NOTE: Due to Youth being 14 years of age or older, they are required to sign the consents. Please ensure they are available to sign the following form prior to submission.
By selecting the "I Accept" button and typing my name below, I am signing this consent electronically. I agree that my electronic signature (‘e-signature’) is the legal equivalent of my manual signature and that I am legally bound by the terms and conditions of the consents and agreements I electronically sign.
I further agree that my use of a key pad, mouse or other device to select an item, button, icon or similar act/action, constitutes my “e-signature.”
I agree that no certification authority or other third party verification is necessary to validate my e- signature and that the lack of such certification or third party verification will not in any way affect the enforceability of my e-signature or any resulting contract/agreement between myself and Ocean Partnership for Children.
I understand that I may withdraw my consent to use electronic signatures at any time. In order to withdraw my consent, I will notify Ocean Partnership for Children in writing that I wish to withdraw consent and request that future documents, notices, and disclosures be provided in paper format.
I represent and warrant that:
The following items are essential to the care of your family while participating with Ocean Partnership For Children, Inc. (OPC By signing this consent form, you acknowledge receipt, understanding and agreement with the following:
CONSENT FOR EMERGENCY MEDICAL TREATMENT: In the event that my child is the victim of an accident, injury or illness while on outings with an Ocean Partnership for Children, Inc. employee and I am unable to be reached I authorize the Care Manager or the Care Manager’s designee to take action and give consent on my behalf as his or her judgment dictates.
CONSENT FOR PARTICIPATION IN SUPERVISED SPORTS & RECREATIONAL ACTIVITIES: I give my consent for my child/children to participate in supervised sports and recreational activities that are scheduled as part of the program, which may be outside of the home and may require transportation outside of Ocean County. I understand and acknowledge that some of the activities may involve unanticipated risks and could result in injury to the child, to property or to third parties. I agree to accept and assume all of the risks involved in activities within and outside of my home. Transportation for activities may be furnished by Ocean Partnership For Children, Inc.
CONSENT/WAIVER OF RESPONSIBILITY FOR PERSONAL INJURY: I give my consent for my children to possess certain items of personal property. I understand that Ocean Partnership For Children, Inc. is not responsible for the loss, theft, or damage of personal property or money.
CONSENT FOR TRANSPORTATION: I hereby give my consent for my child/children to be transported by Ocean Partnership For Children, Inc., as needed.
CONSENT FOR INFORMATION TO BE USED IN RESEARCH: I give my consent for the evaluation of data obtained during my enrollment in Ocean Partnership For Children, Inc. for research to evaluate effectiveness of the program. I understand that this research may be presented at conferences, universities, and in publication. I understand that information collected for this research is part of the usual Ocean Partnership For Children, Inc. evaluation procedures. I understand that my family’s confidentiality will be protected. No information that is presented to the public will contain any identifying information such as name, pictures, address, or telephone number.
CONSENT FOR PARTICIPATION IN OPC PROGRAMS AND SERVICES:
This notice is about the privacy of the information that has been collected by Ocean Partnership for Children, Inc. (OPC), to assist in planning for services for your child and family. This notice is required by Federal laws for health providers due to dramatic changes in electronic information that have taken place in the past few years. For your information, Ocean Partnership for Children, Inc. maintains all client records – in either electronic and/or hard copy files – in compliance with all federal and state laws and regulations through its partnership with the New Jersey Department of Children and Families (Children’s System of Care) and its designated Contract System Administrator.
We have always taken great care to protect confidential information and now government regulations require your rights to be spelled out. That is what you will find in our Notice of Privacy Practices.
We believe that privacy is part of the trust that you have placed in our organization, and we are committed to preserve that trust.
If you have any questions about this notice, please contact your Care Manager or OPC’s Privacy Officer at 732.202.1585. Either party will be sure to answer your questions, or find out the answers and respond back to you in a timely manner.
The confidentiality of client records is protected by federal and state laws and regulations. Release of such information is limited and requires a written release from/on behalf of the service recipient, as follows.
