Patient Onboarding

As the parent or legal guardian of ______________________________, I hereby give permission and consent to Positive Pathways Behavioral Health and consulting professional to conduct Psychiatric, Psychological Education, and Psychosocial Evaluations for the purpose of treatment planning.

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I understand that Positive Pathways Behavioral Health is a behavioral health organization operating on a cost reimbursement basis only.

With the intent to bind my heirs, relatives, legal representative and assigns, I expressly release and hold harmless Positive Pathways Behavioral Health, employees, and all other persons working with them on their behalf, from all liability, loss, damage, claims, actions or judgments of any kind which may arise in connection with the treatment which I have received or will receive.

All services received and all information obtained is kept confidential and cannot be released without your permission. You need to know however, that there are special situations under which confidential information could be revealed as such:

1. You (or your legal guardian) sign written release of confidential information, thus giving your permission.
2. In the case of an emergency where a "Duty to Warn" and "Duty to Protect" ethic requires your counselor to break confidentiality when a danger exists to you or to someone else. (This includes suspected or confirmed reports of child/elderly or incapacitated adult abuse, neglect or exploitation.)
3. Under very special circumstances, the court may subpoena your records, and may order a counselor to give testimony during a court hearing.

I have read this disclaimer and release of liability and understand and have executed it as my free and voluntary act.

As required by the Health Insurance Portability and Accountability Act of 1996 this practice may not use your personal health information for the purpose of treatment, payment or health care operations. The specified uses and disclosures that we intend to make are described in our Notice of Information Practices. You have the right to review the Notice of Information Practices prior to signing this consent form. You may request restrictions on the uses and disclosures described in the notice of information practices by describing the requested restrictions in the restriction request section of this form. You may revoke this consent at any time by signing and dating the revocation section on your copy of the form and returning it this office.

Consent Section

I________________________________ hereby consent to the use and disclosure of my child’s personal health information for the purpose of treatment, payment and health care operations. My signature below indicates that I have been given an opportunity to read the Notice of Information Practices and have any questions answered before signing.

I understand that I may request restrictions on the uses and disclosures of my health information at any time by completing and signing the restriction section of this form. I further understand that the practice is not required to accept my restriction request.

I understand that I may revoke this consent at any time by signing the revocation section of my copy of this form and returning it to the agency. I further understand that any such revocation does not apply to me extent that persons authorized to use or disclose my health information have already cited in reliance to this consent.

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I,_________________________ have been informed that Positive Pathways Behavioral Health, LLC provides a 24 hour, 7 days a week emergency telephone number for the use of consumers or family members in crisis situations. This individual answering this phone number will contact the ON-CALL staff (Clinical Manager, Mental Health Professional, or Mental Health Specialist) 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 when needed.

READ CAREFULLY-THIS AFFECTS YOUR LEGAL RIGHTS

In exchange for participation in the activity of transporting a client in an employee’s vehicle organized by Positive Pathways Behavioral Health, and/or use property, facilities and services of POSITIVE PATHWAYS BEHAVIORAL HEALTH, I agree for myself and (if applicable) for the members of my family, to the following:

1. I agree to observe and obey all posted rules and warning, and further agree to follow any oral instructions or directions given by POSITIVE PATHWAYS BEHAVIORAL HEALTH, or the employees, representatives or agents of POSITIVE PATHWAYS BEHAVIORAL HEALTH.
2. I recognize that there are certain inherent risks associated with the above described activity and I assume full responsibility for personal injury to myself and (if applicable) my family members, and further release and discharge POSITIVE PATHWAYS BEHAVIORAL HEALTH for injury, loss of damage arising out of my family’s use of or presence upon the facilities of POSITIVE PATHWAYS BEHAVIORAL HEALTH, whether caused by the fault of myself, my family, POSITIVE PATHWAYS BEHAVIORAL HEALTH or other third parties.
3. I agree to indemnify and defend POSITIVE PATHWAYS BEHAVIORAL HEALTH against all claims cause of action, damages, judgments, costs or expenses, including attorney’s fees and other litigation costs, which may in any way arise from me or my family’s use of or presence upon the facilities of POSITIVE PATHWAYS BEHAVIORAL HEALTH.
4. I agree to pay for all damages to the facilities of POSITIVE PATHWAYS BEHAVIORAL HEALTH caused by me or my family’s negligent, reckless, or willful actions.
5. I consent to the participation of myself and or minor child for transportation in an employee’s vehicle, and agree on behalf of myself and or minor child to all the terms and conditions of this Agreement. By signing this Release of Liability, I attest that I have legal authority over and custody of_______________________.
6. In the event of an injury to myself or the above minor during the above described activities, I give my permission to POSITIVE PATHWAYS BEHAVIORAL HEALTH or to employee, representatives or agents of POSITIVE PATHWAYS BEHAVIORAL HEALTH to arrange for all necessary medical treatment for which I shall be financially responsible. POSITIVE PATHWAYS BEHAVIORAL HEALTH shall have the following powers:
   
