Demographics (Additional Information)

Health and Treatment Information (Admission Profile)

Financial Information (Admission)

Household Information

Legal History

Referral Information

Assumption of Responsibility

The undersigned, responsible party, agrees whether he/she signs as guarantor or as Client that in consideration of services to be rendered, to the Client named above, that the responsible party will guarantee the payment of all charges for such services and incidentals incurred by said Client. Delinquent fees may be turned over to a collection service, and reported to the Credit Bureau of Alaska.

The undersigned, responsible party, agrees to pay the Organization (Alaska Behavioral Health) the stated percentage of the actual charge per visit that is set in the current fee set. The agreed upon fee is payable at the time of service.

The undersigned, responsible party, agrees to advise the Organization of any changes in financial status.

Authorization to Release Information

The undersigned, responsible party, hereby authorizes the Organization to release demographical and medical information officially acquired in the course of examination and treatment for the purpose of filing for insurance benefits and other financial coverage.

Insurance Information

It is the practice of this Organization to accept most major medical insurance companies, Medicaid, and Medicare. It is the Organization’s goal to provide fast and efficient billing as a courtesy to the client. Our Organization needs the clients’ and/or responsible parties help to accomplish this goal. The clients’ providing complete and accurate insurance information is necessary. It is the clients’ responsibility to notify the Organization immediately if insurance or financial information changes.

Email and texting

Alaska Behavioral Health is able to use Email and texting to communicate with clients, upon mutual agreement between the provider and the client. This can be very helpful and convenient but is not guaranteed to be secure. 

  

 E-mail

We use an encrypted secure method to send and respond to emails.

We will use the minimum necessary amount of Protected Health Information (PHI) to respond to any emails you may send to us.  We will make every effort to keep PHI secure, in accordance with State and Federal law.  

Email communication is a convenience and not appropriate for all circumstances.  Please remember the following:

·         Emails are not to be used for emergencies or time-sensitive issues. 

·         Emails are not to be used as a therapy session. 

·         No one can guarantee the privacy of e-mail messages. 

o   For example, if your work e-mail is used, even though sent securely by us, your employer may have the right to access any e-mail received or sent from your work computer.

·         The Organization is not responsible for access of PHI due to your sharing or loss of your User ID and password, or an unattended email account.  Any PHI accessed in this manner is no longer protected by our privacy practices.

    Texting

Texting is a convenient method of communicating brief information, but it is not secure.  We have a system available for you to opt into that texts your next appointment as a courtesy reminder.  This requires you to have a cell phone that is able to make and receive text messages. 

Texting is:

·         Not for emergencies

·         Not to be used for therapy services

·         To be used as a reminder or services only.

·         No one can guarantee the privacy of text messages. 

o   For example, if you use a work phone, or your work has the right to access your phone, your employer may have the right to view your text messages.

 

You are not required to use email or texting.

 

Fax Policy

 

The use of faxing can be very helpful and convenient but is not guaranteed to be secure. There is some risk that any PHI that may be contained in such fax may be disclosed to, or intercepted by, unauthorized third parties. We will use the minimum necessary amount of PHI and will make every effort to keep your information secure as required by law. 

Communication Consent

If you personally wish to communicate with us via Email, Fax, and/or texting please provide the apporpriate information below. You are not required to consent and provide this information. 

I understand the risks associated with electronic communications and initialed my communication preferences above.  If I have authorized electronic communications, I do so with the following understanding:

• Electronic communication methods can be misdirected to or intercepted and disclosed by unintended third parties and may not be a confidential form of communication.  I understand and agree that electronic communication is being used for the convenience of myself and the ORGANIZATION does not warrant the confidentiality or security of this transmission. 

 

Telehealth services are provided for the convenience of our clients. Telehealth service is not required and is only used upon mutual agreement between provider and client. Telehealth services are subject to the following:

• Telehealth services are not the same as an in-person visit, as you will not be in the same room as your provider. If your provider determines that telehealth is not adequate for a particular issue, the provider may choose to terminate the session and request an in-person session.

