Supportinc.org
CHESTNUT OFFICE Intake Checklist
**PLEASE TURN IN DOCUMENTATION IN THE SAME ORDER THAT APPEARS ON THIS CHECKLIST**
|Date of Intake: ____________ Intake QMHP:_______________ Evaluation Clinician: ________________ |
|Service Referred To: _______________________________________________ |
|Future appointment dates, times, and name of provider/clinician: ____________________________________________________________ |
Front Desk Staff
|Required Task |Yes |No |N/A |Comments |
|Provide client/guardian with all 3 consumer handbooks | | | | |
|Obtain copy of insurance card, birth certificate, and proof of guardianship (if necessary) and | | | | |
|attach to intake packet | | | | |
|Verify client/guardian address, phone number(s), etc. | | | | |
|Pass off printed intake packet to evaluating clinician for completion | | | | |
Evaluation Clinician
|Required Task |Yes |No |N/A |Comments |
|Complete Consumer Choice form with client | | | | |
|Check appropriate boxes (what services client will be receiving from Support, Inc.) at the top of | | | | |
|the Consent for Services form and have client/guardian sign the form | | | | |
|Complete High Risk Survey, if applicable, and enter data into the web-based system at: | | | |No hard copy needs to be completed if internet access|
|s/supporthighrisksurvey | | | |is available during intake appointment |
|Ensure all FACE Sheet sections are completed | | | |NO BLANK FIELDS ARE ALLOWED ON THIS PAGE |
|Complete Assignment of Benefits form with client/guardian and ensure all insurance information is | | | | |
|listed | | | | |
|Ensure client/guardian has completed and signed all other intake paperwork and review specific | | | |Answer any questions the client/guardian has about |
|forms, as appropriate | | | |intake paperwork; don’t forget to have the |
| | | | |client/guardian sign the Treatment Plan Signature |
| | | | |page if recommending outpatient or school-based |
| | | | |therapy |
|Sign as a witness on all intake paperwork, as indicated on the forms | | | | |
|Call the front desk to schedule outpatient therapy and/or medication management appointments, as | | | |If you are recommending an enhanced service, please |
|needed | | | |tell the family that staff from the receiving |
| | | | |department will contact them as soon as possible to |
| | | | |initiate treatment; please also ensure outpatient |
| | | | |therapy appointments are scheduled for treatment to |
| | | | |begin within 5-10 days of intake appointment |
|Review IIH Description form with parent/guardian and have guardian sign the form | | | |ONLY IF RECOMMENDING INTENSIVE IN-HOME SERVICES |
|Complete AIMS testing | | | |ONLY IF CONSUMER IS CURRENTLY TAKING AN ANTIPSYCHOTIC|
| | | | |MEDICATION |
|Provide consumer or caretaker with crisis line information card | | | | |
|Obtain client/guardian signature on evaluation signature page | | | | |
|Provide client/guardian with the medication management referral packet, if applicable | | | |Packet should include the appropriate scales |
|Add Treatment Plan goals to the appropriate widgets within the consumer’s chart in Patagonia | | | | |
|Place Treatment Plan Signature Page into the appropriate Intake QP’s box | | | |ONLY IF RECOMMENDING A BASIC SERVICE |
|Give all signed intake paperwork to Candy for review and processing | | | | |
|Input all diagnoses into the Problems List widget of Patagonia | | | | |
|Complete Enrollment in Alpha MCS system, if needed. Inform administrative staff of client’s record | | | |This is typically only needed if the consumer is |
|number once obtained. Be sure to update Record # in Patagonia to reflect assigned Alpha number | | | |using IPRS funding and has never received services |
| | | | |before (Please call Donna Beasely @ 704-842-6416 if |
| | | | |you have difficulty accessing a record #) |
|Type referral date & source, insurance type & #, intake team, stakeholders, recommendations for | | | |Do this immediately upon completion of the evaluation|
|Support & services being referred to outside providers in comments section of Patient Details | | | |appointment |
|screen | | | | |
|Complete symptoms & observations, diagnosis, and recommendations on the same date of the evaluation| | | |ONLY IF RECOMMENDING ENHANCED SERVICES |
|appointment and send this draft of the Clinical Evaluation in an e-mail with the subject as | | | | |
|“Record # DRAFT” to Michaele Conners, Ashley Trudnak, and the supervisor of the receiving | | | | |
|department (Rozzie Fuller- IIH; Nancy Henley, Kiana Boatwright, John Jenson, Sam Rosen- DTX; Emily | | | | |
|McGuire- TFC), and assigned OPT/SBT therapist; include detailed information in e-mail on what is | | | | |
|attached, any updates or safety issues with client, state the name of referring agency (if any, | | | | |
|this is so receiving staff can obtain PCP) and whether the client is involved with DJJ, DSS, or is | | | | |
|considered high risk | | | | |
|Complete changes/corrections according to Michaele’s feedback and e-mail final version with the | | | | |
|subject “Record # FINAL” to Michaele Conners and Candy McKinney | | | | |
|Complete LOCUS or CALOCUS worksheet | | | |Attach this to the final, signed clinicial evaluation|
|Complete and sign Transfer/Referral/Assignment form and attach to completed Clinical Evaluation for| | | |Intake Administrative staff or Intake QP will obtain |
|processing | | | |supervisor signature on the |
| | | | |Transfer/Referral/Assignment form |
|E-mail Clinical Evaluation and Transfer/Referral/Assignment Form to intake administrative staff | | | | |
|immediately upon completion | | | | |
|Give hard copy of Clinical Evaluation with signatures and completed Transfer/Referral/Assignment | | | | |
|form to intake administrative staff immediately upon completion | | | | |
Administrative Staff
|CONSENTS |
|Consent for Services/Emergency Treatment | | | | | |
|Insurance Verification/Assignment of Benefits/Payment Agreement | | | | | |
|Annual Fee Evaluation Data Collection Form and Financial Agreement| | | | | |
|Statement | | | | | |
|Client Rights | | | | | |
|FACE Sheet | | | | | |
|Notice of Privacy Practices/ Assurance of Confidentiality | | | | | |
|Record of Consent & Acknowledgement of Support, Inc. Operations | | | | | |
|Authorizations for: | | | | | |
|Primary Care | | | | | |
|School | | | | | |
|DSS/DJJ | | | | | |
|Hospital | | | | | |
|Other mental health agencies | | | | | |
|Any spouse, stepparent, or other individual | | | | | |
|Partners | | | | | |
|CCNC | | | | | |
|Consumer Choice | | | | | |
|Client Orientation | | | | | |
|Medication Management Policies | | | | |Required if client is going to be receiving psychiatric |
| | | | | |services from Support, Inc. |
|Required Task |Yes |No |N/A |Comments |
|Create consumer’s chart in Valant EMR system | | | |Create consumer’s chart in Valant EMR system |
|Fax Consent for Services and Emergency Treatment Form to Carol McManus at 704-852-3129 | | | |ONLY FOR DJJ INVOLVED CONSUMERS |
| | | | |(See Patagonia chart for involvement status) |
|Ensure all documents have been completed and headers are correct and complete on every | | | |Correct name, insurance type & #, DOB, & client # |
|page | | | |must be on all documentation before uploading to |
| | | | |chart |
|Ensure all diagnoses listed on the clinical evaluation are in the Problems List widget | | | |Make sure diagnosis dates are correct and a primary |
|in the consumer’s Patagonia chart | | | |diagnosis is marked for the first listed diagnosis |
|Scan all intake paperwork and upload into consumer’s Patagonia and Valant charts | | | |Must be uploaded into chart within 24 hours of intake|
| | | | |appointment |
|Scan Clinical Evaluations with all signatures and upload into consumer’s Patagonia and | | | | |
|Valant charts | | | | |
|Input the full name of the consumer’s current school in the “Employer” field of the | | | | |
|“Patient” tab of the Patient Details screen in Patagonia | | | | |
|Input current insurance information into the “Insurance” tab of the Patient Details | | | |ONLY input information for NCHC, Medicaid, or IPRS |
|screen in Patagonia | | | |consumers; private insurance plans will be entered by|
| | | | |the billing department |
|Input the consumer’s Primary Care Physician information into the “Providers” tab of the | | | | |
|Patient Details screen | | | | |
|Attach together Behavioral Health Agency Request for Information form, copy of the | | | |Signed copies of this form will be given to the front|
|primary care consent, a copy of last 3 pages of Clinical Evaluation, and Accounting of | | | |desk staff to fax to primary care providers |
|Disclosure form and give to front desk staff | | | | |
|Pass on Transfer/Referral/Assignment Form to Intake QP for final signature to then be | | | |FOR BASIC SERVICES ONLY |
|passed on to the new case responsible staff person/department supervisor | | | | |
|Pass on Transfer/Referral/Assignment Form to Michaele Conners for final signature to | | | |ONLY IF RECOMMENDING ENHANCED SERVICES |
|then be passed on to the new case responsible department supervisor | | | | |
|Submit hard copies of all completed documentation to Medical Records for filing | | | | |
|Send “New Consumer Referral Notification” e-mail with the Clinical Evaluation and | | | |Include the following information in the e-mail: |
|Transfer/Referral/Assignment form attached as Word documents to the new case responsible| | | |Current record number, “Clinical Evaluation has also |
|staff and that staff member’s supervisor (if new case responsible staff person is | | | |been uploaded into Patagonia,” insurance type, any |
|unknown, just send to program supervisor and indicate the case needs to be assigned); | | | |appointments that have been scheduled or need to be |
|always include quality.improvement@, and ben.johnson@ on | | | |scheduled, any DSS or DJJ involvement, whether there |