   a. The power to seek appropriate medical treatment or attention on behalf of myself and or minor child as may be required by the circumstances, including without limitation, that of a licensed medical physician and/or a hospital;
   RELEASE OF LIABILITY (Page 2 of 2)
   b. The power to authorize treatment or medical procedures in an emergency situation; and
   c. The power to make appropriate decisions regarding clothing, bodily nourishment and shelter.
   Any legal or equitable claims that may arise from participation in the above shall be resolved under Mississippi law.

I HAVE READ THIS DOCUMENT AND UNDERSTAND IT. I FURTHER UNDERSTAND THAT BY SIGNING THIS RELEASE, I VOLUNTARY SURRENDER CERTAIN LEGAL RIGHTS.

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Psychotherapy or counseling is a process of growth and problem solving. It is an effort that requires sincerity, hard work and commitment from the client(s) and the therapist.

Our commitment to you is to use our knowledge and skills to assist you in meeting your specific needs. All information will be held confidential and treated within the HIPAA guidelines and other applicable laws. Your personally identifying health information may be disclosed for treatment purposes, to obtain payment for treatment provided and as necessary for the operations of the practice of Positive Pathways Behavioral Health. These uses and disclosures are more fully explained in the Privacy Notice that has been provided and that you have had the opportunity to review. You may request that Positive Pathways Behavioral Health restrict how your health Information is used or disclosed. Positive Pathways Behavioral Health does not have to agree to the request, but if the agency does agree, it is bound by the restriction as agreed. In general, our practice is to ask for a release prior to disclosing any information.

We anticipate our work together will be productive, but no guarantees or assurances can be made as to the results that may be realized, as there are numerous influencing factors. If you think this therapy or counseling is not meeting your needs, we encourage you to bring this to our attention without delay in order that adjustments or explanations may be made. We believe that our mental/emotional health affects our spiritual health and vice versa.

By my signature below, I hereby agree to the following:

1. I consent to such treatment procedures as are deemed necessary by the provider, including those which are in addition to or different from those initially contemplated, and which are deemed necessary or advisable by the provider in the course of treatment.
2. I give our consent to the provider and its agents to use or disclose our protected health information (PHI) to carry out treatment, payment, or health care operations. The provider may release, use, or disclose our PHI to other health care personnel including, but not limited to, physicians, nursing staff, physician assistants, child life specialists, physical therapists, occupational therapists, and other such entities or persons as are deemed related to treatment, payment, and health care operations, as determined in the sole discretion of the provider, his practice group, and their respective agents.
3. If another provider who is involved with treatment, payment, or health care operations relating to me requests our medical records, I consent to the release of our entire medical record maintained by the provider to those other providers.
4. I agree, as part of this consent for payment operations, that the provider, his group, and their billing personnel, billing agents, or management company can disclose billing information to any person that calls the provider with billing questions after the provider inquires as to the identity of the calling person and the calling person provides our correct social security number and/or health plan number.
5. I agree that the provider or its agents or representatives may call and leave voice mail messages at our home or other number I provide them regarding medical appointments, billing or payment issues, or other information related to treatment, payment or health one operations. I also agree that similar messages may be left with someone who answers the phone at any of the numbers provided.
6. I understand the limitations of electronic communication privacy. Emails are stored, text messaging can be stored and wireless communications can be intercepted. Additionally, such electronic communications may be viewable by others if they intentionally or unintentionally have access to personal electronic devices and/or accounts. With this understanding and the understanding that the provider will attempt to be as discreet as possible; I prefer the following methods of communicating with the provider and grant permission for the provider to use  electronic communication with me or others who may be involved in our treatment.
7. I agree that the provider may discuss our PHI with any person that accompanies me to a session or consultation or is present with me when the provider is present. The provider may rightly assume that if another person is with me, I have no objection to disclosure of our PHI to that person. I also agree the provider may discuss our PHI with any person that identifies him or herself as active in our mental, physical, emotional or spiritual care, including, but not limited to family friends, clergy, and patient advocates. I also agree that the provider, his practice group, and their agents may disclose our PHI to employers who arrange and pay, directly or indirectly for our medical treatment.
8. If applicable, I agree that the provider, his practice group, and their agents may discuss our child's PHI with the person accompanying the child. I agree that the provider may discuss PHI with both natural parents and stepparents. I acknowledge that state law may grant our child certain privacy rights regarding the child's PHI, and that I have no right to receive this information.
9. I agree that the provider, his practice group, and their agents may, upon request by the following entities, disclose our PHI to public health agencies, law enforcement, and the FDA.

I, _____________________________________, have read, understand and agree to the stipulations above and give our consent to receive therapy or counseling. I understand that I am responsible for the payment of our assessed fees will be billed to insurance.

I have received or had opportunity to view a copy of the Statement of Rights and Responsibilities, Professional Disclosure Statement, Notice of Privacy Practices and Emergency Contact Information.

This consent will remain in effect commencing on the date of admission until I have been discharged and/or fees have been settled. I understand that I have the right to revoke/ withdraw any part or all of this consent in writing at any time. My revocation/ withdrawal will be effective upon being presented to Positive Pathways Behavioral Health except to the extent -that the agency has already taken action in reliance on our consent for use or disclosure of our health information.

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POSITIVE PATHWAYS BEHAVIORAL HEALTH, Positive Pathways Behavioral Health program acknowledge the dignity of and will protect the rights of all clients served as well as their families. This agency will ensure that each client has a freedom of choice with regard to selecting providers of services, including this one. All participation in the program is voluntary and no client will be forced to receive services for which he or she is eligible.

POSITIVE PATHWAYS BEHAVIORAL HEALTH: Positive Pathways Behavioral Health Program operates in accordance with Title VI and VII of the Civil Rights Act of 1964, as amended, and the Vietnam Veterans Readjustment Act of 1974 and all requirements imposed by or pursuant to the regulation of the U.S. Department of Health and Human Services. This means that individuals are accepted and that all services and facilities (waiting room, toilet, etc) are available to persons without regard to race, age, sex, or national origin.

Each recipient of our services and/or parent shall have the opportunity to participate in any meeting involving the assessment of needs of the planning of care for that individual.

Except as required by law, no information, written or verbal, concerning the client or his /her family shall be released or requested without a signed, dated and witnesses’ statement made by the client of his/her agent authorizing Positive Pathways Behavioral Health to do so. The statement of authorization shall indicate by name to whom and for whom information will be transmitted and for what purpose.

As client, you have the right to voice a grievance against the manner in which you are treated without fear of reprisals. When doing so, you should follow the chain of command. For example, if you have problems with a staff member working with you or your family, you should first discuss it with that person. If the result is not satisfactory bring the problem to the attention of their Supervisor and/or Program Manager. If the problem is not resolved to your satisfaction, you should bring it to the attention of the Department of Mental Health in Jackson, MS 39201 at 601-359-1288

As a consumer OR as a guardian of a consumer of Positive Pathways Behavioral Health, upon admission I have been instructed in or given written materials regarding:

1. Rights and responsibilities of the person served. Grievance and appeal procedures.
2. Ways in which input is given regarding:

1. The quality of care.
2. Achievement of outcomes.
3. Satisfaction of the person served.

An explanation of the organization’s:

1. Services and activities.
2. Expectations.
3. Hours of operation.
4. Access to after-hour services.
5. Code of ethics.
6. Confidentiality policy.
7. Requirements of follow-up for the mandated person served, regardless of his or her 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 codes, emergency exits and/or shelters, fire suppression equipment, and first aid kits.