• Telehealth services will be scheduled in advance.

• Telehealth services provided via computer should be accessed through a safe and secure connection. Be sure to use a computer that is in a confidential or private area and always fully close all online counseling sessions when they are complete.

• Telehealth services may also include online functionality, such as posting of notes or chat logs during the session. This information may be printed by your provider, and if so, it will be treated as confidential.

• If telehealth services cannot be conducted due to technical difficulties, you should immediately contact your provider to schedule a new session.

• Telehealth services are not appropriate for emergency situations.

• Some videoconferencing services, such as Skype, may retain certain personal information for its users. This could include user contacts and addresses, and other personal information you provide to the service. You should review the privacy policy for the internet service provider if you have any questions about the confidentiality of such information.

Using telehealth services is entirely voluntary and will not impact the quality of care you receive from the Organization should you decide not to use these services.

Alaska Behavioral Health is not liable for any claims and/or damages arising from following:

i. Interruption in the ability to conduct telehealth services due to technical difficulties, technical maintenance, or system failure.

ii. Access by friends, family members or other third parties who may enter the room on the client side during telehealth sessions.

iii. Breaches of privacy and security due to the fault of the third-party videoconferencing provider (such as Zoom, or Skype, etc.).

I acknowledge that I have received a copy of the Alaska Behavioral Health HIPAA Notice of Privacy Practices and have been given the chance to ask questions about it.

Joint Notice of Privacy Practices

I acknowledge that I have received a copy of the Consumer Rights & Responsibilities and the Consumer Grievance Process and have been given the chance to ask questions about it.

Consumer Rights & Responsibilities

Consumer Grievance Process

I acknowledge I have received the Appointment Policy and Agreement Form and have been given the chance to ask questions about it.

Appointment Policy & Agreement

I acknowledge that I received a copy of the Safety Guidelines and Procedures and consent to these steps to keep myself and others safe.

Consumer Safety Guidelines & Procedures

 

By Signing below, I request and voluntarily consent to receive mental health services from Alaska Behavioral Health (Organization). and its mental health staff.   Such care may include routine diagnostic procedures and/or related services that the mental health staff may recommend as medically necessary. No guarantees have been made to me by the Organization as to the result of services or evaluation.

 

I understand that as part of my healthcare, this Organization originates and maintains health records that are used for Treatment, Payment and Health Care Operations. 

 

With your permission we may ask to record your session to provide quality feedback, supervision to your clinician and to improve overall quality of our care to you.  This recording is kept in a secure location until it has been reviewed by a supervisor and then it is stored in a secure location.  I understand that my session with my therapist after obtaining my permission may be recorded for quality purposes.

 

Consent for Data Collection

You are choosing to receive services at Alaska Behavioral Health.  Your participation and sharing information will help us better serve our communities in Alaska.  The data we provide to the Substance Abuse and Mental Health Services Administration (SAMHSA) is not individually identifiable by them.

This form provides information so you can make an informed decision about your participation. Please read this form carefully and ask questions if you have them.

What is the purpose of the data collection?

Alaska Behavioral Health is partially funded by the United States Department of Health and Social Services/Substance Abuse and Mental Health Services Administration (SAMHSA). As part of this funding, SAMHSA requires Alaska Behavioral Health to collect and report information on all individuals served at our Organization to evaluate program effectiveness.  If you choose to participate, the information you provide will help us improve our services.

What Information will I be asked to provide?

If you agree to participate, we will collect information in a face-to-face structured interview with you when you begin receiving services, every six months you remain in services, and when you leave services. The structured interview will use the SAMHSA National Outcome Measures (NOMs), Client-level Measures for Discretionary Service Programs Providing Direct Services Tool, child or adult version. 

Demographic information will be obtained at the first interview including gender, ethnicity, race, and month and year of birth.  At each interview, participants will be asked questions regarding:

Functioning
Military Family and Deployment
Substance Use
Violence and Trauma
Housing
Education
Crime and Criminal Justice
Perception of Care
Social Connectedness
How will my privacy be protected?

