Important Forms, Insurance and Scheduling Information

Transcription

1 Four Winds Saratoga Adolescent Intensive Outpatient Program Important Forms, Insurance and Scheduling Information Prior to Your First Visit We have attached a number of forms that you should complete at home and bring with you to your evaluation appointment. If you do not have time to complete them prior to your first visit, please arrive at the office 15 minutes early so that the forms can be filled out at that time. The policy holder of the insurance must sign these forms. Included you will find: Patient Information and Consent Patient Clinical Information Authorizations for Release of Information: Medical Doctor/PCP Therapist Psychiatrist School Pharmacy Also included in this packet are the Patient Bill of Rights and Notice of Privacy Practices. These forms are for you to review and to keep. A parent or guardian should plan to accompany the teenager to the evaluation in order to obtain a comprehensive history. We understand that this is not always possible, but it is necessary that at least one parent/guardian must attend with your child. Insurance and Billing Information Please bring your insurance card to the first visit so that we can make a copy. Your co-payment or full payment, if required, is always due at the time of service. Cancellation and Contact Information If you are unable to attend your evaluation and need to reschedule, or if you have any questions about billing, insurance or the program, please call us so that we may assist you. Our voic system is available 24-hours every day, so please feel free to call us, anytime, at , dial ext or ask for the Adolescent Intensive Outpatient Program, and then follow the prompts. Calls will be returned to you during our office hours: Monday Friday from 8 a.m. 5 p.m. Four Winds Saratoga 30 Crescent Avenue, Saratoga Springs, NY

2 PATIENT INFORMATION Date: MRN: (Office Use Only) Patient s Name: Date of Birth: Sex: Male Female Patient s Social Security Number: - - Age: Street Address Apt# City: State Zip Code: County: Patient s Home Phone Number: ( ) Okay to call: Yes No PARENT INFORMATION / PERSONS TO BE CONTACTED IN CASE OF EMERGENCY: Mother s or Father s Name: Relationship: Address (if different): Home Phone:( ) Work Phone:( ) Cell Phone: ( ) Other Parent s or Contact s Name : Relationship: Address (if different): Home Phone:( ) Work Phone:( ) Cell Phone: ( ) Primary Care Physician: Phone Number: ( Address: INSURANCE INFORMATION: ) Primary Insurance: Policy #: Group #: Subscriber s Name: Subscriber s Date of Birth: Subscriber s Social Security # - - Subscriber s Address (if different than patient): Subscriber s Employer: Relationship to Patient: Secondary Insurance: Policy #: Group #: Subscriber s Name: Subscriber s Date of Birth: Subscriber s Social Security # - - Subscriber s Address (if different than patient): Relationship to Patient: Subscriber s Employer: RELEASE OF INFORMATION I authorize the release of information for claims, certification/case management/quality improvement, and other purposes related to the benefits of my Health Plan. (Releasing information to providers, family, etc., requires separate forms). I understand and agree to all of the information above. / Patient, if 18 or older Signature Printed Name Date Witness Date / Parent (or Guardian) Signature Parent (or Guardian) Printed Name Date Witness Date Rev: 7/18/08, 3/12/12, 1/13 I03-AIOP-010

3 CONSENT AND POLICY ACKNOWLEDGEMENT Please read and sign below to show your understanding and agreement to the following contract terms: CONSENT FOR TREATMENT I authorize and request that Four Winds - Saratoga carry out psychological examinations, treatments, and/or diagnostic procedures, which now or during the course of my care as a patient my physician deems advisable. I understand that the purpose of these procedures will be explained to me and that I will have an opportunity to ask questions. I understand that I can revoke my consent at any time. CONFIDENTIALITY I have received a copy of the Four Winds Saratoga Patient Bill of Rights and the Notice of Privacy Practices. I hereby consent to the taking of my/my child s photograph for identification purposes only. I understand that, upon discharge, my photograph will be kept by Four Winds Saratoga and filed in my medical record. FINANCIAL TERMS I understand that upon verification of health plan/insurance coverage and policy limits, my insurance carrier will be billed and Four Winds - Saratoga will be paid directly by the carrier. I agree that I am responsible for the full payment, if I am not eligible at the time services are rendered. I understand that deductibles, co-payments and/or outstanding balances are always due at the time of service. I will incur a Billing Service Fee of $10 whenever a copayment is not paid at the time of service. I will incur a Returned Check Fee of $20 on any bounced check. APPEALS AND GRIEVANCES I understand that I have the right to submit a complaint or grievance to Four Winds-Saratoga with respect to any aspect of the care provided. Further, I risk nothing in exercising this right. Complaints or grievances may be expressed in person or if I prefer I may put my concern in writing. Forms for written complaints and grievances are available at the receptionist s desk. ASSIGNMENT OF BENEFITS I, the undersigned, certify that I (or my dependent) have the above insurance coverage and I assign directly to Four Winds - Saratoga the right to payment under such insurance benefits. I understand that I am financially responsible for all charges for services rendered, whether or not paid by insurance. I have read and understand the terms set forth above. / Patient, if 18 or older Signature Printed Name Date Witness Date / Parent (or Guardian) Signature Parent (or Guardian) Printed Name Date Witness Date Rev: 7/18/08, 3/12/12, 1/13 I03-AIOP-023

