Outpatient - Opening Consents
Youth Date of Birth:
Parent/Legal Guardian Name(s):
Description and Consent to Services and Supports- Includes the following:
Request for Alternative Communication
Video Telehealth Consent
(Due to COVID-19 restrictions, opting out of telehealth services may result in delayed start to services or being placed back on a waitlist until such time that the agency fully resumes in-person services.)
Please note that any applicable Releases of Information need to be completed individually and separately from this intake paperwork. Completion of additional forms may also be requested to support treatment.
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.
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.
For Intensive In-Home Behavioral Health Treatment (IIBHT) clients: IIBHT is a short-term program designed to offer intensive services to families, in their preferred location, to stabilize behaviors and help youth maintain in their current placement, decreasing the likelihood of referral to more restrictive settings or out of home placement.
OCP assigns a Team Lead to coordinate IIBHT services and to be the child’s guardian’s primary point of contact. Team Leads work closely with the guardian and OCP clinical team to ensure timely and accurate support and updates to the child’s treatment, crisis and safety plans. They utilize a variety of measures to track and assess outcomes, some daily, with the goal of improving wellbeing and stability of the family system. Families enrolled in IIBHT have 24-7-365 access to their Team Lead or an equivalent provider to support them in managing emotional and behavioral crises and in learning behavior management strategies to decrease the frequency of crises. Enrolled families are offered upwards of 4 hours of services weekly, comprised of family therapy, individual therapy, skills training, youth and family peer support, case management, psychiatry and telephonic or in-home proactive support and crisis response. Monthly team meetings are scheduled and include members of the child’s broader team (e.g., school personnel, WRAP facilitators, natural supports, etc.)
On average, IIBHT services last between 3-6 months, after which program staff oversee the transition to an appropriate level of care. Transfer programs may include lower levels of care within OCP.
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 teambased 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.
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, and case coordination. 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.
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.\
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 and Pacific Source Community Solutions 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.
All children and families who participate in services at OCP have rights including:
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.
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:
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 the nature of the grievance is time sensitive, then you may request an expedited review and receive a response within 48 hours of receipt of the grievance.
Grievance forms are available from reception, your case manager, or from any OCP staff member. If you are dissatisfied or would like to talk to someone outside of the program staff, you may contact your CCO and request a grievance form. Trillium members may contact the Trillium Ombudsman at (541) 345-6466 or Trillium Member Services Line at 1-877-600-5472. PacificSource members may contact member services at 1-800-431-4135. 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.
I, as parent or guardian, by signing below indicate that:
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:
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.
In accordance with Oregon’s Child Abuse Reporting Law ORS 418.747, 418.748, 418.749 and 419B.005 to 419B.045, OCP employees and treatment foster care parents have a legal responsibility to immediately report suspected child abuse or neglect by calling the appropriate child abuse reporting hotline. Mandatory reports made to the child abuse hotline will be clearly documented in the client’s health record.
Oregon Community Programs May Use and Disclose Information Without Your Authorization:
Uses and Disclosures in Special SituationsOCP 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 requestlimitations.
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.
Your Protected Health Information Privacy Rights
Your rights include the following:
How to contact OCP to Review, Correct, or Limit Your Protected Health Information (PHI)
You may contact your lead clinician to:
OCP may deny your request to look at, copy or change your records. If OCP denies your request, OCP will send you a letter that tells you why your request is being denied and how you can ask for a review of the denial. You will also receive information about how to file a complaint with OCP or with the U.S. Department of Health and Human Services, Office for Civil Rights.
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, LMFTOregon Community Programs, Executive DirectororYvonne Hubbard, HIPAA Privacy OfficerOregon Community Programs, Operating Manager
1170 Pearl StreetEugene, OR 97401(541) 743-4340
Your signature on the OCP Intake Paperwork coversheet indicates that you have read and understand the information above, have had your questions answered, and that you give your informed consent to treatment.