The program’s policies regarding:

1. The use of seclusion or restraint.
2. Smoking.
3. Illicit or licit drugs brought into the program.
4. Weapons brought into the program.
5. 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:

1. Any restrictions the program may place on the person served.
2. Events, behaviors, or attitudes that may lead to the loss of rights or privileges for the person served.
3. 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 services and activities include:

1. Expectations for consistent court appearances.
2. Identification of therapeutic interventions, including:

• Sanctions.
• Interventions.
• Incentives.
• Administrative discharge criteria.

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I, ________________________________, give permission for Positive Pathways Behavioral Health to give me behavioral health Recipient Name
treatment. I consent to abide by the Agency’s specific policies and procedures relating to services that have been reviewed with me, which include provisions for termination of services at request by me, the physician, or the Agency.

I allow Positive Pathways Behavioral Health to file for insurance benefits to pay for the care I receive. I request the payment of authorized benefits be made to Positive Pathways Behavioral Health on my behalf.

I understand that:

• Positive Pathways Behavioral Health will have to send my medical record information to my
  insurance company and authorized external review agencies to verify eligibility, confirm benefits, or pay claims. I authorize my records to be reviewed for any necessary audits or accrediting surveys by representatives of CARF and/ or state agencies.
• I understand that no limitations are placed on dates, history of illness, or diagnostic and therapeutic information, including any treatment for alcohol and drug abuse, and psychiatric/ psychosocial information. I understand this can be revoked at any time by written request except that disclosure has already occurred in reliance on this consent.

I understand that:

• I have the right to refuse any procedure or treatment.
• I have the right to discuss all medical treatments with my provider.

I understand that I will receive some or all of the following services: o Outpatient Therapy (Home and Community)

• Day Treatment
• ‍Individual Counseling
• Family Counseling
• Psychiatric Diagnostic Assessment
• Medication Management

I acknowledge receipt of Positive Pathways Behavioral Health handbook, which includes Rights and Responsibilities. The contents have been explained to me and I understand the meaning. I have participated in the care planning process and agree to all of the above.

Advance Directives are legal documents, which express your wishes regarding your mental health treatment should you become incapable. You have the right to make decisions in advance about mental health treatment, which includes but is not limited to psychoactive medication, short-term (not to exceed 15 days) admission to a treatment facility, and outpatient services. Advance Directives also allows you to let someone else make decisions about your mental health treatment.

Under federal and state law, Positive Pathways Behavioral Health is required to explain your rights to make personal decisions regarding your medical care and to ask whether or not you have documented your wishes. Positive Pathways Behavioral Health helps in developing an advance psychiatric directive if you choose.

If you have already completed Advance Directives previously, please provide Positive Pathways Behavioral Health with a copy of your signed document.

In the absence of an Advance Directive or a physician’s order, we will provide all care necessary to sustain life. We will not discriminate against you on the basis of whether or not you have signed Advance Directives.

You may choose to discuss these matters with an attorney although there is no requirement to do so. Anyone 18 or over can make his/her own determination by signing Advance Directives.

Positive Pathways Behavioral Health recognizes your rights to decline treatment and refuse assistance with developing Advance Directives to the extent permitted by law without threat of coercion, discrimination, reprisal, or unreasonable interruption of services.

I understand that each authorization signed below will remain in effect for 180 days after I sign and date the form. Each authorization may be withdrawn at any time in writing except to the extent that action has already been taken. Upon receipt of written revocation, further release of information shall cease immediately, except as allowed by law. Recipients of this information are forbidden to re-disclose this information without my specific authorization.

I understand that if I have authorized PPBH to disclose my information to person who are not required by Federal or State law to keep the information confidential, these persons receiving my records may disclose my protected health information to other without my consent or authorization. PPBH will not be responsible for the misuse or re-release of information by another individual, agency, or entity.

Notice To Recipient Of Information: This information has been disclosed to you from records protected by Federal Confidentiality Rules. The Federal Rules prohibit the recipient of the protected health information from making further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR, Part 2. A general authorization for the release of medical or other information is not sufficient for this purpose. The Federal Rules restrict any use of information to criminally investigate or prosecute any alcohol or drug abuse client.