4 Patient s Name: FAMILY MEDICAL QUESTIONNAIRE ONGOING MEDICAL PROBLEMS Name of Your Child s Primary Medical Provider: Patient s Date of Birth: Phone Number: Date of Last Visit to Your Child s Primary Medical Provider: HAS YOUR CHILD EVER HAD: Chicken Pox Illness Yes No Chicken Pox Vaccine Yes No Asthma Yes No Allergies Yes No High Blood Pressure Yes No Heart Condition or Murmur Yes No Head Injury Yes No Diabetes Yes No Seizures/Convulsions Yes No Tuberculosis or Positive Skin Test Yes No Undescended Testicles Yes No Last Menstrual Period/Age at 1 st Period Yes No Eye/Ear/or Speech Problem Yes No List Any Surgeries or Hospitalization Your Child Has Had: Reason for this Visit: COMMENTS CHECK AND EXPLAIN ANY OF THE FOLLOWING CURRENT OR ONGOING PROBLEMS: Weight Loss Yes No Weight Gain Yes No Sore Throat Yes No Frequent Headaches Yes No Skin Rashes/Eczema Yes No Difficulty Breathing Yes No Cough Yes No Sinus Problems Yes No Diarrhea Yes No Constipation Yes No Vomiting Yes No Problems With Urination Yes No Bedwetting Yes No Joint Problems or Pain Yes No OTHER: Rev. 07/14/09, 02/09/12 CD7-IP-033 Please continue on to the back of the form.

5 DEVELOPMENTAL HISTORY 1. Were there problems in pregnancy, labor, or delivery? If yes, what happened? 2. Did the mother use cigarettes, drugs or alcohol during pregnancy? 3. Did your child experience any problems during the first year? If yes, please describe. 4. Do you believe your child s development was normal? If no, why? YES NO 5. At what age did your child first walk? At what age did your child first use words correctly? MEDICATIONS/ALLERGIES 6. What medication(s) is your child currently taking? 7. Is your child allergic to anything? Yes No If yes, what? MEDICAL HISTORY 8. Do you believe you child is healthy? Yes No If no, why? 9. Are your child s immunizations (shots) up-to-date? Yes No Does your child attend school in NYS? Yes No 10. Has your child ever been hospitalized overnight or longer? Yes No If yes, when and for what reason? 11. Your child s dentist is: 12. Date of last dental check-up: TB RISK FACTOR SCREENING 1) Any history of foreign of birth or travel greater Yes No If so, which country or countries: than a three month stay in a country with higher risk of TB than the USA? 2) Any history of close contact with a person diagnosed with active TB? Yes No Relationship: When: 3) Any current symptoms of TB (i.e., cough greater than two weeks, unexplained weight loss, night sweats or bloody sputum). Yes No If yes, give details: Signature: Relationship to Patient: Date: Physician/NPP/FNP Signature: Title: Date: Time: Rev. 07/14/09, 02/09/12 CD7-IP-033

6 Helpful Not Helpful Current Use History of Use Adverse Reaction MEDICATION QUESTIONNAIRE Name: Date: Date of Birth: DIRECTIONS: Please place a check mark in the box that describes your experience with any of the medications listed below. Patient, Parent, Generic Name Trade Name Guardian or Physician/NPP Comments ANTIDEPRESSANTS Amitriptyline Elavil Bupropion Wellbutrin, Wellbutrin SR, Wellbutrin XL, Zyban Citalopram Celexa Clomipramine Anafranil Desipramine Norpramin Desvenlafaxine Pristiq Doxepin Sinequan, Silenor Duloxetine Cymbalta Escitalopram Lexapro Fluoxetine Prozac, Sarafem Fluvoxamine Luvox, Luvox CR Imipramine Tofranil Isocarboxazid Marplan Mirtazapine Remeron, Remeron SolTab Nefazodone Serzone Nortriptyline Pamelor Paroxetine Paxil, Paxil CR Phenelzine Nardil Selegiline Transdermal Emsam Sertraline Zoloft Tranylcypromine Parnate Trazodone Desyrel, Oleptro Venlafaxine Effexor, Effexor XR Vilazodone Viibryd ANTIPSYCHOTICS major tranquilizers Aripiprazole Abilify Asenapine Saphris Chlorpromazine Thorazine Clozapine Clozaril, Fazaclo Fluphenazine Prolixin, Prolixin Decanoate Haloperidol Haldol, Haldol Decanoate Iloperidone Fanapt Loxapine Loxitane Lurasidone Latuda Molindone Moban Rev. 08/05/10, 1/30/2012, 8/13 CD9-IP-057 1