5.I specifically authorize the use and/or disclosure of the following type of highly confidential information identified by my initials next to the information type (YOUTH MUST SIGN IF APPLICABLE):
I/We understand that by authorizing this release, the above information may be shared, in whole or in part, to the extent necessary to develop and implement an individualized service plan. This information may become a part of a participating agency or individual’s confidential record. The New Jersey Children’s System of Care requires that all participants respect the confidential nature of the records, information and the proceedings of any meetings. Further release or use for any other purpose is prohibited and there may be penalties for any unauthorized disclosure of this information. With this release, I/We understand that this information may appear on electronic records.
I/We understand that I/We may refuse to sign this authorization and that refusal to sign will not affect the above-named youth from obtaining treatment, payment to be made, or the above-named child’s eligibility for benefits or services, however, it may affect determination of appropriate level of care. Subject to applicable law, I/We may inspect or copy any written information used/disclosed under this authorization.
I/We understand that if the person or entity that receives the information is not a healthcare provider or health plan covered by federal privacy regulations, the information described above may be re-disclosed and no longer protected by these regulations. However, the recipient may be prohibited from disclosing substance abuse information under the federal Confidentiality of Alcohol and Drug Abuse Patient Records regulations set forth at 42 CFR Part 2.
I understand that Ocean Partnership for Children is permitted under state and federal laws to charge a fee for photocopies of my records and any applicable mailing/postage fees.
I/We understand that I/We may revoke this authorization in writing at any time, except to the extent that action has been taken in reliance on this authorization. The request to revoke this authorization must be provided to in writing to the Ocean Partnership for Children’s Privacy Officer at the address listed on this form. The revocation will be effective on the date that the Privacy Officer receives the request.
I/We understand that this authorization will automatically expire upon termination of service from Ocean Partnership for Children. I/We can receive a copy of this authorization.
(**If disclosure involves HIV/AIDS records, signature of youth age 12 or older is required; for alcohol/substance use disorder records, signature of youth is required, regardless of age)
Notice to Recipient: Participants are required to adhere to the confidentiality and release of information requirements; records are protected under applicable federal and state law and regulations, including but not limited to 42 CFR Part 2 and HIPAA.
Notice to Part 2 Recipient: This information has been disclosed to you from records protected by federal confidentiality rules (42 CFR Part 2 The federal rules prohibit you from making any further disclosure of information in this record that identifies a patient as having or having had a substance use disorder either directly, by reference to publicly available information, or through verification of such identification by another person unless further disclosure is expressly permitted by the written consent of the individual whose information is being disclosed 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 (See 42 CFR § 2.31The federal rules restrict any use of the information to investigate or prosecute with regard to a crime any patient with a substance use disorder, except as provided at §§ 2.12(c5) and 2.65.
I understand that the use of electronic messaging to communicate with me does not substitute for regular, direct face- to-face contact and phone calls.
I recognize that electronic communications present risk and are not completely private. I realize that computer hackers can invade email with viruses. I understand that emails may be misdirected, intercepted, or forwarded to unintended recipients. I understand the risks associated with using email.
I recognize that images of confidential documents will be used on OPC business phones that are password protected, and once securely filed at OPC, those images will be deleted from that phone.
I further understand that text messaging or document imaging could present additional risks in the event that my password-protected phone is lost, stolen or accessed by persons other than myself.
If I have checked the box that authorizes use of electronic messaging to communicate with members of the Child-Family Team, then I understand that the Care Manager will use email to communicate with the Child-Family Team members on matters related to the above-named youth’s plan of care.
I understand that OPC is not responsible for the privacy of Child-Family Team members’ computer systems. I acknowledge that each member of the Child-Family Team is responsible for maintaining confidentiality with regard to the above-referenced youth’s and/or the family’s information.
I understand that electronic messaging is to be used for communication, and when appropriate, may be incorporated into the above-referenced youth’s record.
I understand that electronic imaging of documents is to be used for operational reasons, and as required, may be incorporated into the record for the above-referenced youth.
I acknowledge that I can terminate or modify this consent at any time. I will give the Care Manager written notice of my wish to modify or terminate all or any portion of this consent.
I understand that OPC is not responsible for any of my personal expenses associated with communicating via electronic messaging.
I agree to keep OPC informed of any changes to my email address and/or mobile number, as appropriate.
I hearby consent for my child/self to participate in telehealth services with Ocean Partnership for Children (“OPC”). I understand the following will apply: