CONSENT FOR RELEASE OF INFORMATION

CONSENT FOR RELEASE OF INFORMATION

POLICY     Prior to obtaining a consent for release of confidential information, the Qualified Professional or his designee, shall inform the client or his legally responsible person that the provision of services is not contingent upon such release. The client or legally responsible person shall give consent voluntarily. The Ship Group Community Services ensures that confidential information regarding clients will not be released until Consent for Release form has been obtained. The Ship Group Community Services ensures that confidential information regarding clients will be protected from disclosure without consent. The dignity and privacy of all clients are protected by vigilant oversight of confidential records and information. All records are maintained in accordance with the APSM 45-1.

All confidential information consents will be documented on The Ship Group Community Services form Consent for Release of Information. The consent form must be complete with all specified information.(Area or state agency employees may not release any confidential information until a Consent for Release form as described in Rules .0202 and .0203 of this Section has been obtained. Disclosure without authorization shall be in accordance with G.S 122C-52 through 56 and Section .0300 of this Subchapter.) Each consent form will contain the following information:

1. Client name

2. Name of agencies releasing the information

3. Name of individual or individuals, agency or agencies to whom information is being released

4. Information to be released

5. Purpose for the release

6. Length of time consent is valid

7. A statement that the consent is subject to revocation at any time except to the extent that action has been taken in reliance on the consent

8. Signature of the client or the client’s legally responsible person and

9. Date consent is signed.

Consent forms must be time and information specific, and will be valid for a maximum of one year. Unless revoked sooner by the client or the client’s legally responsible person, a consent for release of information shall be valid for a period not to exceed one year except under the following conditions:

a. A consent to continue established financial benefits shall be considered valid until cessation of benefits; or

b. A consent for release of information to the Division of Motor Vehicles, the Court and the Department of Correction for information needed in order to reinstate a client’s driving privilege shall be considered valid until reinstatement of the client’s driving privilege.

A consent for release of information received from an individual or agency does not have to be on the form utilized by The Ship Group Community Services however, The Ship Group Community Services will determine that the content of the consent form meets all requirements.

A clear and legible photocopy of a consent for release of information shall be considered to be as valid as the original.

Confidential information regarding HIV, AIDS or AIDS related conditions shall only be released in accordance with NC general statutes 130A – 143. Whenever authorization is required for the release of this information, the consent shall specify that the information to be released includes information relative to HIV infection, AIDS or AIDS related conditions.

PERSONS WHO MAY SIGN CONSENT FOR RELEASE

The following persons may sign a release of confidential information:

1. A competent adult client;

2. The client’s legally responsible person;

3. A minor client under the following conditions:

1. Pursuant to G.S. 90-21.5 when seeking services for venereal disease and other diseases reportable under G.S. 130A-135, pregnancy, abuse of controlled substances or alcohol, or emotional disturbances;

2. When married or divorced

3. When emancipated by a decree issued by a court of competent jurisdiction;

4. When a member of the armed forces; or

Personal representative of a deceased client if the estate is being settled or next of kin of a deceased client if the estate is not being settled.

SIGNATURE BY MARK

The Ship Group Community Services does permit the use of “signature by mark”. As such, our clinical practices require notation in the permanent client record of special circumstances that, either permanently or temporarily result in the permissible use of “signature by mark”. Acceptance of signature by mark is further defined by The Ship Group Community Services Care to specifically pertain to instances where a legally responsible party is unable to physically sign or legibly sign due to injury, disability, or literacy limitations.

The notation must include the actual “mark” that will be utilized and recognized as the signature and must be documented using the author’s own penmanship. When signature by mark is utilized, all consents must be co-signed by two witnesses. Staff are not permitted to sign in lieu of the legally responsible party or to highlight form signature areas using any marks such as “X”. The acknowledgement and disclosure of “signature by mark” use must be filed as the first page in the client record and, when applicable, directly preceding any consents in the record

for reference.

Authorization for use and Disclosure of Protected Health Information

45 C.F.R. Parts 160 and 164; 42 C.F.R., Part 2 ; G.S. 122 C

This authorization form implements the requirements for client authorization to use and disclose health information protected by the federal health privacy law (45 C.F.R. Parts 160, 164) the federal drug an alcohol confidentiality law (42 C.F.R Part 2) and the state confidentiality law governing mental health, developmental disabilities, and substance abuse services (G.S. 122 C).