|these e-mails; if basic services are recommended, also include the appropriate Intake QP| | | |are any stakeholders that need intake follow-up |
|on this e-mail | | | |information, whether the consumer is high risk or |
| | | | |not, and whether an NC TOPPS is required |
|Complete Referred Out/Dr Only Information form and turn completed packet into Michaele | | | |ONLY IF CONSUMER IS BEING REFERRED OUT OR WILL BE |
|Conners | | | |CONSIDERED A DOCTOR ONLY CONSUMER |
|Send a transfer e-mail to michaele.conners@, | | | |ONLY IF CONSUMER IS BEING REFERRED OUT OR WILL BE |
|quality.improvement@ and billing@ with the Referred Out/Dr. | | | |CONSIDERED A DOCTOR ONLY CONSUMER |
|Only Information form attached; in the body of the e-mail, please state what agency the | | | | |
|consumer is being referred to and what services he or she will be receiving | | | | |
Intake QP (to complete ONLY if basic services are recommended)
|Required Task |Yes |No |N/A |Comments |
|Obtain service order | | | | |
|If client is already enrolled in Alpha system, complete Client Update. On clinical page, | | | |If no target pop is necessary or there are no current|
|update diagnoses, target pop (for IPRS services only), and current medications | | | |medications, note in comments box on Client Update |
| | | | |page |
|Fax Partners Authorization for Use and Disclosure of NC TOPPS information to 704-884-2710 | | | |You only need to do this if the consumer is coming |
| | | | |from another provider AND has an open NC TOPPS with |
| | | | |that provider |
|Scan signed treatment plan and upload it to the consumer’s chart in Patagonia | | | | |
|Complete authorization: SAR in Alpha for Medicaid or IPRS consumers, ORF in ValueOptions for| | | | |
|NCHC consumers | | | | |
|Enter authorization requested, as appropriate, in client’s Patagonia chart. | | | | |
|Complete Accounting of Disclosure form for PCP, Clinical Evaluation, or other documentation | | | | |
|distributed to Partners BHM, ValueOptions, or any other agency | | | | |
|Place Treatment Plan Signature Page into the receiving clinician’s box | | | | |
|Add the service and provider to the Service Enrollment tab of the consumer’s Patagonia Chart| | | |This is a tab within the Patient Details screen |
|Submit remaining documentation (SAR letter, etc.) to medical records for filing | | | | |
|Email password protected Evaluation with Treatment Plan to: Identified therapist, Michaele | | | | |
|Conners, quality.improvement@, billing@. Indicate what services | | | | |
|client will be receiving and with what provider, any scheduled appts, SAR start & end date, | | | | |
|# of units requested of each code, if client is high risk & why, if NCTOPPS must be | | | | |
|completed (OR if you have had a previous NC TOPPS transferred to us from another provider), | | | | |
|and anything receiving person must do/complete in the body of email. Subject of email | | | | |
|should be client ID and services to be received at Support, Inc. | | | | |
OFF-SITE Intake Checklist
**PLEASE TURN IN DOCUMENTATION IN THE SAME ORDER THAT APPEARS ON THIS CHECKLIST**
|Date of Intake: ____________ Intake QMHP:_______________ Evaluation Clinician: ________________ |
|Service Referred To: _______________________________________________ |
|Future appointment dates, times, and name of provider/clinician: ____________________________________________________________ |
Evaluation Clinician
|Required Task |Yes |No |N/A |Comments |
|Obtain copy of insurance card, birth certificate, SS card, and any proof of | | | | |
|guardianship (if needed) and attach to intake packet | | | | |
|COMPLETE THE FOLLOWING DOCUMENTATION: |--- |--- |--- | |
|Consent for Services/Emergency Treatment | | | | |
|Insurance Verification/Assignment of Benefits/Payment Agreement | | | | |
|Annual Fee Evaluation Data Collection Form and Financial Agreement Statement | | | | |
|Client Rights | | | | |
|FACE Sheet | | | | |
|Notice of Privacy Practices/Assurance of Confidentiality | | | | |
|Record of Consent & Acknowledgement of Support, Inc. Operations | | | | |
|Authorizations for: | | | |*You only need to get the Partners NC TOPPS transfer|
|Hospital | | | |authorization signed if the consumer is coming from |
|Primary Care | | | |another provider AND has an open NC TOPPS with that |
|School | | | |provider |
|DSS/DJJ | | | | |
|Other mental health agencies | | | | |
|Any spouse, stepparent, or other individual | | | | |
|Partners | | | | |
|Consumer Choice | | | | |
|Client Orientation | | | | |
|Medication Management Policies | | | |Required if client is going to be receiving |
| | | | |psychiatric services from Support, Inc. |
|Obtain client/guardian signature on evaluation signature page | | | | |
|Obtain client/guardian signatures on Treatment Plan Signature Page | | | |ONLY IF RECOMMENDING BASIC SERVICES |
|Complete High Risk Survey, if applicable, and enter data into the web-based system | | | |No hard copy needs to be completed if internet |
|at: s/supporthighrisksurvey | | | |access is available during intake appointment |
|Review IIH Description form with parent/guardian if IIH is being recommended, have | | | |ONLY IF RECOMMENDING INTENSIVE IN-HOME SERVICES |
|guardian | | | | |
|Ensure all paperwork is signed and correct before consumer/parent leaves building | | | | |
|Call front desk to schedule outpatient therapy and/or medication management | | | |If you are recommending an enhanced service, please |
|appointments, as needed | | | |tell the family that staff from the receiving |
| | | | |department will contact them as soon as possible to |
| | | | |initiate treatment; please also ensure outpatient |
| | | | |therapy appointments are scheduled for treatment to |
| | | | |begin within 5-10 days of intake appointment |
|Provide client/guardian with the medication management referral packet, if | | | |Packet should include the appropriate scales |
|applicable | | | | |
|Provide client or guardian with all 3 consumer handbooks | | | | |
|Provide consumer or caretaker with crisis line information card | | | | |
|Place Treatment Plan Signature Page into the appropriate Intake QP’s box | | | |ONLY IF RECOMMENDING A BASIC SERVICE |
|Give all signed intake paperwork to Candy for review and processing | | | | |
|Add Treatment Plan goals to the appropriate widget within the consumer’s Patagonia | | | |ONLY IF RECOMMENDED A BASIC SERVICE |
|chart | | | | |
|Input all diagnoses into the Problems List widget of Patagonia | | | | |
|Complete Enrollment in Alpha MCS system, if needed. Inform administrative staff of | | | |This is typically only needed if the consumer is |
|client’s record number once obtained. Be sure to update Record # in Patagonia to | | | |using IPRS funding and has never received services |
|reflect assigned Alpha number | | | |before (Please call Donna Beasely @ 704-842-6416 if |
| | | | |you have difficulty accessing a record #) |
|Type referral date & source, insurance type & #, intake team, stakeholders, | | | |Do this immediately upon completion of the |
|recommendations for Support & services being referred to outside providers in | | | |evaluation appointment |
|comments section of Patient Details screen | | | | |
|Complete symptoms & observations, diagnosis, and recommendations on the same date of| | | |ONLY IF RECOMMENDING ENHANCED SERVICE TO BE PROVIDED|
|the evaluation appointment and send this draft of the Clinical Evaluation in an | | | |BY SUPPORT, INC. |
|e-mail with the subject as “Record # DRAFT” to Michaele Conners, Ashley Trudnak, and| | | | |
|the supervisor of the receiving department (Rozzie Fuller- IIH, Nancy Henley- | | | | |
|Lincoln DTX, Donna Conner- Gaston DTX, Emily McGuire- TFC), include detailed | | | | |
|information in e-mail on what is attached, any updates or safety issues with client,| | | | |
|state the name of referring agency (if any, this is so receiving staff can obtain | | | | |
|PCP) and whether the client is involved with DJJ, DSS, or is considered high risk | | | | |
|Complete changes/corrections according to Michaele’s feedback and e-mail final | | | | |
|version with the subject “Record # FINAL” to Michaele Conners and Candy McKinney | | | | |
|Complete LOCUS or CALOCUS worksheet | | | |Attach this to the final, signed clinical evaluation|
|Copy of insurance card, Insurance Verification/Assignment of Benefits/Payment | | | |Must be faxed the same day as the intake takes place|
|Agreement and Annual Fee Evaluation Data Collection Form and Financial Agreement | | | | |
|Statement forms faxed to billing (704- 867-0638) | | | | |
|Make a copy of Consent for Services and Emergency Treatment Form and place it in | | | |ONLY FOR DJJ INVOLVED CONSUMERS |
|Carol McManus’ box at Gaston DJJ | | | | |
|Complete and sign Transfer/Referral/Assignment form and attach to completed Clinical| | | |Intake Administrative staff or Intake QP will obtain|
|Evaluation for processing | | | |supervisor signature on the |
| | | | |Transfer/Referral/Assignment form |
|E-mail Clinical Evaluation and Transfer/Referral/Assignment Form to intake | | | | |
|administrative staff immediately upon completion | | | | |
|Give hard copy of Clinical Evaluation with all signatures, signed documentation, and| | | | |
|completed Transfer/Referral/Assignment form to intake administrative staff | | | | |
|immediately upon completion | | | | |
Administrative Staff
|Required Task |Yes |No |N/A |Comments |
|Ensure all documents have been completed and headers are correct and complete on every | | | |Correct name, insurance type & #, DOB, and client # |
|page | | | |must be on all documentation before passing it on to |
| | | | |Intake QP or receiving department |
|Ensure all diagnoses listed on the clinical evaluation are in the Problems List widget | | | |Make sure diagnosis dates are correct and a primary |