7 Helpful Not Helpful Current Use History of Use Adverse Reaction MEDICATION QUESTIONNAIRE Name: Date: Date of Birth: Generic Name Trade Name Olanzapine Zyprexa, Zyprexa Zydis, Zyprexa Relprevv Paliperidone Invega, Invega Sustenna Perphenazine Trilafon Quetiapine Seroquel, Seroquel XR Risperidone Risperdal, Risperdal Consta Thioridazine Mellaril Thiothixene Navane Trifluoperazine Stelazine Ziprasidone Geodon ANXIOLYTICS anti-anxiety minor tranquilizers Alprazolam Xanax, Xanax XR Buspirone BuSpar Chlordiazepoxide Librium Clonazepam Klonopin, Klonopin Wafers Diazepam Valium Hydroxyzine Vistaril, Atarax Lorazepam Ativan Oxazepam Serax ANTICHOLINESTERASE/ALZHEIMER S AGENTS Donepezil Aricept Galantamine Razadyne Memantine Namenda Rivastigmine Exelon Tacrine Cognex ALCOHOL/DRUG/SMOKING CESSATION AGENTS Acamprosate Campral Buprenorphine/ Suboxone Naloxone Disulfiram Antabuse Methadone Dolophine Naltrexone ReVia, Vivitrol Varenicline Chantix Patient, Parent, Guardian or Physician/NPP Comments MOOD STABILIZING AGENTS/AED s Carbamazepine Tegretol Fluoxetine/Olanzapine Symbyax Gabapentin Neurontin Lamotrigine Lamictal, Lamictal XR Levetiracetam Keppra, Keppra XR Lithium Eskalith, Eskalith CR, Lithobid Rev. 08/05/10, 1/30/2012, 8/13 CD9-IP-057 2

8 Helpful Not Helpful Current Use History of Use Adverse Reaction MEDICATION QUESTIONNAIRE Name: Date: Date of Birth: Generic Name Trade Name Olanzapine Zyprexa, Zyprexa Zydis Oxcarbazepine Trileptal Tiagabine Gabitril Topiramate Topamax Valproate Depakene, Depakote, Depakote ER PSYCHOSTIMULANTS Amphetamine Salts Adderall, Adderall XR Atomoxetine Strattera Dexmethylphenidate Focalin, Focalin XR Dextroamphetamine Dexedrine, Dextrostat Armodafinil Nuvigil Lisdexamfetamine Vyvanse Methylphenidate Ritalin, Ritalin SR, Ritalin LA, Concerta, Metadate ER/CD Methylphenidate Daytrana Transdermal Modafinil Provigil Pemoline Cylert SEDATIVE/HYPNOTICS Chloral Hydrate Noctec Eszopiclone Lunesta Ramelteon Rozerem Temazepam Restoril Zaleplon Sonata Zolpidem Ambien, Ambien CR, Intermezzo OTHER Benztropine Cogentin Clonidine Catapres, Kapvay Diphenhydramine Benadryl Guanfacine Tenex, Intuniv Prazosin Minipress Propranolol Inderal Trihexyphenidyl Artane HERBAL PREPARATIONS Patient, Parent, Guardian or Physician/NPP Comments I am unable or unwilling to complete this form. Signature of Patient/Parent/Guardian: Reviewed over the phone with the parent/guardian of the patient. Reviewed in person with the parent/guardian of the patient. Signature of Psychiatrist/NPP: I have completed this form to the best of my ability. Date: Date/Time: Rev. 08/05/10, 1/30/2012, 8/13 CD9-IP-057 3