Client Name:______________________________ Date of Birth:______________________________

I, ________________________________________ hereby authorize, The Ship Group Community Services

                           (Client Name or Legal Guardian)

to (exchange) use or disclose to and/or with ________________________________________________________

                                                                  (Name and address of agency or person to whom the requested use or disclosure will be made)

This Data Shall Include (Please initial in spaces that apply)

_____ Assessments 

_____ Service Notes

_____ Substance Abuse/Treatment

____ Psychiatric Evaluations 

_____ Service Plans/Goals 

_____ HIV/AIDS Information

_____ Psychological Evaluations 

_____ Discharge Summary

____ Social, Developmental, Medical History

_____ Diagnosis

 _____ Financial/Reimbursement

_____ Other

Purpose of disclosure: (Please Initial in Spaces that apply)

_____ At the request of the individual

_____ Court Proceedings

_____ Assessment/Evaluation

_____ Determination of Benefits

_____ Coordination of Services

Information requested should be mailed to this address:___________________________________________________________

Redisclosure: Once information is disclosed pursuant to this legal authorization, I understand that the federal privacy law (45 C.F.R. Parts 160 & 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 we disclose mental health and developmental disabilities information protected by state law (G.S. 122C) or substance abuse treatment information protected by federal law (42 C.F.R, Part 2, we must inform the recipient of the information that disclosure is prohibited except as permitted or required by these two laws.

Revocation and Expiration: I understand that, with certain exceptions, I have the right to revoke this authorization at any time. However, your revocation will not be effective to the extent that The Ship Group Community Services has taken action in reliance on this authorization or if this authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.

If not revoked earlier, this consent shall be valid for one year from the date signed unless otherwise indicated below:

__________________________________________________                   ________________________________________

    Date of expiration, if less than one year                                                       Event, if less than one year

Notice of Voluntariness: I understand that I may refuse to sign this authorization form. I understand that Continue Care Services will not deny or refuse to provide treatment, payment, enrollment in a health plan, or eligibility for benefits if I refuse to sign.

_______________________ _____   ________ ____      ___________________                                                            ______

Signature of Client                                         Date                       Witness (required if symbol or mark is used by client or LRP)

___________________________________________                                        __________                  __                    

Signature of legally responsible person, if required                                                              Date 

Staff Signature: __________________________________________              Date: ________________________

DOCUMENTATION OF RELEASE

Whenever confidential information is released with consent, a delegated employee shall ensure that documentation of release is placed in the client record. This documentation shall include the consent form, the date the information was released, and full and legible signature of the delegated employee releasing the information.

Persons Designated to Disclose Confidential Information

The area or state agency director shall be responsible for the disclosure of confidential information but may delegate the authority for disclosure to others persons under his supervision. Such delegation should be in writing.

PROHIBITION AGAINST REDISCLOSURE

When The Ship Group Community Services releases information we will inform the recipient that re-disclosure of such information is prohibited without client consent. A stamp will be used to fulfill this requirement.

RELEASE TO HUMAN RIGHTS COMMITTEE MEMBERS

Human Rights Committee members may have access to confidential information only upon written consent of the client or the client’s legally responsible person.

The Director or Qualified Professional will release confidential information upon written consent to the Human Rights Committee members only when such members are engaged in fulfilling their function as set forth in 10NCAC 14G.0207, and when involved in or being consulted in connection with training or treatment of the client.

RELEASE TO AREA BOARD MEMBERS

Area board members may have access to the confidential information only upon written consent of the client or the client’s legally responsible person or pursuant to other exceptions to confidentiality as specified in GS 122C-53 through 122C-55. Area board members may have access to non-identifying client information.

Upon request by the Secretary, internal client advocates may disclose to the Secretary or his designee confidential information obtained while fulfilling monitoring and advocacy functions.

DISCLOSURE OF CONFIDENTIAL INFORMATION WITHOUT CONSENT

Notice To Client

Each area or state agency that maintains confidential information shall give written notice to the client or the legally responsible person at the time of admission that disclosure may be made of pertinent information without his expressed consent in accordance with G.S 122C-52 through 122C-56. This notice shall be explained to the client or legally responsible person as soon as possible. The giving of notice to the client or legally responsible person shall be documented in the client record.