|in the consumer’s Patagonia chart | | | |diagnosis is marked for the first listed diagnosis |
|Create consumer’s chart in Valant EMR system | | | | |
|Scan all intake paperwork and upload into consumer’s Patagonia and Valant charts | | | |Must be uploaded into chart within 24 hours of intake|
| | | | |appointment |
|Scan Clinical Evaluation with all signatures and upload into consumer’s Patagonia and | | | | |
|Valant charts | | | | |
|Input the full name of the consumer’s current school in the “Employer” field of the | | | | |
|“Patient” tab of the Patient Details screen in Patagonia | | | | |
|Input the current insurance information into the “Insurance” tab of the Patient Details | | | |ONLY input information for NCHC, Medicaid, or IPRS |
|screen | | | |consumers; private insurance plans will be entered by|
| | | | |the billing department |
|Input the consumer’s Primary Care Physician information into the “Providers” tab of the | | | | |
|Patient Details screen | | | | |
|Attach together Behavioral Health Agency Request for Information form, copy of the | | | |Signed copies of this form will be given to the front|
|primary care consent, a copy of last 3 pages of Clinical Evaluation, and Accounting of | | | |desk staff to fax to primary care providers |
|Disclosure form and place in Dr. Melendez’s pending paperwork basket | | | | |
|Pass on Transfer/Referral/Assignment Form to Michaele Conners for final signature to | | | |ONLY IF RECOMMENDING ENHANCED SERVICES |
|then be passed on to the new case responsible department supervisor | | | | |
|Pass on Transfer/Referral/Assignment Form to Intake QP for final signature to then be | | | |ONLY IF RECOMMENDING BASIC SERVICES |
|passed on to the new case responsible clinician | | | | |
|Submit hard copies of all completed documentation to Medical Records for filing | | | | |
|Send “New Consumer Referral Notification” e-mail with the Clinical Evaluation and | | | |Include the following information in the e-mail: |
|Transfer/Referral/Assignment form attached as Word documents to the new case responsible| | | |Current record number, “Clinical Evaluation has also |
|staff and that staff member’s supervisor (if new case responsible staff person is | | | |been uploaded into Patagonia,” insurance type, any |
|unknown, just send to program supervisor and indicate the case needs to be assigned); | | | |appointments that have been scheduled or need to be |
|always include quality.improvement@, and ben.johnson@ on | | | |scheduled, any DSS or DJJ involvement, whether there |
|these e-mails; if basic services are recommended, also include the appropriate Intake QP| | | |are any stakeholders that need intake follow-up |
|on this e-mail | | | |information, whether the consumer is high risk or |
| | | | |not, and whether an NC TOPPS is required |
|Complete Referred Out/Dr Only Information form and turn completed packet into Michaele | | | |ONLY IF CONSUMER IS BEING REFERRED OUT OR WILL BE |
|Conners | | | |CONSIDERED A DOCTOR ONLY CONSUMER |
|Send a transfer e-mail to michaele.conners@, | | | |ONLY IF CONSUMER IS BEING REFERRED OUT OR WILL BE |
|quality.improvement@, and billing@ with the Referred Out/Dr.| | | |CONSIDERED A DOCTOR ONLY CONSUMER |
|Only Information form attached; in the body of the e-mail, please state what agency the | | | | |
|consumer is being referred to and what services he or she will be receiving | | | | |
Intake QP (to complete ONLY if basic services are recommended)
|Required Task |Yes |No |N/A |Comments |
|Obtain service order | | | | |
|If client is already enrolled in Alpha system, complete Client Update. On clinical page, | | | |If no target pop is necessary or there are no current|
|update diagnoses, target pop (for IPRS services only), and current medications | | | |medications, note in comments box on Client Update |
| | | | |page |
|Fax Partners Authorization for Use and Disclosure for NC TOPPS info to 704-884-2710 | | | |You only need to do this if the consumer is coming |
| | | | |from another provider AND has an open NC TOPPS with |
| | | | |that provider; you can find the authorization |
| | | | |uploaded in the Patagonia chart |
|Scan signed treatment plan and upload to the consumer’s chart in Patagonia. | | | | |
|Add treatment plan goals to the appropriate widget within the consumer’s chart in Patagonia | | | | |
|Complete authorization: SAR in Alpha for Medicaid or IPRS consumers, ORF in ValueOptions for| | | | |
|NCHC consumers. | | | | |
|Enter authorization requested, as appropriate, in client’s Patagonia chart | | | | |
|Complete Accounting of Disclosure form for PCP, Clinical Evaluation, or other documentation | | | | |
|distributed to Partners BHM, ValueOptions, or any other agency | | | | |
|Place Treatment Plan Signature Page into the receiving clinician’s box | | | | |
|Add the service and provider to the Service Enrollment tab of the consumer’s Patagonia Chart| | | |This is a tab within the Patient Details screen |
|Submit remaining documentation (SAR letter, etc.) to medical records for filing | | | | |
|Email password protected PCP to: Identified therapist, Michaele Conners, | | | | |
|quality.improvement@supportinc,org, and billing@. Indicate what services | | | | |
|client will be receiving and with what provider, any scheduled appts, SAR start & end date, | | | | |
|# of units requested of each code, if client is high risk & why, if NCTOPPS must be | | | | |
|completed (OR if you have had a previous NC TOPPS transferred to us from another provider), | | | | |
|and anything receiving person must do/complete in the body of email. Subject of email | | | | |
|should be client ID and services to be received at Support, Inc. | | | | |
CONSENT FOR SERVICES AND EMERGENCY TREATMENT FORM
CONSENT FOR SERVICES
Support Incorporated provides periodic and day/night services to individuals with varying developmental disabilities and/or mental health diagnoses. The staff members are trained to provide appropriate treatment as needed to help the individual.
I agree to participate in the treatment, services, and supports that have been explained to me and are provided by Support, Incorporated as outlined in the client’s service plan. I have been informed of the above services in terms that I can understand. I have also been informed of the alleged benefits, potential risks and possible alternative methods of treatment.
The services have been explained and include:
Assessment Services Outpatient Services Therapeutic Foster Care Services
Developmental Therapy Psychological Testing/Evaluation CAP Waiver Services
Individual/Caregiver Training and Education Crisis Services Day Treatment Intensive In-Home Services Psychiatric Evaluation/Med Clinic
Other: ______________________________ Substance Abuse Services
REPORTING OF SUSPECTED ABUSE/NEGLECT
Support Incorporated professionals are required by state laws to report suspected abuse or neglect to the appropriate authorities. If you have any questions about this, please feel free to ask for a better understanding before you sign this document. Your signature below acknowledges receipt of this information.
PERMISSION FOR TRANSPORTING AND OFF SITE ACTIVITIES
During the course of treatment, the client may require transporting to school and events, be on activities in the community outings in and out of the State of North Carolina. During these times, the client/parent/guardian agrees to release Support, Incorporated from all liability and responsibility. The parent/guardian gives permission for Support, Incorporated staff to transport the client during program hours for treatment purposes by use of personal or agency vehicles. This consent is valid until separation from the program or by written termination of permission by parent/guardian.
REQUIRED REPORTING
Support, Incorporated is required by state and federal regulations to report non-identifying client information for the purpose of evaluation and funding purposes. It will also be necessary for us to use and disclose certain information about you in order to carry out treatment, payment and health care operations. I have received the client confidentiality handout, which has been explained to me, and I understand the contents to be released, the need for information and that there are statutes and regulations protecting the confidentiality of information. I further acknowledge that I have received the Notice of Privacy statement and understand information contained in the document and this agency’s methods for protecting the privacy of my health information that is used in providing health care services to me.
EMERGENCY TREATMENT /RESTRICTIVE INTERVENTION / EMERGENCY INFORMATION
In case of sudden illness/accident/emergency, I hereby give permission to the staff of Support, Incorporated to seek emergency medical care and treatment on behalf of the above named client should the need arise. It is understood that a qualified medical professional, physician, and/or hospital emergency room personnel will provide this treatment. In addition, a copy of current medications and known medical conditions and allergies may be released. Every attempt will be made to contact the consumer’s parent/guardian/relative before obtaining emergency medical care unless life threatening. Emergency restrictive interventions will only be utilized when a consumer presents an imminent danger to him/herself or others or when substantial property damage is occurring. Whenever possible, less restrictive interventions will be used prior to the use of restrictive intervention.
|Emergency Contact |Address |
|«Emergency_Contact_Name_» |«EC_full_address_» |
|Home telephone # |Work telephone # |Cellular telephone # |
|«EC_home_phone_» |«EC_work_phone_» |«EC_cell_phone_» |
The above consents have been read by me or to me and explained to me by an employee of Support, Incorporated. I agree with the above consents as evidenced by the X or check marks.