The primary forms of communication for therapy services are telephone, fax, or face‐to‐face conversation or Zoom Telehealth because these methods can assure reasonable confidentiality. Some clients and guardians prefer to use other means of communication for quicker or easier contact. Completion of this form will allow some specific alternative means of communication. Please note that when email or text services are used, OCP has no ability to assure security, confidentiality, or encryption of the content. These means of communication can be used with client/guardian permission, but are often not secure to the standards of HIPAA Omnibus Rule of 2013.
Please note that we will not ask you why you are requesting alternative communications. Also, we may be unable to agree to accommodate your request (i.e. it is unreasonable, we do not have the technology, in an emergency). We may deliver your electronic request in the format you request, or if we do not have the software to accommodate that, in a similar electronic format. If we agree to your request, we will follow the instructions stated on the intake coversheet until such time as you instruct us otherwise in writing. A signed, dated copy of this Request shall be as effective as the original.
Please indicate on the OCP Intake Paperwork coversheet, if you are opting in or out of alternative forms of communication and provide preferred contact information (if applicable).
By signing the OCP Intake Paperwork coversheet, I hereby give permission to Oregon Community Programs to call and obtain the service of a physician or hospital for medical care for my child should an emergency arise. I understand that a conscientious effort will be made to locate me before any action will be taken. I also authorize Oregon Community Programs to involve my child in certain potentially hazardous activities. (e.g., transporting my child in a car during session, visiting an indoor trampoline park, playground activities, etc.)
For purposes of this Notice “us” “we” and “our” refers to Oregon Community Programs (OCP) and “you” or “your” refers to our patients (or their legal representatives as determined by us in accordance with state informed consent law). When you receive healthcare services from us, we will obtain access to your medical information (i.e. your health history). We are committed to maintaining the privacy of your health information and we have implemented numerous procedures to ensure that we do so.
The Federal Health Insurance Portability & Accountability Act of 2013, HIPAA Omnibus Rule, (formally HIPAA 1996 & HI TECH of 2004) require us to maintain the confidentiality of all your healthcare records and other identifiable patient health information (PHI) used by or disclosed to us in any form, whether electronic, on paper, or spoken. HIPAA is a Federal Law that gives you significant new rights to understand and control how your health information is used. Federal HIPAA Omnibus Rule and state law provide penalties for covered entities, business associates, and their subcontractors and records owners, respectively that misuse or improperly disclose PHI. Starting April 14, 2003, HIPAA requires us to provide you with the Notice of our legal duties and the privacy practices we are required to follow when you first come into our office for health‐care services. If you have any questions about this Notice, please ask to speak to our HIPAA Privacy Officer.
Our doctors, clinical staff, employees, Business Associates (outside contractors we hire), their subcontractors and other involved parties follow the policies and procedures set forth in this Notice. If at this facility, your primary caretaker / doctor is unavailable to assist you (i.e. illness, on call coverage, vacation, etc.), we may provide you with the name of another healthcare provider outside our practice for you to consult with. If we do so, that provider will follow the policies and procedures set forth in this Notice or those established for his or her practice, so long as they substantially conform to those for our practice.
OUR RULES ON HOW WE MAY USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION
Under the law, we must have your signature on a written, dated Consent Form and/or an Authorization Form of Acknowledgement of this Notice, before we will use or disclose your PHI for certain purposes as detailed in the rulesbelow.
DocumentationYou will be asked to sign an Authorization / Acknowledgement form when you receive this Notice of Privacy Practices. If you did not sign such a form or need a copy of the one you signed, please contact our Privacy Officer. You may take back or revoke your consent or authorization at any time (unless we already have acted based on it) by submitting our Revocation Form in writing to us at our address listed above. Your revocation will take effect when we actually receive it. We cannot give it retroactive effect, so it will not affect any use or disclosure that occurred in our reliance on your Consent or Authorization prior to revocation (i.e. if after we provide services to you, you revoke your authorization / acknowledgement in order to prevent us billing or collecting for those services, your revocation will have no effect because we relied on your authorization/ acknowledgement to provide services before you revoked it).