Individuals employed in area and state and employees governed by the State personnel Act, G.S Chapter 126, are subject to suspension, dismissal or disciplinary action for failure to comply with the rules in this Subchapter.

All individual whether area, student, volunteer or state agents of DHHS who fail to comply with the rules in subchapter 126 shall be denied access to confidential information by the agency.

The rules governing confidentiality permit the disclosure of confidential information without consent under specific conditions only. The Ship Group Community Services will document the release and notify the client and or legal representative if disclosure must be made without consent. At admission information will be given to the client or responsible person regarding the circumstances under which confidential information may be released without consent.

The following conditions permit the release of confidential information without consent:

1. When court of competent jurisdiction issues an order compelling disclosure.

2. For purposes of filing an involuntary commitment petition.

3. For purposes of filing a petition for the adjudication of incompetence of a client and the appointment of an interim guardian.

4. When there is imminent danger to the health and safety of the client or others or there is likelihood of the commission of a felony or violent misdemeanor.

5. When emergency medical services are being provided to a client.

All other exchanges of information require a valid signed consent form.

DOCUMENTATION OF DISCLOSURE

With the exception of disclosure of confidential information pursuant to GS 122c-54(b), (c), 122c-55(h), or 122c-56, the Director, Qualified Professional or designee will ensure that documentation of the disclosure is recorded in the client record and contains the following:

1. Name of recipient;

2. Extent of information disclosed;

3. Specific reasons for disclosure;

4. Date; and

5. Full and legible signature of the individual who disclosed the information and his title.

Whenever this agency makes repeated disclosure to a provider of support services concerning the same client, the disclosing agencies may document such disclosures one time in the client record.

Whenever confidential information is disclosed in accordance with GS 122c-55(e), the reason written consent could not be obtained will be documented in the client’s record.

Area board members may have access to confidential information only upon written consent of the client or the client’s legally responsible person or pursuant to other exceptions to confidentiality as specified in G.S. 122C-53 through 122C-55. Area board members may have access to non-identifying client information.

Upon request by Secretary, internal client advocates may disclose to the secretary or his designee confidential information obtained while fulfilling monitoring and advocacy functions, to included state and Area agency, psychiatric hospital to determine whether the client is eligible for services.

INFORMATION PROVIDED TO FAMILY / OTHERS

Information shall be provided to the next of kin or other member, who has a legitimate role in the therapeutic services offered, or other person designated by the client of his legally responsible person in accordance with GS 122C-55(j) through (l).

INFORMATION RECEIVED FROM OTHER AGENCIES/INDIVIDUALS

Whenever The Ship Group Community Services receives confidential information from another agency or individual, such information shall be treated as any other confidential information generated by The Ship Group Community Services The Ship Group Community Services will not release or disclosure such information. If such information is requested and is accompanied by a valid consent for exchange of information the requestor will be redirected to the originator of the information.

GENERAL CONSENTS OF MEDICAL RECORDS

Every Client Record maintained by The Ship Group Community Services will contain the following:

• Identification/ Face Sheet
• Documented eligibility for services
• Referral / intake form
• Service orders
• Plan of care / Treatment Plan
• Progress notes
• Psychological and Social history
• Correspondence
• Admission Assessment
• Discharge Summaries (if applicable)
• MAR (if applicable)
• Medication orders
• Orders for and copies of Lab Test
• Signed acknowledgement of receipt of client rights information
• Consent to seek emergency medical care from a physician and/or hospital
• Name, phone number and address of person to contact in case of emergency of accident
• and name, address and phone number of consumers' preferred physician
• Consents to exchange information (as applicable)
• Documentation of disclosure of confidential information (as applicable)
• Consent for treatment
• Current consumer physical
• Medication education documentation (if applicable)

AIDS INFORMATION AND COMMUNICABLE DISEASES

Confidential information regarding HIV, AIDS or related conditions shall only be released in accordance with NC general statutes 130A – 143. Whenever information of this nature is to be released, it must be specifically identified in the consent.