__________________________________________________ _______________
Consumer/Guardian Signature Date
__________________________________________________ _______________
Witness Signature Date
Consent Form (2/22/13) Policy 3.12
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FACE SHEET/CONSUMER EMERGENCY FORM
|CONSUMER INFORMATION |
|Admission date: |Referral source agency/person: «Ref_agency» «Ref_Person» |
|Services requested: «Services_requested» |Referral source phone & fax #: P: «Ref_Phone_» F: «Ref_Fax_» |
|Referral source address: «Ref_Address» |
|Consumer last name: «Last_Name» |First name: «First_Name» |Middle name: «Middle_Name» |
|SS#: «SS» |DOB: «DOB» |Sex: «Gender» |Race: «Race_» |Marital status: «Marital_Status» |
|Physical address: «Client_Address» |
|Insurance type: «Insurance_Type» |Insurance ID#: «Insurance_ID» |MCO: |
|Policy holder name: «Policy_Holders_Name» |Policy holder relationship: |Policy holder DOB: «Policy_Holders_DOB» |
| |«Policy_Holders_Relationship» | |
|Policy holder SS#: «SS» |Policy holder phone #: «Policy_Holders_Phone_» |Policy holder employer: |
| | |«Policy_Holders_Employer» |
|Legal guardian name: «Guardian_name» |Relationship to consumer: «Relationship_to_consumer» |
|Is guardian court appointed: «Does_client_have_a_courtappointed_legal» |Home phone #: «Guardian_home_phone_» |Cell phone #: «Guardian_cell_phone_» |
|Legal guardian address: «Guardian_address» |
|EMERGENY CONTACT INFORMATION |
|Name: «Emergency_Contact_Name_» |Home phone #: «Client_home_phone_» |Work phone #: «EC_work_phone_» |Cell phone #: «EC_cell_phone_» |
|Address: «EC_full_address_» |
|Preferred physician: «PCP_physician_name» |Agency name: «Clinic_name» |Phone #: «PCP_phone_» |
|Address: «PCP_full_address» |
|All known allergies: «Known_allergies» |
|FAMILY BACKGROUND INFORMATION (IF APPLICABLE) |
|Father’s name: «Fathers_name» |Home phone #: «Father_s_home_phone_» |Cell phone #: «Fathers_cell_phone_» |
|Address: «Fathers_full_address_» |
|Mother’s name: «Mothers_name» |Home phone #: «Mothers_home_phone_» |Cell phone #: «Mothers_cell_phone_» |
|Address: «Fathers_full_address_» |
|Number of siblings: «M__of_siblings» |Sex & ages of siblings: «Sex__ages_of_siblings» |
| |
|TO BE COMPLETED BY SUPPORT, INC. STAFF ONLY |
|Intake date: |Intake appointment time: |
|Intake location: |Intake team: |
|Services recommended: |
|Agency(ies) providing recommended services: |
FACE SHEET, CONT’D.
|REASON FOR VISIT: «Reason_for_visit1» |
| |
|Current Behavioral/Functional Problems: Please check all that apply, H=past history and/or C=current. |
|H C Abandonment Issues H C Anxiety H C Arson H C Alcohol/Drug Abuse |
|H C Antisocial Behavior H C Assaultive (Physical) H C Truancy H C Stealing |
|H C Assaultive (Sexual) H C Assaultive (Verbal) H C Bed Wetting H C Eating Disorder |
|H C Depression H C Destroying Property H C Fire Setting H C Multiple Placements |
|H C Developmental Disability H C Hyperactive H C Impulsive H C Lying |
|H C Low Self Esteem H C Loss/Grief Difficulties H C Physical Impair H C Intellectual Disability |
|H C Neglect Issues H C Perception Reality H C Phobic H C Oppositional |
|H C Self Destructive H C Sibling Difficulty H C Social Immaturity H C Cruelty to Animals |
|H C Sexually Inappropriate Behav. H C Suicide Attempts H C Running Away H C Unruly/Ungovernable |
|H C Attention/Concentration H C Suicide Ideation H C Cutting Behaviors H C Angry Outbursts |
|H C Crying Spells H C Increased Appetite H C Memory Issues H C Forgetfulness |
|H C Attention/Concentration H C Decreased Appetite H C Disorganized H C Racing Thoughts |
|H C School Difficulty H C Talking out of turn H C Unable to sit still H C Sleep Issues |
|H C No interest - Bored H C Irritable H C Worries a lot H C Paranoia |
|H C Hallucinations - Sight H C Alcohol Use H C Dizzy Spells H C Increased Thirst |
|H C Hallucinations - Hearing H C Drug Use H C Chest Pain H C Heart Racing |
|H C Hallucinations - Smell H C Feels On Guard H C Dry Skin H C Increased Sweating |
|H C Easily Startled H C Constant Dieting H C Repeats Behaviors H C Panic Attacks |
|H C Up & Down Moods H C Vomiting after meals H C Weight Loss/Gain H C Angry Outbursts |
| |
|Psychiatric and Family History: Please check all that apply, S=Self/Consumer and/or F=Family. |
|S F Depression S F Bipolar Disorder S F PTSD S F Anxiety |
|S F Schizophrenia S F Eating Disorder S F Alcohol Abuse S F Drug Abuse |
|S F Suicide Attempt S F Completed Suicide S F Psychiatric Hospitalization S F ADHD |
|S F Developmental Disorder S F Autism S F Medical Hospitalizations S F Stroke |
|S F High Blood Pressure S F Diabetes S F Thyroid Problems S F Cancer |
|S F Seizures S F Head Trauma S F Surgeries S F Heart Disease |
|S F Smoke Cigarettes S F Consume Caffeine S F Run away from home |
|PSYCHIATRIC MEDICATION TREATMENT |
|Prescribing Physician : «Prescribing_physician» |
|Clinic name: «Clinic_name» |
|Current Medications (include dosages) : |
| |
|Past Medications (include dosages/allergies/reactions): |
| |
|Employment status: «Employment_status» |
|Hx of psychiatric hospitalization? (if yes, please list most current month and year) «History_of_psychiatric_hospitalizations» |
|Hx or current suicidal/homicidal behavior? «SH_Thoughts_Intent_Plan_Means» |
|DSS involvement?: «DSS_Involved» |County: «DSS_County» |Caseworker: «DSS_caseworker_name» |
|DJJ involvement?: «DJJ_Involved» |County: «DJJ_County» |Caseworker: «DJJ_Caseworker_name» |
|Last school attended: «Last_school_attended» |Grade: «Grade» |
|Hx of suspensions or expulsions?: «History_of_expulsions_or_suspensions» |# in current/last school year: «M__in_currentlast_school_yer» |
|Primary care physician and clinic name: |
|FACE SHEET POLICY # 3.01 |
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RECORD OF CONSENT & ACKNOWLEDGEMENT OF SUPPORT, INC. OPERATIONS
Please initial in the blank space to the left of the statements listed below.
Your initials indicate agreement to the statement.
CONSUMER PHOTOGRAPH
_________ I hereby authorize the staff of Support, Inc. to take a photograph of my image to use in my electronic health record.
INTERN CONSENT
_________ I hereby authorize any clinical intern affiliated with Support, Inc. to observe and participate in the behavioral health services I receive from Support, Inc.
METHOD OF CONTACTING
_________ I hereby authorize Support, Inc. to contact me in the following ways, using the information I provide for my electronic health record:
Home or cell phone number Work phone number Leaving messages on voice mailboxes on my home or cell phone number
Mail to home or mailing address
TEXT MESSAGING
____________ I understand that I am willingly revealing personal health information through an unsecured and non-HIPAA compliant platform when I choose to contact Support, Inc. staff via text messaging. I also understand that Support, Inc. only authorizes staff to communicate regarding treatment scheduling via text messaging. All other treatment communication must be done via telephone conversation or face-to-face contact.
_________ I understand that it is my responsibility to notify Support, Inc. of any changes regarding my contact information and ways I wish for the agency to contact me.
CLIENT ACKNOWLEDGEMENT OF SAFETY & 24-HOUR ON-CALL SUPPORT
_________ I have been informed that Support, Incorporated provides a 24 hour, 7 day a week emergency telephone number (980-329-9200) for the use of client or family members in crisis situations. I agree to use this number or another form of support (i.e. family member, friend, neighbor, hospital, police etc.) if I have thoughts to harm myself or others. The individual answering Support Inc.’s emergency phone will be qualified to provide crisis intervention up to and including face-to-face services. Furthermore, I have been given this number and encouraged to post it for emergency accessibility if I need assistance in an emergency situation.
YOUR RIGHT TO REVOKE THIS CONSENT
I understand I have the right to change or revoke this consent at any time without notice or reason by written notice to Support Incorporated.
_______________________________________________ ____________________
Signature of consumer or legal representative Date
_______________________________________________ ____________________
Witness/relationship to consumer Date
MEDICATION MANAGEMENT POLICIES
708 S. Chestnut Street Gastonia, NC 28054 ▪ (704) 865-3525 P ▪ (704) 865-3520 F ▪
Gaston ▪ Lincoln ▪Cleveland▪ Iredell
Welcome to Support, Inc.!
We appreciate you choosing Support, Inc. for medication management services. Here are a few things that you should know. We have found that discussing these things up front allows us to provide the best possible service to you.
Listed below are our policies in regards to medication management services:
Disability: Our primary focus is treating patients and helping them to regain their abilities, not to document a disability. In order to have a well-informed, honest opinion that someone is disabled, we must have treated the person for a minimum of six months and be convinced the patient has actively worked to improve.
