanding any information presented;
(p) Have family and guardian involvement in service planning and delivery;
(q) Have an opportunity to make a declaration for mental health treatment, when legally an adult;
(r) File grievances, including appealing decisions resulting from the grievance;
(s) Exercise all rights set forth in ORS 109.610 through 109.697 if the individual is a child, as defined by these rules;
(t) Exercise all rights set forth in ORS 426.385 if the individual is committed to the Authority; and
(u) Exercise all rights described in this rule without any form of reprisal or punishment.
Beyond these rights, youth are encouraged to suggest and negotiate desired changes in their program. This can be done by contacting therapists, counselors, or case managers.
For youth in OCP foster care programs: Foster Parents will routinely be included in advocating and implementing plans to assure client rights. Participation in BRS treatment foster care placement is voluntary, and discharge may be requested within 3 business days. Youth choosing to make this request will be promptly put in contact with their caseworker or juvenile counselor/probation officer to discuss options and alternatives.
Grievances
We encourage you to be active participants in your own treatment and to first address concerns, questions, or potential issues with the clinician working most directly with you. If you ever have questions or concerns about this information or about the services you receive, please feel free to speak with your therapist/lead clinician at OCP or their supervisor. You have the right to make a verbal or written complaint to either the therapist or their supervisor without fear of retaliation or negative impact on treatment services. If during the course of treatment you have a grievance that you cannot work out with the lead clinician or supervisor, please request a grievance form from reception or contact our Executive Director (Ana Day) or Outpatient Program Director (Evyan Stuart) at (541) 743-4340 to initiate the grievance process in accordance with OAR 309-019-0215.
The steps to file a grievance are:
Complete the grievance form and submit to OCP staff. An oral request to file a grievance can be sufficient, and OCP staff can assist you
Grievances will be received and reviewed by the Executive Director who will offer to meet with you to understand your concerns.
A written response to the grievance will be provided within 30 calendar days from the date of OCP’s receipt of the grievance. For Medicaid funded services, the response will be delivered within 5 business days, unless you are notified that a 30 calendar day response timeline is required.
You will receive a response to the grievance at the conclusion of the relevant timeframe. The response will include next steps that may apply to the situation, including the appeal process.
If you would like to appeal the outcome, it must be submitted in writing to the Health Systems Division within 10 working days of grievance OCP’s response, and OCP staff can help you to complete the appeal upon request.
If you are dissatisfied or would like to talk to someone outside of the program staff, you may contact the Trillium Ombudsman at (541) 345-6466 or Trillium Member Services Line at 1-877-600-5472. Youth in the Monitor Program will be given the OYA Hotline number. Youth in BRS foster care programs have the right to call their caseworker or juvenile counselor/probation officer, attorney, or CASA at any time.
Acknowledgement & Informed Consent to Services & Support:
I, as parent or guardian, by signing below indicate that:
I willingly agree to participate in the program
I understand that information gathered about my child and my family will be kept strictly confidential with the exceptions listed above
I understand the risks and benefits of services and support
I understand that I have the right to withdraw from services
I may file a grievance without retaliation. I have been informed of and understand the grievance process.
I have been informed of my rights
I understand that if my child is covered by OHP, my file will periodically be reviewed by my assigned CCO), Oregon Health Authority and the OCP Performance Quality Improvement Committee
I have received a copy of this document which includes: Description of Services and Support; Expected Outcomes, Benefits and Possible Risks of Service; Confidentiality Statement; Authorization for Audiovisual Recording; Fee Agreement; Notification of Rights; Acknowledgement and Informed Consent to Services and Support; and Your Protected Health Information Privacy Rights.
I have received a copy of the Notice of Privacy Practices
I understand that OCP will use and disclose health information in the manner described above. I understand that my health information may include information both created and received by OCP; may be in the form of written or electronic records or spoken words; and may include information about my health history, health status, symptoms, examinations, test results, diagnoses, treatments, procedures, prescriptions, mental health records, drug/alcohol abuse diagnoses, genetic testing information, sexually transmitted diseases, and/or similar types of health-related information.
I understand and agree that OCP may use and disclose my health information in order to:
Make decisions about and plan for my care and treatment;
Refer to, consult with, coordinate among, and manage along with other health care providers for my care and treatment;
Determine my eligibility for health plan or insurance coverage and to submit bills, claims, and other related information to insurance companies or others who may be responsible to pay for some or all of my health care; and
Perform various office, administrative, and business functions that support my practitioner/provider’s effort to provide me with, arrange, and be reimbursed for quality, cost-effective health care.
I also understand that I have the right to receive and review a written description of how OCP will handle health information about me. This written description is known as a Notice of Privacy Practices and describes the uses and disclosure of health information made and the information practices followed by the employees, staff, and other office personnel of OCP, and my rights regarding health information.
I understand that the Notice of Privacy Practices may be revised from time to time, and that I am entitled to receive a copy of any revised Notice of Privacy Practices. I also understand that a copy or a summary of the most current version of OCP’ Notice of Privacy Practices in effect will be posted in the waiting/reception area.
I understand that I have the right to ask that some or all of my health information not be used or disclosed in the manner described in the Notice of Privacy Practices, and I understand that OCP is not required by law to agree to such requests.
This Notice of Privacy Practices will tell you how OCP may use or disclose information about you. Not all situations will be described. OCP is required to give you a notice of our privacy practices about the information we collect and keep about you. OCP is required to follow the terms of the notice currently in effect.