9 AUTHORIZATION FOR RELEASE OF INFORMATION FOUR WINDS SARATOGA 30 CRESCENT AVENUE SARATOGA SPRINGS, NEW YORK PHONE: (518) FAX: (518) Patient Name Date of Birth I authorize Four Winds Saratoga to obtain from or release to any Person/Program within the Organization/Facility/Program(s) listed below Person/Agency: Address: City, State, Zip: Covering the period of healthcare: last 1 yr or last 2 yrs or From date to date Obtain Release Diagnosis Only Dates of Admission and Discharge Integrated Assessments/Suicide Risk and Substance Abuse Assessments Clinical Discharge Summary Verbal/Written Communication for Discharge Medical: H&P, Labs, EKG, Immunizations, etc. Progress Notes Phone: Obtain Fax: Release School Discharge Summary/Educational Materials/Verbal Academic Reports Medication Information only Billing Issues & Payment Arrangements Applications Psychological Testing Other(Specify): Whole Record (a fee of $0.75/page may be applied) This information will be used for the following purpose(s): Evaluation and Continuing Treatment Coordinating Care Educational Placement/Other Educational Concerns/Billing School District for Education Insurance Eligibility/Benefits/Claims Resolution Legal Other (specify): I understand that I have the right to revoke this authorization at any time, by submitting a revocation in writing to the Health Information Management. The revocation will not apply to information that has already been released in response to this authorization. I also understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. This authorization will expire in one year from the date of the signature below and may be used until such time for either a one time release or periodic release of information. If the disclosure is for educational purposes, I understand that the recipient may be my child s home school district and any school within the home school district. Disclosure to any other school or educational entity requires a separate authorization. I understand that authorizing the disclosure of this information is voluntary. I understand that I can refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment. I understand that I have a right to receive a copy of this authorization. I understand that any disclosure of information carries with it the potential for an unauthorized re-disclosure by the recipient, and the information may not be protected by the federal privacy rules or by New York State law. Signature of Patient or Legal Guardian Date If Signed by Legal Guardian, Relationship to Patient Signature of Witness (over the age of 18) TO CANCEL PERMISSION OR REFUSE DISCLOSURE OF RECORDS FILL OUT THE INFORMATION BELOW I hereby cancel my permission to release information to the above named person or entity. Signature of Patient or Legal Guardian I hereby refuse to authorize the release of information to the above named person or entity. Date CD30-MRD-004 Rev. 3/11/03, 4/16/03, 4/17/03, 5/6/03, 7/14, 5/15

10 AUTHORIZATION FOR RELEASE OF INFORMATION FOUR WINDS SARATOGA 30 CRESCENT AVENUE SARATOGA SPRINGS, NEW YORK PHONE: (518) FAX: (518) Patient Name Date of Birth I authorize Four Winds Saratoga to obtain from or release to any Person/Program within the Organization/Facility/Program(s) listed below Person/Agency: Address: City, State, Zip: Covering the period of healthcare: last 1 yr or last 2 yrs or From date to date Obtain Release Diagnosis Only Dates of Admission and Discharge Integrated Assessments/Suicide Risk and Substance Abuse Assessments Clinical Discharge Summary Verbal/Written Communication for Discharge Medical: H&P, Labs, EKG, Immunizations, etc. Progress Notes Phone: Obtain Fax: Release School Discharge Summary/Educational Materials/Verbal Academic Reports Medication Information only Billing Issues & Payment Arrangements Applications Psychological Testing Other(Specify): Whole Record (a fee of $0.75/page may be applied) This information will be used for the following purpose(s): Evaluation and Continuing Treatment Coordinating Care Educational Placement/Other Educational Concerns/Billing School District for Education Insurance Eligibility/Benefits/Claims Resolution Legal Other (specify): I understand that I have the right to revoke this authorization at any time, by submitting a revocation in writing to the Health Information Management. The revocation will not apply to information that has already been released in response to this authorization. I also understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. This authorization will expire in one year from the date of the signature below and may be used until such time for either a one time release or periodic release of information. If the disclosure is for educational purposes, I understand that the recipient may be my child s home school district and any school within the home school district. Disclosure to any other school or educational entity requires a separate authorization. I understand that authorizing the disclosure of this information is voluntary. I understand that I can refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment. I understand that I have a right to receive a copy of this authorization. I understand that any disclosure of information carries with it the potential for an unauthorized re-disclosure by the recipient, and the information may not be protected by the federal privacy rules or by New York State law. Signature of Patient or Legal Guardian Date If Signed by Legal Guardian, Relationship to Patient Signature of Witness (over the age of 18) TO CANCEL PERMISSION OR REFUSE DISCLOSURE OF RECORDS FILL OUT THE INFORMATION BELOW I hereby cancel my permission to release information to the above named person or entity. Signature of Patient or Legal Guardian I hereby refuse to authorize the release of information to the above named person or entity. Date CD30-MRD-004 Rev. 3/11/03, 4/16/03, 4/17/03, 5/6/03, 7/14, 5/15