Benzodiazepines: We do not, as a rule, prescribe benzodiazepines. This includes Xanax (alprazolam), Ativan (lorazepam), Klonopin (clonazepam), and numerous others. If you are currently taking a benzodiazepine, we will help you wean off of it and we will prescribe, if needed, appropriate non-addictive treatment.
Appointments: We are a very busy clinic treating many patients; therefore, if you are 10 minutes or more late for your appointment, we will have to reschedule you in our next open slot.
Prescription refills: Please keep track of your prescriptions. If you realize that you will need more medication before your next appointment, please call the office at least SEVEN BUSINESS DAYS before you run out. If you request a refill with less than 7 days of medication left, we cannot guarantee it will be ready in time.
No show appointments: You will not receive medication refills if you do not show up for a medication management appointment. A no show appointment is when you do not call at least 24 hours ahead of time and let us know that you will be unable to come to your medication management appointment. If you do not show up for an appointment and need medication, you will be required to come in to see a doctor to receive refills. You will be asked to come in to the office on the next business day at 1pm and wait for a doctor to work you into his or her schedule.
Rescheduled appointments: If you call ahead and request to reschedule an appointment, you may receive enough refills to last a few days, but you must come in to see a doctor within a week of the rescheduled appointment.
Therapy compliance: Therapy is the most important tool and medication management is an adjunct service to other therapeutic services being received. As a result, all patients receiving medication management are required to participate in at least one other service with Support, Inc., or another outside agency as approved by the Medical Director. If you miss two therapy appointments in 30 days or are inactive from therapy for 60 days, your upcoming medication appointments will be canceled and refills will not be authorized until you attend 2 consecutive therapy appointments (this includes canceled and rescheduled appointments). If you are scheduled to begin therapy before your first medication appointment and you miss your first appointment, your first medication appointment will be canceled until you begin therapy. If you believe that you do not need any other services besides medication management, we will assist with linking you to another psychiatric provider.
Thank you for your attention to these details. We look forward to establishing a helpful working relationship with you.
I have read and understand Support Incorporated’s policies in regards to medication management services, which describes the policies Support, Inc. follows when treating patients.
«First_Name» «Last_Name»
Print name of consumer being treated
_____________________________ ____________
Signature of consumer or legal representative Date
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Client Rights
• You have the right to have all your family and personal information kept confidential.
• You have the right to a copy of our policies.
• You have the right to privacy. We will respect you and your property.
• You have the right to get the right amount of the right kind of care.
• You have the right to be protected from abuse, neglect, retaliation, humiliation, exploitation.
• You have the right to ask questions and make your ideas known.
• You have the right to receive medications as ordered by the doctor.
• You have the right to access an accurate record of your treatment here, including any medications, treatment plans, and notes about your goals.
• You have the right to take part in talking about, developing, and reviewing all the important information needed to develop your treatment plan.
• You have the right to participate in services decisions.
• You have the right to decide whether to receive services.
• You have the right to refuse services.
• You have the right to know the possible consequences if you choose to refuse services.
• You have the right to hear and talk about your family strengths, risks, and safety issues.
• You have the right to know when your information is requested and where it’s sent.
• You have the right to know who can help you speak out for yourself. When you need advocacy support services, you have the right to contact the Disability Rights Council of North Carolina at 1-877-235-4210, the Agency under federal and state law that protects and advocates for the rights of person with disabilities. The TTY (for deaf and hard of hearing) is 1-888-235-4673.
• You have the right to have your concerns looked into and to get an answer.
• You have the right to receive services where you need them.
• You have the right to know about treatment methods and ways to measure treatment progress.
• You have the right to know in advance the cost of services.
• You have the right to know the understand benefits and risks of treatments and interventions.
• You have the right to know who your workers are.
• You have the right to protection from others’ behavioral disruptions.
• You have the right to 24 hour crisis intervention
• You have the right to equal access to treatment no matter your race, ethnic background, gender, age, sexual orientation, or sources of payment. You have the right to be treated with courtesy & respect.
• You have the right to voice your opinions and concerns and even file a formal complaint or grievance.
• If you have a complaint or grievance, if you need our help we will give you the forms and help you fill them out.
• You have the right to receive an answer to your complaint and/or grievance in writing.
• You always have the right to appeal any decision about your treatment and services.
• You have the right to ask your case manager any questions you have.
• You have the right to request a different worker or a different provider at any time.
• You have the right to call Partners Behavioral Health Management at 1-888-235-4673 for information about different service providers.
• Your treatment is about you, for you, and with you.
• You have the right to have these rights read and explained to you.
If I have any questions about my rights, I will ask my Support Incorporated staff. As a consumer, I am aware that I have the right to request a different staff at any time. I would need to discuss this with either my staff or his/her supervisor or the Executive Director. If I have questions about the availability of another provider in my network, I can call Partners Behavioral Health Management at 1-888-235-4673. If I believe my rights may have been violated, I can file a complaint/grievance. If I am not satisfied with the response, I can take my concerns to Support Incorporated’s Board of Directors. Any Support Incorporated staff may assist me in doing this. The above rights have been read by me or to me and explained to me by a staff of Support Incorporated. I have received a Support Incorporated Consumer Handbook.
_________________________________________________ __________________
Consumer or guardian signature Date
Policy #C-010
(Updated 12/28/2011)
Client Rights (rev. 11/1/2012)
SUPPORT, INC. CLIENT ORIENTATION FORM
As a client of Support, Incorporated, upon admission I have been instructed in or given written materials regarding:
• Rights and responsibilities of the person served.
• Grievance and appeal procedures.
• Ways in which input is given regarding: the quality of care, achievement of outcomes, satisfaction of the person served.
• An explanation of the organization's: services and activities, expectations, hours of operation, access to after-hour services, code of ethics, confidentiality policies, requirements for follow-up for the mandated person served, regardless of his or he discharge outcome.
• An explanation of any and all financial obligations, fees, and financial arrangements for services provided by the organization.
• Familiarization with the premises, including emergency exits and/or shelters, fire suppression equipment, and first aid kits.
• The program’s policies regarding: the use of seclusion or restraint, smoking, illicit, prescription, or over the counter medication and drugs brought into the program, weapons brought into the program, abuse, and neglect.
• Identification of the person responsible for service coordination.
• A copy of the program rules to the person served that identifies the following: any restrictions the program may place on the person served; events, behaviors, or attitudes that may lead to the loss of rights or privileges for the person served; means by which the person served may regain rights or privileges that have been restricted.
• Education regarding advance directives, if appropriate.
• Identification of the purpose and process of the assessment.
• A description of how the individual plan will be developed and the person’s participation in it.
• Information regarding transition criteria and procedures.
• When applicable, an explanation of the organization’s policies, services, and activities include: expectations for consistent court appearances; identification of therapeutic interventions, including legally required appointments, sanctions, court notifications, interventions, incentives, administrative discharge criteria, administrative follow-up to discharge (if planned, 30 days, 90 days, and 6 months after discharged; if unplanned, 72 hours after discharge).
Signature of consumer or legal representative Date
Print name of consumer or legal representative
Insurance verification / Assignment of benefits / Payment agreement
LEGAL GUARDIAN INFORMATION
|Legal guardian’s name: «Guardian_name» |
|Legal guardian’s address: «Guardian_address» |
|Legal guardian’s phone number: «Guardian_home_phone_» «Guardian_cell_phone_» |
INSURANCE PLAN INFORMATION
|Insurance company name: «Insurance_Type» |
|Insurance company address: |
|Insurance company phone number: |
|Insurance policy ID number: «Insurance_ID»«CLIENT_INFO» Group Number: |
|Policy holder’s name and birthdate: «Policy_Holders_Name»«Policy_Holders_DOB» |
|Policy holder’s employer: «Policy_Holders_Employer» |
|Policy holder’s relationship to insured: «Policy_Holders_Relationship» |
|Policy holder’s social security number: «Policy_Holders_SS» |
|Policy holder’s phone number: «Policy_Holders_Phone_» |
|Effective date of insurance: |
ASSIGNMENT OF BENEFITS/PAYMENT AGREEMENT STATEMENT
If applicable, I authorize payment by my insurance carrier or Medicare/Medicaid to be paid directly to Support Inc. for services rendered. I understand that I am financially responsible to Support Inc. for any non-covered services, for any charges applied to my insurance deductible, and for all charges limited by the insurance carrier (co-pays, coinsurance, etc.). I may choose to develop a payment plan with Support Inc. that stipulates rate of pay and payment timeframe. An invoice shall be sent to the responsible guardian’s address. Fee shall be paid or Payment Plan negotiated and signed within 30 days of invoice. If I fail to pay for services rendered, then I understand that services may be terminated. I also authorize Support, Inc. to release any information necessary regarding my treatment to process a claim, which may include information pertaining to drug abuse, and/or alcoholism or Acquired Immunodeficiency Syndrome (AIDS) or Human Immunodeficiency Virus (HIV) to «Insurance_Type» (name of insurance company). I understand that there are state statutes and federal regulations (42 CFR, part 2) that protect the confidentiality of authorized information prohibiting anyone from making further disclosure of any released information. I have been informed that this consent will be valid for no more than one year. I understand that I may withdraw my consent at any time, except to the extent that action based on this consent has been taken.