General RuleIf you do not sign our authorization/ acknowledgement form or if you revoke it, as a general rule (subject to exceptions described below under “Healthcare Treatment, Payment and Operations Rule” and “Special Rules”), we cannot in any manner use or disclose to anyone (excluding you, but including payers and Business Associates) your PHI or any other information in your medical record. By law, we are unable to submit claims to payers under assignment of benefits without your signature on our authorization/ acknowledgement form. You will however be able to restrict disclosures to your insurance carrier for services for which you wish to pay “out of pocket” under the new Omnibus Rule. We will not condition treatment on you signing an authorization / acknowledgement, but we may be forced to decline you as a new patient or discontinue you as an active patient if you choose not to sign the authorization/ acknowledgement or revoke it.
Healthcare Treatment, Payment and Operations RuleWith your signed consent, we may use or disclose your PHI in order:
Additionally, you should be made aware of these protection laws on your behalf, under the new HIPAA Omnibus Rule:
Special RulesNotwithstanding anything else contained in this Notice, only in accordance with applicable HIPAA Omnibus Rule, and under strictly limited circumstances, we may use or disclose your PHI without your permission, consent or authorization for the following purposes:
Minimum Necessary RuleOur staff will not use or access your PHI unless it is necessary to do their jobs (i.e. doctors uninvolved in your care will not access your PHI; ancillary clinical staff caring for you will not access your billing information; billing staff will not access your PHI except as needed to complete the claim form for the latest visit; janitorial staff will not access your PHI). All of our team members are trained in HIPAA Privacy rules and sign strict Confidentiality Contracts with regards to protecting and keeping private your PHI. So do our Business Associates and their Subcontractors. Know that your PHI is protected several layers deep with regards to our business relations. Also, we disclose to others outside our staff, only as much of your PHI as is necessary to accomplish the recipient’s lawful purposes. Still in certain cases, we may use and disclose the entire contents of your medical record:
In accordance with HIPAA law, we presume that requests for disclosure of PHI from another Covered Entity (as defined in HIPAA) are for the minimum necessary amount of PHI to accomplish the requestor’s purpose. Our Privacy Officer will individually review unusual or non‐recurring requests for PHI to determine the minimum necessary amount of PHI and disclose only that. For non‐routine requests or disclosures, our Privacy Officer will make a minimum necessary determination based on, but not limited to, the following factors:
Incidental Disclosure RuleWe will take reasonable administrative, technical and security safeguards to ensure the privacy of your PHI when we use or disclose it (i.e. we shred all paper containing PHI, require employees to speak with privacy precautions when discussing PHI with you, we use computer passwords and change them periodically (i.e. when an employee leaves us), we use firewall and router protection to the federal standard, we back up our PHI data off‐site and encrypted to federal standard, we do not allow unauthorized access to areas where PHI is stored or filed and/or we have any unsupervised business associates sign Business Associate Confidentiality Agreements).
However, in the event that there is a breach in protecting your PHI, we will follow Federal Guide Lines to HIPAA Omnibus Rule Standard to first evaluate the breach situation using the Omnibus Rule, 4‐Factor Formula for Breach Assessment. Then we will document the situation, retain copies of the situation on file, and report all breaches (other than low probability as prescribed by the Omnibus Rule) to the US Department of Health and Human Services at: http://www.hhs.gov/ocr/privacy/hipaa/administrative/breachnotificationrule/brinstruction.html
We will also make proper notification to you and any other parties of significance as required by HIPAA Law.
Business Associate RuleBusiness Associates are defined as: an entity, (non‐employee) that in the course of their work will directly / indirectly use, transmit, view, transport, hear, interpret, process or offer PHI for this Facility.
