NOTE
_______________________

You will now sign 5 documents in the order below.  If you stop in the middle, you will need to start over again.

We suggest that you print them each before you sign.

>Consent for Treatment
   Members Rights
   Program Rules
   Financial Agreement
   ROI-Orchard Medical

 

Consent for Treatment

This is a binding contract and required before we can provide treatment services. Please read carefully and sign at the bottom.


I, the undersigned below, am requesting treatment from Recovery Help and the treatment team at Recovery Help. As a condition of that treatment, I acknowledge the following items and agree with them.

Consent for Treatment Services

I hereby consent to health care, therapy, self-learning and coaching services provided by the employees and independent contractors of Recovery Help for the benefit of myself and my family.

Independent Contractors

I understand that some of the Therapists, Coaches, Physicians, support staff, and mentors may be independent contractors or business associates and not employees of Recovery Help.

Right to Refuse Treatment

I understand that I have the right to refuse any or all parts of the recommendations for my treatment except emergency treatment designed to protect the health and safety of others and myself.

No Guarantee

The treatment team and management believe that the outpatient treatment strategies the program uses to provide a useful intervention for chemical dependence problems; however, no specific outcome can be guaranteed.

Release of Liability

I recognize that there are inherent risks associated with the activities described herein and I assume full responsibility for personal injury to myself and my family members. I further release and discharge Recovery Help, contractors, 3rd party providers, business associates and any referring, accrediting or regulator parties including State Governments and their agencies for injury, loss or damage arising out of my or my family’s use of the programs, treatment protocols, self-learning modules or other resources of Recovery Help, whether caused by the fault of myself, my family, Recovery Help or other members of my treatment team.

Indemnification

I agree to indemnify and defend Recovery Help, contractors, 3rd party providers, business associates and any referring, oversight parties including State Governments and their agencies against all claims, causes of action, damages, judgments, cost or expenses, including attorney fees and other litigation costs, which may in any way arise from my or my family’s use of the programs, treatment protocols, self-learning modules or 3rd party resources provided by Recovery Help.

Consent for release of information to 3rd party coaches

I hereby consent for a limited release of information to 3rd party coaches, who will be providing Intentional coaching™ as a part of my treatment team.

Clarification of the Separate Roles of Licensed Therapists and Intentional Coaches

I understand that Intentional Coaches are not Licensed Therapists and will not provide therapy. I agree to keep my medical information private and not share with Intentional Coaches except as needed to accomplish my Intentional goals.

Your Consent for Communicating Protected Health Information

I understand that I have the right to give or withdraw consent for communicating my Protect Health Information (PHI.) Every request must be made in writing using the online or paper “Release of Information” (ROI) form. Your verbal instructions cannot be followed without a written confirmation. Your initial request is included in this agreement for the purpose of determining your appropriateness to our programs and to coordinate payment. I understand that I must give written consent for future release to and from my spouse, family, attorney, court, parole officer, doctor, family member, trusted person or others before Recovery Help can communicate with them.

Release of Information to Insurance Companies and 3rd Party Payors

I hereby give my written permission to share my assessment, diagnosis and clinical notes as needed with insurance companies and 3rd party payors for obtaining treatment authorizations and/or claim reimbursements.

Privacy of Information

Recovery Help is required by law to make and keep records of the Member's medical treatment. The Facility safeguards those records, and it uses and discloses such records and the information they contain only in accordance with State and Federal privacy laws.

Clarification of Record Keeping

Records generated as a part of my self-learning modules will not be construed as medical records and will not be stored or protected under Recovery Help’s privacy statement.

3rd Party Resources and Programs

During my treatment, I may receive links and access to third-party online resources. I understand that these resources are provided to me as a resource only and that I must read and accept the privacy policy of each 3rd party web site. Recovery Help does not monitor my use of these resources and is not responsible for any interaction or information that I may I post on these sites.

Electronic Health Record

I understand that as a Member, an electronic file will be developed for my treatment and that I may have a copy of all records upon request.

Treatment Referrals

With my written consent hereby given by signature below, I understand that my therapist or supervising clinical staff may make treatment referrals or request professional consultation outside of Recovery Help for the sole purpose of my care.

Video Conference Treatment

I understand that all treatment and coaching will be by secure video conference or telephone. I understand that privacy is required and that I will follow all program rules during treatment including the privacy of my location.

I understand that Recovery Help does not make recordings of any session. Instead, for program quality and training purposes, I do give my consent for an authorized observer to attend any group meeting that I may be attending.

Confidentiality of Group Sessions

All information disclosed in private and group sessions is strictly confidential and may not be revealed to anyone outside the program staff without the written permission of the other Members.

Exceptions to Privacy

The exceptions are when disclosures are required or permitted by law. Those situations typically involve (1) insurance claim processing, (2) when you display substantial risk of physical harm to yourself or to others and (3) suspected abuse of children or the elderly.

Discontinuing Service

I understand that I can be discharged from the program/treatment if deemed therapeutic by my therapist/counselor or for disobeying program rules.

Accomplishing treatment goals also requires the cooperation and active participation of myself and my family. If the lack of cooperation by myself and family interferes with the program’s ability to render services effectively, I understand that I can be discharged from the program.

Other Member Privacy

I understand that as a Member of Recovery Help IOP program I may become aware of information relating to other Members. I understand that I cannot reveal or discuss any information regarding Members with anyone outside Recovery Help. This privacy protection is for my welfare and the welfare of others in treatment.

Federal Confidentiality Regulations 42 CRF Part 2 prohibits me from making any disclosures without specific written consent of the person to whom which disclosure pertains. A general authorization for the release of information (a general, medical or clinical) would not be sufficient.

I further understand that Act 63 contains no criminal penalties for breach of confidentiality. However, Federal Regulations cover such breaches and provide for the fine of $500.00 for the first offense. For each subsequent offense, the fine may be as high as $5,000.00.

Electronic Signature

I understand that when I interact online with Recovery Help systems and websites that my typed name becomes my electronic signature instead of written signatures. I also understand that faxed or scanned copies of documents with my signature are to be considered original signatures.

Acknowledgement

By signing below, I acknowledge that I have read, understand and commit to abide by these terms and conditions.

Signature (Type Your Name)..