Signature of policy holder or legal representative: Date:___________________________
FOR STAFF USE ONLY
INSURANCE VERIFICATION INFORMATION
*If insurance needs to be verified, inform client that we will call them back after verification is completed with an appointment date and time. If client does not have insurance, give them the first available time.
|Number of insurance carriers: |
|Type of insurance carriers: Private insurance Medicare Medicaid (verify via NCTracks) |
|Mental Health Coverage Substance Abuse Coverage Percentage or Co-Pay: |
|Number of Visits Authorized: Amount of Deductible: Met this year: |
|Do outpatient visits need to be authorized? Yes No |
|Are there “Out of Network” benefits? Yes No If no, are we an impaneled provider? Yes No |
Send completed form to Patient Accounts (Fax: 704-867-0638)
Annual Fee Evaluation Data Collection Form and Financial Agreement Statement
Section I- Family size and income (for client or legal representative to complete)
Total number of people living in the household: _______
# of parents living in the household with client: _______
# of siblings living in the household with client: _______
Please list any additional persons living in the household and indicate their relationship to the consumer:
__________________________________________________________________________________________________
Please list your annual family income: ___________________
Please list your source(s) of income: ____________________________________________________________________
What is your source verification of income? (Pay stubs, disability payment statements, etc.): ________________________
|Persons in | Annual Family Income |COPAY |
|household | | |
| | From | To | |
|1 | $ - | $ 33,510.00 | $ 3.00 |
|2 | $ - | $ 45,390.00 | $ 3.00 |
|3 | $ - | $ 57,270.00 | $ 3.00 |
|4 | $ - | $ 69,150.00 | $ 3.00 |
|5 | $ - | $ 81,030.00 | $ 3.00 |
|6 | $ - | $ 92,910.00 | $ 3.00 |
|7 | $ - | $ 104,790.00 | $ 3.00 |
|8 | $ - | $ 116,670.00 | $ 3.00 |
|For each additional person add 11,880.00 |
| |
Section II- Service information (for Support, Inc. staff to complete)
Please list the services this client is/will be receiving from our agency :
____________________________________________________________________________
Please Check one: This consumer IS receiving services that are subject to fee requirements as outlined in NCGS §122C-146
This consumer IS NOT receiving services that are subject to fee requirements as outlined in NCGS §122C-146.
Section III- Other Insurance/Third Party Coverage (for Support, Inc. staff to complete)
Please check and complete any section below that is applicable. It is required that prior to receipt of IPRS dollars, all other payment sources must be exhausted. If client has other coverage, it is required to submit claims to those carriers prior to submission of claims for IPRS dollars.
_____ Medicaid: I certify that I am a beneficiary of the NC Medicaid Program. I understand and accept financial responsibility for any services that are not billable or reimbursable by Medicaid due to a spend down, deductible, or a Medicaid non-transfer of assets.
_____ Medicare: I certify that I am a beneficiary of the Federal Medicare Program. I understand that I am responsible for any Medicare deductibles and/or co-pays. I understand that I must be notified up front of any services that are non-covered by the Medicare program or if this program is not a participating Medicare provider. I should be afforded the opportunity to choose a Medicare provider for any Medicare covered services.
_____ Commercial insurance: I certify that I have insurance coverage through a Commercial Insurance Carrier. I understand that all commercial insurance must be filed prior to payment from any publically funded program (Copy of Card front and back should be obtained and submitted with this form to the LME)
_____ Integrated Payment Reporting System (IPRS) funded: This certifies that the consumer has been deemed eligible to participate in the IPRS program for payment of services. It is understood that all other payment sources must be exhausted and Coordination of Benefits process applied prior to submission of any claims for payment by IPRS.
_____ Self Pay: I certify that I have been informed that I do not qualify for any of the above funding due to no insurance coverage or exceeding the requirements for income/dependents as outlined in the IPRS Fee Schedules. I understand that I am responsible for payment of all services received. My financial obligation is between the provider agency and myself. Partners BHM has no responsibility regarding financial relationships that occur in situations where no public dollars will be utilized.
Section IV- Fee Notification (for Support, Inc. staff to complete)
Not applicable (Section is for IPRS consumers only)
Based upon Section III information, does the client qualify for IPRS Benefits?:
Yes, Consumer does qualify based upon family size and income data
Consumer is an adult and will have an IPRS Co-Pay of $3.00 Consumer is a minor and will have no Co-Pay
Section V- Attestation/Certification (for client or legal representative and Support, Inc. staff to complete, together)
By signing this agreement, I certify that the information on this form is accurate and true to the best of my knowledge. I have been informed of my financial obligations and expectations. I understand that I may have a copy of this form if requested.
Signature of Client or legal representative Date Printed name of client or legal representative Date
Legal representative’s relationship to client:
Signature of provider agency representative Date Printed name of provider agency representative Date
Please note: NCGS §122C-146 requires the implementation of a co-payment schedule for publicly funded services. These rules were adopted to comply with the requirements of HB 628 Session Law 2011-145. Requirements are found in 10NCAC 27A.0501- 10NCAC 27A.0505. These rules do not establish an entitlement and do not apply to MH/DD/SA residential services. Please reference these rules for additional information. The below is considered part of your health information and is protected in accordance with the Health Insurance Portability and Accountability Act (HIPPA) of 1996. This information is required to be gathered by contractual providers for Partners Behavioral Health Management per General Statute 122C-146 which addresses compliance with implementation of co-payment schedule.
NOTICE OF PRIVACY PRACTICES OF SUPPORT, INCORPORATED
SUPPORT, Incorporated must collect timely and accurate health information about you and make that information available to members of your health care team in this agency, so that they can accurately diagnose your condition and provide the care you need. There may also be times when your health information will be sent to service providers outside this agency for services that this agency cannot provide. It is the legal duty of SUPPORT, Incorporated to protect your health information from unauthorized use or disclosure while providing health care, obtaining payment for that health care and for other services relating to your health care.
The purpose of this Notice of Privacy Practices is to inform you about how your health information may be used within SUPPORT, Incorporated, as well as reasons why your health information could be sent to other service providers outside of this agency.
This Notice describes your rights in regards to the protection of your health information and how you may exercise those rights. This Notice also gives you the names of contacts should you have questions or comments about the policies and procedures SUPPORT, Incorporated uses to protect the privacy of your health information.
Please review this document carefully and ask for clarification if you do not understand any portion of it.
Client Acknowledgement
I have received SUPPORT, Incorporated’s Notice of Privacy Practices, which describes this agency’s methods for protecting the privacy of my health information that is used in providing health care services to me.
_______________________________________________/_________________________
Consumer (or Personal Representative) Date
Note: SUPPORT, Incorporated retains this signed page. Consumer retains the Notice of Privacy Practices document.
Notice of Privacy Practices 7/31/06
Policy # 1.071
ASSURANCE OF CONFIENTIALITY FOR GROUP THERAPY TREATMENT
By signing below, I agree to follow the Confidentiality Regulations developed by the Division of Mental Health, Developmental Disabilities, and Substance Abuse Services for the purpose of making sure all information shared by members of this group remains confidential. This means that, except as required by law (see “Confidentiality of Your Information” form), in order to protect the privacy of all members of this group, I agree to not share any information I hear during group therapy with those who are not part of this group. In other words, what is said in group therapy remains in group therapy. I further understand the civil penalties for the improper release of confidential information.
Consumer signature: ______________________________ Date: ________________
Legal guardian printed name: _____________________________________________________
Guardian signature: _______________________________ Date: ________________
I, __________________________________________________________________, do hereby authorize Partners BHM and
_______________Support, Inc.______________________________________________________________________________________________
_______________________________________________________ Located at _________175 W. Franklin Blvd. Gastonia, NC 28052______, to
share the following protected Health Information:
Please be specific when requesting. Data covers the time period of ____________________to___________________. Data authorized for release may include the following (initial if applicable)
The Purpose of the disclosure is(check which are applicable):
RE-DISCLOSURE: Once information is disclosed pursuant to this signed authorization, I understand that the Federal Health Privacy Law (45 CFR Part 164) may not apply to the recipient of the information and, therefore, may not prohibit the recipient of the information from re-disclosing it. Other laws, however, may prohibit re-disclosure. When information is released from this agency protected by state law (NCGS 122C) or substance abuse treatment information protected by federal law (42 CFR, part 2), the recipient of the information is informed that re-disclosure is prohibited except as permitted or required by these two laws. Our Notice of Privacy Practices describes the circumstances where disclosure is permitted or required by these laws.
REVOCATION and EXPIRATION: I understand that, this authorization may be revoked in writing at any time, except where action has already been taken on this authorization. The process for how to revoke this authorization, as well as the exceptions to my right to revoke, are explained in Partners Behavioral Health Management Notice of Privacy Practices, a copy of which has been provided to me.
If not revoked earlier, this authorization to disclose expires on:____________________________________________________________________
Notice of Voluntary Authorization: I understand that I may refuse to sign this form. If I choose not to sign this form, I understand that Partners Behavioral Health Management cannot deny or refuse to provide treatment, payment, enrollment in a health plan, or eligibility for benefits based on my refusal to sign unless the provision of health care is solely for the purpose of creating protected health information for disclosure to a third party on provision of an authorization for the disclosure of the protected health information to such third party. I understand that my signature is voluntary on this authorization and that I may request a copy of it once I have signed it.
Authorization for Use, Disclosure, and Exchange of Protected Health Information to and from Support Incorporated and Another Entity
I hereby authorize Support Incorporated to use, disclose and/or exchange my individualized protected health information or, if applicable, the individualized protected health information of whom I am a legal representative, as specified below.
|Entity(ies)/address |Purpose |Information to be Disclosed |Guardian/ |
| | | |Client Initial & |
| | | |Date |
|Gaston Memorial Hospital |to ensure continuity of care and |Emergency Services Screening and Evaluation form, medication orders, tx | |
|2525 Court Drive |maintain open communication with |progress and compliance reports, face sheet, diagnostic assessment/clinical | |
|Gastonia, NC 28054 |treatment team members |evaluation, PCP, diversion form, hospital listing form; may obtain admission | |
| | |and discharge summaries from hospital | |
|«PCP_agency_name» |to ensure continuity of care and |treatment progress and compliance reports, letter indicating that consumer is| |
|«PCP_full_address» |maintain open communication with |receiving mental health services, PCP, clinical evaluation/diagnostic | |
| |treatment team members |assessment, psychiatric evaluation, medication orders, physician notes, | |
| | |medical diagnosis(es) | |
|«Last_school_attended» |to ensure continuity of care and |treatment progress and compliance reports, PCP, clinical evaluation, behavior| |
|«Schools_full_address» |maintain open communication with |reports, may obtain a copy of IEP/504 plan and psycho-educational testing, as| |
| |treatment team members |well as a copy of consumer’s birth certificate | |
|«DSS_County» DSS |to ensure continuity of care and |treatment progress and compliance reports, court documents and legal reports,| |
|«DSS_full_address» |maintain open communication with |PCP, clinical evaluation, psychiatric evaluation, physician notes and | |
| |treatment team members |medication orders | |
|«DJJ_County» DJJ |to ensure continuity of care and |treatment progress and compliance reports, court documents and legal reports,| |
|«DJJ_full_address» |maintain open communication with |PCP, clinical evaluation, psychiatric evaluation, physician notes and | |
| |treatment team members |medication orders | |
|«Previous_MH_agency» |to ensure continuity of care and |treatment progress and compliance reports, PCP, clinical evaluation, | |
|«Previous_MH_agency_address» |maintain open communication with |psychiatric evaluation, physician notes, and medication orders | |
| |treatment team members | | |
|«Previous_MH_agency_2_» |to ensure continuity of care and |treatment progress and compliance reports, PCP, clinical evaluation, | |
|«Previous_MH_agency_2_address_» |maintain open communication with |psychiatric evaluation, physician notes, and medication orders | |
| |treatment team members | | |
|«Name_of_personagency1» |to ensure continuity of care and | | |
|«Person_1_full_address» |maintain open communication with | | |
| |treatment team members | | |
|«Name_of_personagency2» |to ensure continuity of care and | | |
|«Person_2_full_address» |maintain open communication with | | |
| |treatment team members | | |
|Community Care of North Carolina |to ensure continuity of care and |Treatment progress and compliance reports, a record of all services and | |
|2300 Rexwoods Drive |maintain open communication with |service providers billed through the Medicaid ID, treatment history, PCP, | |
|Raleigh, NC 27607 |treatment team members |clinical evaluation, psychiatric evaluation, medication orders, physician | |
| | |notes | |
I understand information regarding my treatment may include information pertaining to psychiatric or psychological treatment, drug and/or alcohol abuse, Acquired Immunodeficiency Syndrome (AIDS), or Human Immunodeficiency Virus (HIV).
REDISCLOSURE: Once information is disclosed pursuant to this signed authorization, I understand that the Federal Health Privacy Law (45CFR Part 164) protecting health information may not apply to the recipient of the information, and therefore, may not prohibit the recipient from redisclosing it. Other laws, however, may prohibit redisclosure. When this agency disclosed mental health and developmental disabilities information protected by state law (NCGS 122C) or substance abuse treatment information protected by federal law (42CFR Part 2), we must inform the recipient of the information that redisclosure is prohibited except as permitted or required by these two laws. Our Notice of Privacy Practices described the circumstances where disclosure is permitted or required by these laws.
REVOCATION AND EXPIRATION: I understand that, with certain exception, I have the right to revoke this authorization at any time. If I revoke this authorization, I must do so in writing. The procedure for how I may revoke this authorization, as well as the exceptions to my right to revoke, are explained in Support, Incorporated’s Notice of Privacy Practices, a copy of which has been provided to me.
If not revoked earlier, this authorization expires upon:
Not to exceed one year from date of signature unless for reasons pertaining to 10A NCAC 26B.0202 (b) (1) and (b) (2)
NOTICE OF VOLUNTARY AUTHORIZATION: I understand that I may refuse to sign this authorization form. If I choose not to sign this form, I understand that Support, Incorporated cannot deny or refuse to provide treatment, payment, enrollment in a health plan, or eligibility for benefits on my refusal to sign unless the provision of health care is solely for the purpose of creating protected health information for disclosure to a third party on provision of an authorization for the disclosure of the protected health information to such third party.
_____________________________________ _____________
Signature of consumer or consumer’s legal representative Date
Please explain representative’s authority to act on behalf of consumer: ___________________________
_____________________________________ ______________
Signature of Witness Date
Authorization Use/Disclosure 4/17/2013 Policy 3.02
Authorization for Use, Disclosure, and Exchange of Protected Health Information to and from Support Incorporated and Another Entity
I hereby authorize Support Incorporated to use, disclose and/or exchange my individualized protected health information or, if applicable, the individualized protected health information of whom I am a legal representative, as specified below.
|Entity(ies)/address |Purpose |Information to be Disclosed |Guardian/ |
| | | |Client Initial & |
| | | |Date |
|«Guardian_name» |to ensure continuity of care and |Treatment recommendations, diagnosis, attendance history, drug screen | |
| |maintain open communication with |results, PCP, treatment progress and compliance reports | |
| |treatment team members | | |
| |to ensure continuity of care and | | |
| |maintain open communication with | | |
| |treatment team members | | |
| |to ensure continuity of care and | | |
| |maintain open communication with | | |
| |treatment team members | | |
| |to ensure continuity of care and | | |
| |maintain open communication with | | |
| |treatment team members | | |
| |to ensure continuity of care and | | |
| |maintain open communication with | | |
| |treatment team members | | |
| |to ensure continuity of care and | | |
| |maintain open communication with | | |
| |treatment team members | | |
| |to ensure continuity of care and | | |
| |maintain open communication with | | |
| |treatment team members | | |
| |to ensure continuity of care and | | |
| |maintain open communication with | | |
| |treatment team members | | |
| |to ensure continuity of care and | | |
| |maintain open communication with | | |
| |treatment team members | | |
| |to ensure continuity of care and | | |
| |maintain open communication with | | |
| |treatment team members | | |
I understand information regarding my treatment may include information pertaining to psychiatric or psychological treatment, drug and/or alcohol abuse, Acquired Immunodeficiency Syndrome (AIDS), or Human Immunodeficiency Virus (HIV).
REDISCLOSURE: Once information is disclosed pursuant to this signed authorization, I understand that the Federal Health Privacy Law (45CFR Part 164) protecting health information may not apply to the recipient of the information, and therefore, may not prohibit the recipient from redisclosing it. Other laws, however, may prohibit redisclosure. When this agency disclosed mental health and developmental disabilities information protected by state law (NCGS 122C) or substance abuse treatment information protected by federal law (42CFR Part 2), we must inform the recipient of the information that redisclosure is prohibited except as permitted or required by these two laws. Our Notice of Privacy Practices described the circumstances where disclosure is permitted or required by these laws.
REVOCATION AND EXPIRATION: I understand that, with certain exception, I have the right to revoke this authorization at any time. If I revoke this authorization, I must do so in writing. The procedure for how I may revoke this authorization, as well as the exceptions to my right to revoke, are explained in Support, Incorporated’s Notice of Privacy Practices, a copy of which has been provided to me.
If not revoked earlier, this authorization expires upon:
Not to exceed one year from date of signature unless for reasons pertaining to 10A NCAC 26B.0202 (b) (1) and (b) (2)
NOTICE OF VOLUNTARY AUTHORIZATION: I understand that I may refuse to sign this authorization form. If I choose not to sign this form, I understand that Support, Incorporated cannot deny or refuse to provide treatment, payment, enrollment in a health plan, or eligibility for benefits on my refusal to sign unless the provision of health care is solely for the purpose of creating protected health information for disclosure to a third party on provision of an authorization for the disclosure of the protected health information to such third party.
_____________________________________ _____________
Signature of consumer Date
Please explain representative’s authority to act on behalf of consumer: ___________________________
_____________________________________ ______________
Signature of Witness Date
Authorization Use/Disclosure 4/17/2013 Policy 3.02
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Consumer Choice of Services and Providers
Support Incorporated is committed to ensuring that consumers have the right to choose the application of the service they qualify for, to decide the provider of the services they qualify for, and to select, if they desire, a change in services and/or providers. This choice process is being initiated during intake, but thereafter will be updated as the child and family team conduct child and family team meetings.
By signing this form, you are stating you understand that you, as the consumer, have the right to choose relevant services and which provider delivers those services and that Support, Incorporated has provided you that choice. Further, you acknowledge that no Support Incorporated employees have, in any way, advertently or inadvertently influenced your choice of services or providers.