11 AUTHORIZATION FOR RELEASE OF INFORMATION FOUR WINDS SARATOGA 30 CRESCENT AVENUE SARATOGA SPRINGS, NEW YORK PHONE: (518) FAX: (518) Patient Name Date of Birth I authorize Four Winds Saratoga to obtain from or release to any Person/Program within the Organization/Facility/Program(s) listed below Person/Agency: Address: City, State, Zip: Covering the period of healthcare: last 1 yr or last 2 yrs or From date to date Obtain Release Diagnosis Only Dates of Admission and Discharge Integrated Assessments/Suicide Risk and Substance Abuse Assessments Clinical Discharge Summary Verbal/Written Communication for Discharge Medical: H&P, Labs, EKG, Immunizations, etc. Progress Notes Phone: Obtain Fax: Release School Discharge Summary/Educational Materials/Verbal Academic Reports Medication Information only Billing Issues & Payment Arrangements Applications Psychological Testing Other(Specify): Whole Record (a fee of $0.75/page may be applied) This information will be used for the following purpose(s): Evaluation and Continuing Treatment Coordinating Care Educational Placement/Other Educational Concerns/Billing School District for Education Insurance Eligibility/Benefits/Claims Resolution Legal Other (specify): I understand that I have the right to revoke this authorization at any time, by submitting a revocation in writing to the Health Information Management. The revocation will not apply to information that has already been released in response to this authorization. I also understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. This authorization will expire in one year from the date of the signature below and may be used until such time for either a one time release or periodic release of information. If the disclosure is for educational purposes, I understand that the recipient may be my child s home school district and any school within the home school district. Disclosure to any other school or educational entity requires a separate authorization. I understand that authorizing the disclosure of this information is voluntary. I understand that I can refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment. I understand that I have a right to receive a copy of this authorization. I understand that any disclosure of information carries with it the potential for an unauthorized re-disclosure by the recipient, and the information may not be protected by the federal privacy rules or by New York State law. Signature of Patient or Legal Guardian Date If Signed by Legal Guardian, Relationship to Patient Signature of Witness (over the age of 18) TO CANCEL PERMISSION OR REFUSE DISCLOSURE OF RECORDS FILL OUT THE INFORMATION BELOW I hereby cancel my permission to release information to the above named person or entity. Signature of Patient or Legal Guardian I hereby refuse to authorize the release of information to the above named person or entity. Date CD30-MRD-004 Rev. 3/11/03, 4/16/03, 4/17/03, 5/6/03, 7/14, 5/15

12 AUTHORIZATION FOR RELEASE OF INFORMATION FOUR WINDS SARATOGA 30 CRESCENT AVENUE SARATOGA SPRINGS, NEW YORK PHONE: (518) FAX: (518) Patient Name Date of Birth I authorize Four Winds Saratoga to obtain from or release to any Person/Program within the Organization/Facility/Program(s) listed below Person/Agency: Address: City, State, Zip: Covering the period of healthcare: last 1 yr or last 2 yrs or From date to date Obtain Release Diagnosis Only Dates of Admission and Discharge Integrated Assessments/Suicide Risk and Substance Abuse Assessments Clinical Discharge Summary Verbal/Written Communication for Discharge Medical: H&P, Labs, EKG, Immunizations, etc. Progress Notes Phone: Obtain Fax: Release School Discharge Summary/Educational Materials/Verbal Academic Reports Medication Information only Billing Issues & Payment Arrangements Applications Psychological Testing Other(Specify): Whole Record (a fee of $0.75/page may be applied) This information will be used for the following purpose(s): Evaluation and Continuing Treatment Coordinating Care Educational Placement/Other Educational Concerns/Billing School District for Education Insurance Eligibility/Benefits/Claims Resolution Legal Other (specify): I understand that I have the right to revoke this authorization at any time, by submitting a revocation in writing to the Health Information Management. The revocation will not apply to information that has already been released in response to this authorization. I also understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. This authorization will expire in one year from the date of the signature below and may be used until such time for either a one time release or periodic release of information. If the disclosure is for educational purposes, I understand that the recipient may be my child s home school district and any school within the home school district. Disclosure to any other school or educational entity requires a separate authorization. I understand that authorizing the disclosure of this information is voluntary. I understand that I can refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment. I understand that I have a right to receive a copy of this authorization. I understand that any disclosure of information carries with it the potential for an unauthorized re-disclosure by the recipient, and the information may not be protected by the federal privacy rules or by New York State law. Signature of Patient or Legal Guardian Date If Signed by Legal Guardian, Relationship to Patient Signature of Witness (over the age of 18) TO CANCEL PERMISSION OR REFUSE DISCLOSURE OF RECORDS FILL OUT THE INFORMATION BELOW I hereby cancel my permission to release information to the above named person or entity. Signature of Patient or Legal Guardian I hereby refuse to authorize the release of information to the above named person or entity. Date CD30-MRD-004 Rev. 3/11/03, 4/16/03, 4/17/03, 5/6/03, 7/14, 5/15