Business Associates and other third parties (if any) that receive your PHI from us will be prohibited from re‐disclosing it unless required to do so by law or you give prior express written consent to the re‐disclosure. Nothing in our Business Associate agreement will allow our Business Associate to violate this re‐disclosure prohibition. Under Omnibus Rule, Business Associates will sign a strict confidentiality agreement binding them to keep your PHI protected and report any compromise of such information to us, you and the United States Department of Health and Human Services, as well as other required entities. Our Business Associates will also follow Omnibus Rule and have any of their Subcontractors that may directly or indirectly have contact with your PHI, sign Confidentiality Agreements to Federal Omnibus Standard.
Super‐confidential Information RuleIf we have PHI about you regarding communicable diseases, disease testing, alcohol or substance abuse diagnosis and treatment, or psychotherapy and mental health records (super‐confidential information under the law), we will not disclose it under the General or Healthcare Treatment, Payment and Operations Rules (see above) without your first signing and properly completing our Consent form (i.e. you specifically must initial the type of super‐confidential information we are allowed to disclose). If you do not specifically authorize disclosure by initialing the super‐confidential information, we will not disclose it unless authorized under the Special Rules (see above) (i.e. we are required by law to disclose it). If we disclose super‐confidential information (either because you have initialed the consent form or the Special Rules authorizing us to do so), we will comply with state and federal law that requires us to warn the recipient in writing that re‐disclosure is prohibited.
Changes to Privacy Policies RuleWe reserve the right to change our privacy practices (by changing the terms of this Notice) at any time as authorized by law. The changes will be effective immediately upon us making them. They will apply to all PHI we create or receive in the future, as well as to all PHI created or received by us in the past (i.e. to PHI about you that we had before the changes took effect). If we make changes, we will post the changed Notice, along with its effective date, in our office and on our website. Also, upon request, you will be given a copy of our current Notice.
Authorization RuleWe will not use or disclose your PHI for any purpose or to any person other than as stated in the rules above without your signature on our specifically worded, written Authorization / Acknowledgement Form (not a Consent or an Acknowledgement). If we need your Authorization, we must obtain it via a specific Authorization Form, which may be separate from any Authorization / Acknowledgement we may have obtained from you. We will not condition your treatment here on whether you sign the Authorization (or not).
Limitations on the disclosure of PHI regarding Remuneration
The disclosure or sale of your PHI without authorization is prohibited. Under the new HIPAA Omnibus Rule, this would exclude disclosures for public health purposes, for treatment / payment for healthcare, for the sale, transfer, merger, or consolidation of all or part of this facility and for related due diligence, to any of our Business Associates, in connection with the business associate’s performance of activities for this facility, to a patient or beneficiary upon request, and as required by law. In addition, the disclosure of your PHI for research purposes or for any other purpose permitted by HIPAA will not be considered a prohibited disclosure if the only reimbursement received is “a reasonable, cost‐based fee” to cover the cost to prepare and transmit your PHI which would be expressly permitted by law. Notably, under the Omnibus Rule, an authorization to disclose PHI must state that the disclosure will result in remuneration to the Covered Entity. Notwithstanding the changes in the Omnibus Rule, the disclosure of limited data sets (a form of PHI with a number of identifiers removed in accordance with specific HIPAA requirements) for remuneration pursuant to existing agreements is permissible until September 22, 2014, so long as the agreement is not modified within one year before that date.
Limitation on the Use of PHI for Paid MarketingWe will, in accordance with Federal and State Laws, obtain your written authorization to use or disclose your PHI for marketing purposes, (i.e.: to use your photo in ads) but not for activities that constitute treatment or healthcare operations. To clarify, Marketing is defined by HIPAA’s Omnibus Rule, as “a communication about a product or service that encourages recipients . . . to purchase or use the product or service.” Under the Omnibus Rule, we will obtain a written authorization from you prior to recommending you to an alternative therapist, or non‐associated Healthcare Covered Entity.
Under Omnibus Rule we will obtain your written authorization prior to using your PHI or making any treatment or healthcare recommendations, should financial remuneration for making the communication be involved from a third party whose product or service we might promote (i.e.: businesses offering this facility incentives to promote their products or services to you). This will also apply to our Business Associate who may receive such remuneration for making a treatment or healthcare recommendations to you. All such recommendations will be limited without your expressed written permission.
We must clarify to you that financial remuneration does not include “as in‐kind payments” and payments for a purpose to implement a disease management program. Any promotional gifts of nominal value are not subject to the authorization requirement, and we will abide by the set terms of the law to accept or reject these.
The only exclusion to this would include: “refill reminders”, so long as the remuneration for making such a communication is “reasonably related to our cost” for making such a communication. In accordance with law, this facility and our Business Associates will only ever seek reimbursement from you for permissible costs that include: labor, supplies, and postage. Please note that “generic equivalents”, “adherence to take medication as directed” and “self‐administered drug or delivery system communications” are all considered to be “refill reminders.”
Face‐to‐face marketing communications, such as sharing with you, a written product brochure or pamphlet, is permissible under current HIPAA Law.
Flexibility on the Use of PHI for Fundraising
Under the HIPAA Omnibus Rule use of PHI is more flexible and does not require your authorization should we choose to include you in any fund‐raising efforts attempted at this facility? However, we will offer the opportunity for you to “optout” of receiving future fundraising communications. Simply let us know that you want to “opt out” of such situations. There will be a statement on your HIPAA Patient Acknowledgement Form where you can choose to “opt out”. Our\ commitment to care and treat you will in no way effect your decision to participate or not participate in our fund‐raising efforts.
Improvements to Requirements for Authorizations Related to ResearchUnder HIPAA Omnibus Rule, we may seek authorizations from you for the use of your PHI for future research. However, we would have to make clear what those uses are in detail.
Also, if we request of you a compound authorization with regards to research, this facility would clarify that when a compound authorization is used, and research related treatment is conditioned upon your authorization, the compoundauthorization will differentiate between the conditioned and unconditioned components.
If you got this Notice via email or website, you have the right to get, at any time, a paper copy by asking our Privacy Officer. Also, you have the following additional rights regarding PHI we maintain about you:
To Inspect and CopyYou have the right to see and get a copy of your PHI including, but not limited to, medical and billing records by submitting a written request to our Privacy Officer. Original records will not leave the premises, will be available for inspection only during our regular business hours, and only if our Privacy Officer is present at all times. You may ask us to give you the copies in a format other than photocopies (and we will do so unless we determine that it is impractical) or ask us to prepare a summary in lieu of the copies. We may charge you a fee not to exceed state law to recover our costs (including postage, supplies, and staff time as applicable, but excluding staff time for search and retrieval) to duplicate or summarize your PHI. We will not condition release of the copies on summary of payment of your outstanding balance for professional services if you have one). We will comply with Federal Law to provide your PHI in an electronic format within the 30 days, to Federal specification, when you provide us with proper written request. Paper copy will also be made available. We will respond to requests in a timely manner, without delay for legal review, or, in less than thirty days if submitted in writing, and in ten business days or less if malpractice litigation or pre‐suit production is involved. We may deny your request in certain limited circumstances (i.e. we do not have the PHI, it came from a confidential source, etc.). If we deny your request, you may ask for a review of that decision. If required by law, we will select a licensed health‐care professional (other than the person who denied your request initially) to review the denial and we will follow his or her decision. If we select a licensed healthcare professional who is not affiliated with us, we will ensure a Business Associate Agreement is executed that prevents re‐disclosure of your PHI without your consent by that outside professional.
To Request Amendment / CorrectionIf another doctor involved in your care tells us in writing to change your PHI, we will do so as expeditiously as possible upon receipt of the changes and will send you written confirmation that we have made the changes. If you think PHI we have about you is incorrect, or that something important is missing from your records, you may ask us to amend or correct it (so long as we have it) by submitting a “Request for Amendment / Correction” form to our Privacy Officer. We will act on your request within 30 days from receipt but we may extend our response time (within the 30‐day period) no more than once and by no more than 30 days, or as per Federal Law allowances, in which case we will notify you in writing why and when we will be able to respond. If we grant your request, we will let you know within five business days, make the changes by noting (not deleting) what is incorrect or incomplete and adding to it the changed language, and send the changes within 5 business days to persons you ask us to and persons we know may rely on incorrect or incomplete PHI to your detriment (or already have). We may deny your request under certain circumstances (i.e. it is not in writing, it does not give a reason why you want the change, we did not create the PHI you want changed (and the entity that did can be contacted), it was compiled for use in litigation, or we determine it is accurate and complete). If we deny your request, we will (in writing within 5 business days) tell you why and how to file a complaint with us if you disagree, that you may submit a written disagreement with our denial (and we may submit a written rebuttal and give you a copy of it), that you may ask us to disclose your initial request and our denial when we make future disclosure of PHI pertaining to your request, and that you may complain to us and the U.S. Department of Health and Human Services.
To an Accounting of DisclosuresYou may ask us for a list of those who got your PHI from us by submitting a “Request for Accounting of Disclosures” form to us. The list will not cover some disclosures (i.e. PHI given to you, given to your legal representative, given to others for treatment, payment or HealthCare operations purposes). Your request must state in what form you want the list (i.e. paper or electronically) and the time period you want us to cover, which may be up to but not more than the last six years (excluding dates before April 14, 2003). If you ask us for this list more than once in a 12‐month period, we may charge you a reasonable, cost based fee to respond, in which case we will tell you the cost before we incur it and let you choose if you want to withdraw or modify your request to avoid the cost.
To Request RestrictionsYou may ask us to limit how your PHI is used and disclosed (i.e. in addition to our rules as set forth in this Notice) by submitting a written “Request for Restrictions on Use, Disclosure” form to us (i.e. you may not want us to disclose your surgery to family members or friends involved in paying for our services or providing your home care). If we agree to these additional limitations, we will follow them except in an emergency where we will not have time to check for limitations. Also, in some circumstances we may be unable to grant your request (i.e. we are required by law to use or disclose your PHI in a manner that you want restricted, you signed an Authorization Form, which you may revoke, that allows us to use or disclose your PHI in the manner you want restricted; in an emergency).
To Request Alternative CommunicationsYou may ask us to communicate with you in a different way or at a different place by submitting a written “Request for Alternative Communication” Form to us. We will not ask you why and we will accommodate all reasonable requests (which may include: to send appointment reminders in closed envelopes rather than by postcards, to send your PHI to a post office box instead of your home address, to communicate with you at a telephone number other than your home number). You must tell us the alternative means or location you want us to use and explain to our satisfaction how payment to us will be made if we communicate with you as you request.
To Complain or Get More InformationWe will follow our rules as set forth in this Notice. If you want more information or if you believe your privacy rights have been violated (i.e. you disagree with a decision of ours about inspection / copying, amendment / correction, accounting of disclosures, restrictions or alternative communications), we want to make it right. We never will penalize you for filing a complaint. To do so, please file a formal, written complaint within 180 days with:
The U.S. Department of Health & Human ServicesOffice of Civil Rights200 Independence Ave., S.W.Washington, DC 202011‐877‐696‐6775
Or, submit a written Complaint form to us at the following address:
Our Privacy Officer:Yvonne HubbardOregon Community Programs1170 Pearl StreetEugene, OR 97401
Office Phone: 541‐743‐4340Office Fax: 541‐743‐4369Email Address: email@example.com
You may get your “HIPAA Complaint” form by calling our privacy officer. These privacy practices are in accordance with the original HIPAA enforcement effective April 14, 2003, and undated to Omnibus Rule effective March 26, 2013 and will remain in effect until we replace them as specified by Federal and/or State Law.
I am the parent or legal guardian and I hereby give my informed consent to treatment.
Leave this empty:
Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: Outpatient - Opening Consents
Agree & Sign