Services qualified for: Chosen provider:
Clinical evaluation/diagnostic assessment Support Incorporated
_______________________________ ______________________________________________________
Other providers offered as choice:
1. ALEXANDER YOUTH NETWORK
2. MONARCH
3. OTHER: ________________________________
I attest that Support Incorporated has not influenced my decision in any way.
_________________________________________________________ _____________________________
Signature of consumer or legal representative Date
_________________________________________________________ _____________________________
Witness Signature Date
Client Choice revised 12/18/11
Policy # 3.21/ 3.4
INTENSIVE IN-HOME PROGRAM DESCRIPTION
The Intensive In-Home team from Support Incorporated will be made up of 3 team members that will work with your family consistently throughout your treatment. You will not typically see all 3 team members at one time. Listed below is an overview of the amount of time you would normally receive services, how often a team member will work with your family, and the types of activities expected. As a reminder, the team members cannot work with your child in the home without you present.
• Short term service (3-5 months)
• Helps to improve child’s disruptive behaviors (anger management, defiance, social skills etc)
• Family focused (improves communication and strengthens relationships)
• Helps families identify what has worked well and what has not worked well within the home.
• Helps provide support for families with DSS or DJJ involvement
• The team may work with your child and family up to 5 days a week during the first two months. This time may also be spent with teachers, court officials etc. (if they are involved with your child).
• The team may work with your child and family up to 4 days a week during the third and fourth month.
• The team may work with your child and family up to 3 days during the last month.
• What would be most helpful for the In-Home team to work on with your family?:
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
My signature verifies that I agree to participate in this intense short term service up to 5 days per week starting immediately and understand that the majority of this service will be delivered in the home.
_________________________________________ _________________
Consumer or Guardian Signature Date
_________________________________________ _________________
Witness Signature Date
Evidence of recipient participation (including family’s):
I ________________________________________, participated in the completion of this Clinical Evaluation.
(Signature of consumer or legal representative)
TREATMENT PLAN SIGNATURES
|PERSON RECEIVING SERVICES: |
|I confirm and agree with my involvement in the development of this treatment plan. My signature means that I agree with the services/supports to be provided. |
|I understand that I have the choice of service providers and may change service providers at any time, by contacting the person responsible for this treatment plan.|
|For CAP-MR/DD services only, I confirm and understand that I have the choice of seeking care in an intermediate care facility for individuals with mental |
|retardation instead of participating in the Community Alternatives Program for individuals with Mental Retardation/Developmental Disabilities (CAP-MR/DD). |
| |
|Legally Responsible Person: Self: Yes No |
|Person Receiving Services: (Required when person is his/her own legally responsible person) |
|Signature: |
|Date: __ / ___ /___ |
|(Print Name) |
|Legally Responsible Person (Required if other than person receiving Services) |
|Signature: |
|Date: __ / ___ /___ |
|(Print Name) |
|Relationship to the Individual: _______________________ |
| |
|II. PERSON RESPONSIBLE FOR THE TREATMENT PLAN: The following signature confirms the responsibility of the QP/LP for the development of this treatment plan. |
|The signature indicates agreement with the services/supports to be provided. |
| |
|Signature: |
|Date: __ / ___ /___ |
|(Person responsible for the PCP) (Name of Case Management Agency) |
|Child Mental Health Services Only: |
|For individuals who are less than 21 years of age (less than 18 for State funded services) and who are receiving or in need of enhanced services and who are |
|actively involved with the Department of Juvenile Justice and Delinquency Prevention or the adult criminal court system, the person responsible for the treatment |
|plan must attest that he or she has completed the following requirements as specified below: |
|Met with the Child and Family Team - Date: __ / ___ /___ |
|OR Child and Family Team meeting scheduled for - Date: __ / ___ /___ |
|OR Assigned a TASC Care Manager - Date: __ / ___ /___ |
|AND conferred with the clinical staff of the applicable LME to conduct care coordination. |
|If the statements above do not apply, please check the box below and then sign as the Person Responsible for the treatment plan: |
|This child is not actively involved with the Department of Juvenile Justice and Prevention or the adult criminal court system. |
|Signature: |
|Date: __ / ___ /___ |
|(Person responsible for the treatment plan) (Print Name) |
|III. SERVICE ORDERS: REQUIRED for all Medicaid funded services; RECOMMENDED for State funded services. |
|(SECTION A): For services ordered by one of the Medicaid approved licensed signatories (see Instruction Manual). |
|My signature below confirms the following: (Check all appropriate boxes.) |
|Medical necessity for services requested is present, and constitutes the Service Order(s). |
|The licensed professional who signs this service order has had direct contact with the individual. Yes No |
|The licensed professional who signs this service order has reviewed the individual’s assessment. Yes No |
|Signature: License #: __ Date: |
|__ / ___ /___ |
|(Name/Title Required) (Print Name) |
|(SECTION B): For Qualified Professionals (QP) / Licensed Professionals (LP) ordering: |
|CAP-MR/DD or |
|Medicaid Targeted Case Management (TCM) services (if not ordered in Section A) |
|OR recommended for any state-funded services not ordered in Section A. |
|My signature below confirms the following: (Check all appropriate boxes.) Signatory in this section must be a Qualified or Licensed Professional. |
| |
|Medical necessity for the CAP-MR/DD services requested is present, and constitutes the Service Order. |
|Medical necessity for the Medicaid TCM service requested is present, and constitutes the Service Order. |
|Medical necessity for the State-funded service(s) requested is present, and constitutes the Service Order |
|Signature: License #: Date: |
|__ / ___ /___ |
|(Name/Title Required) (Print Name) (If Applicable) |
| SIGNATURES OF OTHER TEAM MEMBERS PARTICIPATING IN DEVELOPMENT OF THE PLAN: |
| |
|Other Team Member (Name/Relationship): _____ Date: __ / ___ |
|/___ |
| |
|Other Team Member (Name/Relationship): _____ Date: __ / ___ |
|/___ |
BEHAVIORAL HEALTH AGENCY REQUEST FOR INFORMATION
Date: ____________________
Patient’s name:«First_Name» «Middle_Name» «Last_Name» DOB: «DOB»
This patient is currently receiving Behavioral Health Services at our agency and lists your practice as his/her primary care provider.
☐ If this patient is no longer receiving services in your practice, please check this box and fax back to our agency.
Agency name: Support, Incorporated
Address: 708 S. Chestnut St Gastonia, NC 28052
Phone: 704-865-3525 Fax: 704-865-3520 E-mail: outpatient@
The following Behavioral Health Information is attached:
Diagnosis(es)
Current Clinical Issues
Medication List
Recent Lab Work
Pain Contract
Other: Authorization for Disclosure, Clinical Evaluation
Please complete this section and fax the following Medical Information to:
Contact: Joan Jenkins Fax: 704-865-3010
Most recent physical exam
Medical diagnosis(es)
Medication list
Recent lab work
Pain contract (if applicable)
Practice name: ________________________________________________________________
Carolina Access Referral NPI# & Tax Code:_________________________________________
Specific concerns/requests/recommendations:
Thank you,
____________________________________________________
Name of requesting provider (MD, PA, NP, PhD, LCSW, LPC, LMFT)
ACCOUNTING OF DISCLOSURE
|INFORMATION DISCLOSED |
|Date: |Recipient, Specific Information Disclosed, Specific Reason for Disclosure, Method of |Full signature and date |
| |Disclosure | |
| |PCP and Clinical Evaluation disclosed to ______________________________ via secure website for| |
| |care coordination purposes. | |
| |PCP and Clinical Evaluation disclosed to ______________________________ via fax for care | |
| |coordination purposes. | |
| | | |
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| | | |
| | | |
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[pic]
-----------------------
Authorization for Use, Disclosure, and Exchange of Protected Health Information
[pic]
Client Name: «First_Name» «Last_Name»
DOB: «DOB»
Previous LME/ID:
Partners BHM ID: «Record_»
Medicaid ID: «Insurance_ID»
Client or client representative
Name of Agency that information is to be shared with Agent Staff Name Staff NC-TOPPS ID
Staff e-mail address Address/Phone number of Agency information is to be shared with
__X__ Psychological/Psychiatric Evaluations
__X__ Screening/Contact Assessment
_X__ Service/Treatment Plan
_____ Tuberculosis
__X__ Other/Disclosures to include NC-TOPPS History __________________________________________________ __________________________________________________
__________________________________________________
__X__ Alcohol/Drug treatment
__X_ Diagnostic Information
__X__ Financial/Reimbursement
_____ Hepatitis
_____ Human Immunodeficiency Virus (HIV)
_X__ Intake/Assessment
_X__ !s ! 3 8 9 ? @ N ž Ÿ ¡ ² Ô Õ èν©–?––––?kZF?
hó1àh[pic]TÈ'h2wÄh[pic]TÈ5?CJOJ[?]PJQJ[?]^J[?]aJ!h[pic]TÈ5?CJOJ[?]PJQJ[?]^J[?]aJ'hCåh*S„5?CJOJ[?]PJQJ[?]^J[?]aJ-hE{rMedication Information
__X__ Progress/Service Notes
__X__Service Delivery___x__ Continuity of Care_____ Referral____ Disability___x__Other(specify) Transfer NC-TOPPS responsibility to my new provider
Not to exceed one year from date of signature
Signature of Client Date
Printed Signature of Client Date
Client Legal Representative relationship to client
06/13 **Fax this form to 704-884-2710**
Printed Signature of Client Legal Representative Date
Signature of Client Legal Representative -- if client unable to sign Date
................
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