13 AUTHORIZATION FOR RELEASE OF INFORMATION FOUR WINDS SARATOGA 30 CRESCENT AVENUE SARATOGA SPRINGS, NEW YORK PHONE: (518) FAX: (518) Patient Name Date of Birth I authorize Four Winds Saratoga to obtain from or release to any Person/Program within the Organization/Facility/Program(s) listed below Person/Agency: Address: City, State, Zip: Covering the period of healthcare: last 1 yr or last 2 yrs or From date to date Obtain Release Diagnosis Only Dates of Admission and Discharge Integrated Assessments/Suicide Risk and Substance Abuse Assessments Clinical Discharge Summary Verbal/Written Communication for Discharge Medical: H&P, Labs, EKG, Immunizations, etc. Progress Notes Phone: Obtain Fax: Release School Discharge Summary/Educational Materials/Verbal Academic Reports Medication Information only Billing Issues & Payment Arrangements Applications Psychological Testing Other(Specify): Whole Record (a fee of $0.75/page may be applied) This information will be used for the following purpose(s): Evaluation and Continuing Treatment Coordinating Care Educational Placement/Other Educational Concerns/Billing School District for Education Insurance Eligibility/Benefits/Claims Resolution Legal Other (specify): I understand that I have the right to revoke this authorization at any time, by submitting a revocation in writing to the Health Information Management. The revocation will not apply to information that has already been released in response to this authorization. I also understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. This authorization will expire in one year from the date of the signature below and may be used until such time for either a one time release or periodic release of information. If the disclosure is for educational purposes, I understand that the recipient may be my child s home school district and any school within the home school district. Disclosure to any other school or educational entity requires a separate authorization. I understand that authorizing the disclosure of this information is voluntary. I understand that I can refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment. I understand that I have a right to receive a copy of this authorization. I understand that any disclosure of information carries with it the potential for an unauthorized re-disclosure by the recipient, and the information may not be protected by the federal privacy rules or by New York State law. Signature of Patient or Legal Guardian Date If Signed by Legal Guardian, Relationship to Patient Signature of Witness (over the age of 18) TO CANCEL PERMISSION OR REFUSE DISCLOSURE OF RECORDS FILL OUT THE INFORMATION BELOW I hereby cancel my permission to release information to the above named person or entity. Signature of Patient or Legal Guardian I hereby refuse to authorize the release of information to the above named person or entity. Date CD30-MRD-004 Rev. 3/11/03, 4/16/03, 4/17/03, 5/6/03, 7/14, 5/15

14 PATIENT S BILL OF RIGHTS Four Winds Saratoga Name: Date of Birth: At the time of admission to an inpatient or outpatient program patient's rights are reviewed and explained to the patient (and family, if appropriate) with respect to the care provided at a hospital of the mentally ill, as well as hospital's rules and regulations. Only then is the patient's signature and statement obtained on Admission Application and Status and Rights forms. Four Winds-Saratoga patients shall be afforded the right to: 1. Considerate and respectful care in a manner that assures non-discrimination which acknowledges and is respectful of their ethic and cultural environment; 2. Freedom from abuse and mistreatment; 3. The name of the physician responsible for coordinating his/her care; 4. The name and function of any person providing health care services to the patient; 5. Obtain from his/her physician complete current information concerning his diagnoses, treatment and prognosis in terms the patient can be reasonably expected to understand. When it is not medically advisable to give such information to the patient, the information shall be made available to an appropriate person in his/her behalf; 6. Receive from his/her physician the information necessary to give informed consent prior to the start of any procedure or treatment, or both, and which, except for those emergency situations not requiring an informed consent, shall include as a minimum the specific procedure or treatment, or both, the medically significant risks involved, and the probable duration of incapacitation, if any. The patient shall be advised of medically significant alternatives for care or treatment, if any; 7. Request a review of his/her medical record and receive a complete explanation of the procedure(s) by which appropriate access to the medical record is obtained; 8. Refuse treatment to the extent permitted by law and to be informed of the medical consequences of his/her action; 9. Privacy to the extent consistent with providing adequate medical care to the patient. This shall not preclude discreet discussion of a patient's care or examination of a patient by appropriate health care personnel; Revised: 6/2012, 11/2013 FWS-011 Page 1 of 4

15 PATIENT S BILL OF RIGHTS Four Winds Saratoga 10. Privacy and confidentiality of all records pertaining to the patient's treatment except as otherwise provided by law or third party contract. When indicated, the patient's record shall contain documentation that the rights of the patient and patient's families are protected; 11. A response by the hospital in a reasonable manner to the patient's request for service customarily rendered by the hospital consistent with the patient's treatment; 12. A response by the hospital in a reasonable and timely manner to the patient's need for appropriate medical care not customarily rendered by the hospital; 13. Be informed by his/her physician or delegate of the physician of the patient's continued mental and physical health care requirements following discharge and that before transferring a patient to another facility the hospital first inform the patient of the need for and alternative to such a transfer; 14. A response by the hospital in a reasonable, timely manner to the patient's complaint of physical pain, acute and chronic. Appropriate interventions, education and referral as applicable. 15. The identity, upon request, of other health care and educational institutions that the hospital has authorized to participate in his/her treatment; 16. Examine and receive an explanation of his/her bill, regardless of source of payment; 17. Know the hospital rules and regulations that apply to his/her conduct as a patient; 18. Services within the least restrictive environment as possible; to be informed/educated of methods to assist in anger management, interventions to safety of self/others all in least restrictive way. 19. An individualized treatment plan which is periodically reviewed; 20. Actively participate with their responsible parents or relatives in planning for treatment; 21. Request the opinion of a consultant at their own expense or request an in-hospital review of the patient's individual treatment plan; 22. Receive a written statement of the patient's rights and a copy is posted in each patient unit; 23. Be informed of their rights in a language the patient understands; 24. The current and future use and disposition of products of audio-visual techniques; Revised: 6/2012, 11/2013 FWS-011 Page 2 of 4

16 Revised: 6/2012, 11/2013 FWS-011 Page 3 of 4 PATIENT S BILL OF RIGHTS Four Winds Saratoga 25. To receive full explanation of any research project and the right to refuse participation in any research project; 26. Be informed of the hospital's responsibility, when the patient refuses treatment, to seek appropriate legal alternatives or orders of involuntary treatment with professional standards, to terminate the relationship with the patient upon reasonable notification; 27. Be informed of the source of the facility's reimbursement and any limitations placed on the duration of services; 28. Be informed of any changes in the professional staff responsible for the patient or any transfer of the patient within or out of the hospital; 29. To initiate a complaint or grievance through the unit leadership and/or Director of Quality Management, extension Audio-visual equipment and other procedures where consent is required by law; no such procedure shall be implemented without full consultation with the patient and/or family with full explanation of the reasons and efficacy of such. The use of such techniques shall be employed only in the service of augmented and/or enhanced patient care or for the purpose of internal educative functions for the staff. In either case, following the appropriate explanation, the patient has full right of refusal to participate in such procedures without prejudice to his/he continued stay and treatment at the hospital. In all such cases, written consent shall be obtained prior to implementation of such techniques. 31. Receive all necessary information concerning their rights under the New York State Health Care Proxy Law and assistance by the hospital in completing all necessary procedures relevant to his/her preferred advance directive(s). 32. Applies to Inpatient: Receive visitors, take telephone calls and send a receive mail unless clinically contraindicated as designated by you (or legal guardian), including but not limited to, a spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend. Also included is the right to withdraw or deny such consent at any time. 33. Applies to Inpatient: Suitable areas for patients to visit in private are available, unless clinically contraindicated; 34. You have the right to know the following: Four Winds Saratoga Hospital believes that you are entitled to make informed decisions regarding your medical care. Medical staff, including nurses, clinicians and physicians, are either present at the Hospital or available on-call by telephone at all times. However, a physician is not on-site 24 hours per day, 7 days per week. If a medical emergency arises when a physician is not on-site, the

17 PATIENT S BILL OF RIGHTS Four Winds Saratoga Hospital will initiate its Rapid Response protocol and provide treatment to the patient, and if needed CPR and emergency transport to a local medical facility by an ambulance service dispatched by phoning 911. The physician on-call will be notified. The Hospital hereby notifies you that it meets the federal definition of a physician-owned hospital, pursuant to 42 C.F.R Section The list of the Hospital s physician owners or investors is available to you upon request from Jacqueline Gacek RN MS, the Hospital s Director of Quality Management who may be reached at , ext Be informed of the address and phone numbers of the following agencies: Mental Hygiene Legal Services c/o Capital District Psychiatric Center 75 New Scotland Avenue Unit B - Lower Level Albany, New York Phone: (518) Fax: (518) New York State Office of Mental Health 44 Holland Avenue Albany, New York En Espanol: TDD for people who are deaf or hearing impaired < National Alliance for the Mentally Ill 260 Washington Avenue Albany, New York < The U.S. Department of Health and Human Services 200 Independence Ave,. S.W. Washington, D.C Division of Quality Assurance and Investigations NYS Commission on Quality of Care and Advocacy for Persons with Disabilities 401 State Street Schenectady, New York < Office of Quality Monitoring The Joint Commission One Renaissance Blvd Oak Brook Terrace, IL Toll Free: complaint@jointcommission.org Revised: 6/2012, 11/2013 FWS-011 Page 4 of 4

18 Four Winds Saratoga 30 Crescent Avenue Saratoga Springs, NY If you have any questions about this Notice please contact the Hospital s Privacy Officer, Jacqueline Gacek, RN MS, ext Your Information. Your Rights. Our Responsibilities. This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. Your Rights When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you. For certain types of disclosures of information in your medical record at a psychiatric hospital, New York State law may be more stringent than the federal law. For example the New York Mental Hygiene Law generally does not permit the disclosure of a clinical record except under circumstances specifically set forth in the law. The Hospital will follow New York law when it is more restrictive. Get an electronic or paper copy of your medical record Ask us to correct your medical record Request confidential communications Ask us to limit what we use or share You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this. We will provide a copy or a summary of your health information, usually within 10 days of your request. We may charge a reasonable, cost-based fee. You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this. We may say no to your request, but we ll tell you why in writing within 60 days. You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. We will say yes to all reasonable requests. You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say no if it would affect your care. If you pay for a service or health care item out-of-pocket Notice of Privacy Practices Page 1

19 Get a list of those with whom we ve shared information Get a copy of this privacy notice Choose someone to act for you File a complaint if you feel your rights are violated in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say yes unless a law requires us to share that information. You can ask for a list (accounting) of the times we ve shared your health information for six years prior to the date you ask, who we shared it with, and why. We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We ll provide this accounting for free. You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly. If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take any action. You can complain if you feel we have violated your rights by contacting Brenda Quinn, LMSW, at ext You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C , calling , or visiting We will not retaliate against you for filing a complaint. Your Choices For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions. In these cases, you have both the right and choice to tell us to: Our Uses and Disclosures Share information with your family, close friends, or others involved in your care Share information in a disaster relief situation If you are not able to tell us your preference we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety. How do we typically use or share your health information? We typically use or share your health information in the following ways. To treat you We can use your health information and share it with other professionals who are treating you. Example: The psychiatrist treating you may ask your outpatient psychiatrist about your treatment. Notice of Privacy Practices Page 2

20 Run our organization Bill for your services We can use and share your health information to run our hospital, improve your care, and contact you when necessary. We can use and share your health information to bill and get payment from health plans or other entities. Example: We use health information about you to manage your treatment and services. Example: We give information about you to your health insurance plan so it will pay for your services. How else can we use or share your health information? We are allowed or required to share your information in other ways usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: Help with public health and safety issues Do research Comply with the law Inmates Work with a medical examiner We can share health information about you for certain situations such as: Preventing disease Helping with product recalls Reporting adverse reactions to medications Reporting suspected abuse, neglect, or domestic violence Preventing or reducing a serious threat to anyone s health or safety We can use or share your information for health research. All research projects for patients receiving psychiatric services are subject to a special approval process under New York law. We will share information about you if state or federal laws require it, including with the Department of Health and Human Services or the NYS Office of Mental Health if it wants to see that we re complying with federal and/or state privacy law. We can share health information about you in response to a court or administrative order, or in response to a subpoena. For workers compensation claims For law enforcement purposes or with a law enforcement official With health oversight agencies for activities authorized by law For special government functions such as military, national security, and presidential protective services. If you are an inmate of a correctional facility, we may disclose medical information necessary for making a determination regarding your health care, security, safety or ability to participate in programs when the chief administrative officer of the facility has made a request for it. We can share health information with a coroner or medical examiner when an individual dies. Notice of Privacy Practices Page 3

21 Respond to organ and tissue donation requests Other We can share health information about you with organ procurement organizations. We do not create or manage a hospital directory. We do not contact patients for marketing or fundraising efforts. Our Responsibilities We are required by law to maintain the privacy and security of your protected health information. We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. We must follow the duties and privacy practices described in this notice and give you a copy of it. We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind. For more information see: Changes to the Terms of This Notice We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site. Effective date of this Notice: 09/23/2013. This Notice of Privacy Practices applies to Four Winds Saratoga. Notice of Privacy Practices Page 4