Your Rights

If you receive services through PPBH, you have the right to:

• Be treated with respect and consideration for your dignity and privacy.
• Be treated fairly regardless of race, religion, gender, ethnicity, disability or source of payment.
• Have your treatment and other information kept private. Records may be released without your permission only where permitted by law.
• Easily get care in a timely fashion.
• Receive information on available treatment options and alternatives in a way that is appropriate to your condition and easy to understand.
• Share in developing your plan of care.
• Receive interpretation services at no cost to you. You also have the right to receive information in a language that you can understand. Information is available in other formats if you request it.
• Receive information about Positive Pathways Behavioral Health, its practitioners, programs, services, and role in the treatment process.
• Receive information about the clinical guidelines used in providing and managing your care.
• Ask providers about their work history and training.
• Not be restrained or secluded to make you do something you do not want to do (as specified in federal regulations on the use of restraints and seclusion).
• Give input on PPBH Rights and Responsibilities policy.
• Request certain preferences in a provider.
• Have provider decisions about your care made on the basis of treatment needs.
• Be given health care services that obey state and federal laws that have to do with your rights.
• Participate in decisions regarding your health care. This includes the right to receive a second medical opinion and the right to refuse treatment (except when ordered by a court).
• File a grievance about PPBH or the care you receive.
• File an appeal about a PPBH action or decision. You also have the right to request a State Fair Hearing if you are not satisfied with the result of the appeal.
• Request and receive a copy of your medical records. You can also request that they be changed or corrected.
• Exercise your rights. If you do this, it will not affect the way PPBH and its employees treat you.
• Receive written information on advanced directives and your rights under state law.
• Have candid discussions with Positive Pathways Behavioral Health representatives about appropriate or medically necessary treatment options for your condition regardless of cost or benefit coverage.

Your Responsibilities

Services recipients also have responsibilities with Positive Pathways. Accepting these responsibilities supports your recovery and helps you get the most benefit from your mental health services. It also helps us work with you better. You have the responsibility to:

• Seek treatment that you need from Positive Pathways Behavioral Health.
• Treat those giving you care with dignity and respect.
• Give Positive Pathways Behavioral Health information they need. This is so PPBH can deliver quality care and appropriate services.
• Ask your providers questions about your care. This is to help you and your providers understand your health problems and develop treatment goals and plans that you both agree on, as much as possible.Follo
• w your treatment plan. You and your provider should agree on this plan.
• Follow the plan for taking your medication that you and your provider agreed on.
• Tell your providers and primary care physician about medication changes. This includes medicines given to you by others.
• Keep your appointment. You should call your provider(s) as soon as you know you need to cancel visits.
• Let your provider know when the treatment plan is not working for you.
• Let your provider know about problems with paying for any required co-pays.
• Openly report concerns about the quality of your care.
• Report abuse and fraud. You can report this to the Corporate Compliance Hotline 24 hours a day, seven days a week. This hotline is run by an outside company. You do not have to give your name when you call. All calls will be looked into and will stay private. You can report fraud, waste and abuse using one of following methods.

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As a recipient or as a guardian of a recipient of Positive Pathways Behavioral Health, upon admission I have been instructed in or given written materials regarding:

Ways in which input is given regarding:

1. The quality of care.
2. Achievement of outcomes.
3. Satisfaction of the person served.

An explanation of the organization’s:

1. Services and activities.
2. Expectations.
3. Hours of operation.
4. Access to after-hour services.
5. Code of ethics.
6. Confidentiality policy.
7. Requirements of follow-up for the mandated person served, regardless of his or her 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 codes, emergency exits and/or shelters, fire suppression equipment, and first aid kits.
The program’s policies regarding:

1. The use of seclusion or restraint.
2. Smoking.
3. Illicit or licit drugs brought into the program.
4. Weapons brought into the program.
5. 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:

1. Any restrictions the program may place on the person served.
2. Events, behaviors, or attitudes that may lead to the loss of rights or privileges for the person served.
3. 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 services and activities include:

1. Expectations for consistent court appearances.
2. Identification of therapeutic interventions, including:

• Sanctions.
• Interventions.
• Incentives.
• Administrative discharge criteria.

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