Your Protected Health Information Rights
Oregon Community Programs May Use and Disclose Information Without Your Authorization:
For Treatment. OCP may use or disclose information with health care providers who are involved in your health care. For example, information may be shared to create and carry out a plan for your treatment. There are exceptions to this for some Mental Health and HIV services, and for substance abuse treatment; those services may require a signed Release of Information from you.
To Coordinate Care. OCP is now works with state certified Coordinated Care Organizations (CCO). If you are an OHP Member, OCP may use or disclose your health information to other providers in the CCO (including mental health and HIV diagnoses and treatment) who are involved in your care for the purpose of providing whole-person care.
For Payment. OCP may use or disclose information to get payment or to pay for the health care services you receive. For example, OCP may provide PHI to bill your health plan for health care provided to you.
For Health Care Operations. OCP may use or disclose information in order to manage its programs and activities. For example, OCP may use PHI to review the quality of services you receive.
To Business Associates. If the information is necessary for them to perform functions on behalf of OCP or for medical reviews, legal services, audits or management activities related to HIPAA compliance. They are obligated to protect the privacy of your information.
For Health Oversight Activities. OCP may use or disclose information during inspections or investigations of our services.
As Required by Law and For Law Enforcement. OCP will use and disclose information when required or permitted by federal or state law or by a court order.
For Abuse Reports and Investigations. OCP is required by law to comply with mandatory reporting of suspected child abuse or threat of harm to the Department of Human Services.
To Avoid Harm. OCP may disclose PHI to law enforcement in order to avoid a serious threat to the health and safety of a person or the public.
Uses and Disclosures in Special Situations
OCP may use or disclose your PHI in the situations described below unless you notify us in writing that you would like us not to. See the information below under “Your PHI Privacy Rights” for information about how to request limitations.
Appointments and Other Health Information. OCP may send you reminders for medical care or checkups. OCP may send you information about other treatment or health services that may be of interest to you.
For Government Programs. OCP may use and disclose information for public benefits under other government programs. For example, OCP may disclose information for the determination of Supplemental Security Income (SSI) benefits.
For Research. OCP may use information for studies and to develop reports. These reports do not identify specific people.
Disclosures to Family, Friends, and Others. OCP may disclose information to your family or other persons who are involved in your medical care. You have the right to object to the sharing of this information.
Other Uses and Disclosures Require Your Written Authorization
For other situations, OCP will ask for your written authorization before using or disclosing information. You may cancel these authorizations at any time in writing. OCP cannot take back any uses or disclosures already made with your authorization
Other Laws Protect PHI. Many programs have other laws for the use and disclosure of information about you. For example, under Federal law, you must give your written authorization for the use and disclosure of your alcohol and drug treatment records.
Your Protected Health Information Privacy Rights
Your rights include the following:
Right to See and Get Copies of Your Records. In most cases, you have the right to look at or get copies of your records. You must make the request in writing. You may be charged a fee for the cost of copying your records.
Right to Request a Correction or Update of Your Records. You may ask OCP to change or add missing information to your records if you think there is a mistake. You must make the request in writing, and provide a reason for your request.
Right to Get a List of Disclosures. You have the right to ask OCP for a list of disclosures. You must make the request in writing. This list will not include the times that information was disclosed for treatment, payment, or health care operations. The list will not include information provided directly to you or your family, or information that was sent with your authorization.
Right to Request Limits on Uses or Disclosures of PHI. You have the right to ask that OCP limit how your information is used or disclosed. You must make the request in writing and tell OCP what information you want to limit and to whom you want the limits to apply. OCP is not required to agree to the restriction, in most cases. If requested and consistent with law, OCP shall agree not to send health information to your health plan for payment of health care operating purposes if the information concerns a health care item or service for which you have paid OCP out-of-pocket in full. You can request that the restrictions be terminated in writing or verbally.
Right to Be Notified of a Breach. You have a right to be notified in the event that we (or a business associate) discover a breach of your unsecured health information. Notice of a breach will be made in accordance with federal requirements.
Right to Choose How We Communicate with You. You have the right to ask that OCP share information with you in a certain way or in a certain place. For example, you may ask OCP to send information to your work address instead of your home address. You must make this request in writing. You do not have to explain the basis for your request.
Right to File a Complaint. You have the right to file a complaint if you do not agree with how OCP has used or disclosed information about you.
Right to Get a Paper Copy of this Notice. You have the right to ask for a paper copy of this notice at any time.
How to contact OCP to Review, Correct, or Limit Your Protected Health Information (PHI)
You may contact your lead clinician to:
Ask to look at or copy your records
Ask to correct or change your records
Ask to limit how information about you
Ask to cancel an authorization
Ask for a list of the times OCP disclosed or used information about you
How to File a Complaint or Report a Problem
You may contact any of the people listed below if you want to file a complaint or to report a problem with how OCP has used or disclosed information about you. OCP cannot retaliate against you for filing a complaint, cooperating in an investigation, or refusing to agree to something that you believe to be unlawful.
Ana Day , LMFT
Oregon Community Programs, Executive Director
or
Rachel Troyer , HIPAA Privacy Officer
Oregon Community Programs, Operating Manager
1170 Pearl Street
Eugene, OR 97401
(541) 743-4340
My child is enrolled at another mental health agency: Yes No
Monitor Program
I have received the OYA Keeping Youth Offenders Safe Brochure: Yes No
I have read and understand the information above and have had my questions answered. I hereby give my informed consent to treatment. Yes No
Child's Name
Parent or Guardian Name