Information collected by Alaska Behavioral Health staff during the structured interview will be entered into a secured SAMHSA database called Performance Accountability & Reporting System (SPARS). SPARS is a password protected, web-based system for reporting information on SAMHSA funded programs. Your name will not be provided to SAMHSA.  Instead, your information will be identified with a number assigned by Alaska Behavioral Health staff.  This number does not include any part of your name, date of birth or social security number. This ID number is designed to track a specific recipient through his/her interview(s) while maintaining anonymity. 

How will the information be used?

The primary purpose of data collection is to improve services at Alaska Behavioral Health.  Your clinician will review the results with you to help plan ongoing services.  Additionally, your responses will be used to determine the effectiveness of services at Alaska Behavioral Health.  The results of clinic-wide analyses may be used to report about program services.

SAMHSA uses aggregate data to conduct performance evaluation of federally funded programs. Aggregate data refers to de-identified information that is collected from multiple sources and combined into summary reports, typically for the purpose of public reporting or statistical analysis. With aggregate data sets, it is not possible to identify the information that has been provided by any given respondent.

 

 

 

What are the potential risks of my participation?

The primary risks of participation include potential discomfort with answering questions about sensitive issues and the possibility that someone you have not authorized could gain access to your protected health information. With respect to the first risk, Alaska Behavioral Health makes every effort to provide a safe and supportive therapeutic environment. Your clinician will be available to provide assistance and has been trained in ways to discuss sensitive and personal information. Additionally, if you choose to participate, you have the right to refuse to answer any question(s). With respect to the second risk, Alaska Behavioral Health has strict policies and procedures in place to comply with state and federal laws protecting the confidentiality of health information and substance use.  Your information is not able to be individually identified by SAMHSA, rather the information is assessed as a whole.

What are the potential benefits of my participation?

Your participation will help Alaska Behavioral Health improve services for individuals and families in our community. It will also provide you with important information about your well-being that will facilitate treatment and discharge planning.

Your participation is voluntary:

Your participation in the evaluation is voluntary. If you decide not to participate in the data gathering, you will not be denied services and treatment will not be affected. Additionally, if you and/or your child choose to participate, you are free to withdraw your consent/assent and discontinue participation at any time without this decision affecting your care and treatment with Alaska Behavioral Health.

What if I have questions?

You will receive a copy of this consent/assent form for your records.  If you have questions about the evaluation you can discuss these with your clinician or Pamela Kennedy, Privacy Officer for Alaska Behavioral Health. They will be happy to answer your questions or discuss any concerns.

Privacy Officer:

Pamela Kennedy, LPC-S, CHPC

Chief Patient Experience Officer

(907) 561-1000

Consent

I have been allowed the opportunity to ask questions concerning any and all aspects of this evaluation and the procedures involved. I understand that the evaluators and the program staff have set up procedures to protect the confidentiality of records related to my involvement. I consent to the use and disclosure of my records by Alaska Behavioral Health as described above, and to the disclosure of information to SPARS and SAMHSA. I understand that I can choose not to participate in data gathering or revoke consent at any time, and that if I do so I will not be denied services or benefits.

I understand that my alcohol and/or drug treatment/rehabilitation records (if any) are protected under the Health Insurance Portability Accountability Act of 1996 (HIPAA), and its enacting regulations, and that, depending on the nature of the record and treatment involved, my records may also be protected under the federal regulations governing confidentiality of substance use disorder patient records, 42 C.F.R. Part 2. I understand that only health information covered by 42 C.F.R. Part 2 (i.e., alcohol and drug use or treatment) will continue to be protected by law from redisclosure once it leaves Alaska Behavioral Health. However, if the information is covered only by HIPAA, it is subject to redisclosure by the recipient and may no longer be protected. I understand that my records that are subject to HIPAA cannot be disclosed beyond what is permitted under this consent, unless otherwise permitted by law.

This consent shall not expire until six (6) months after I complete services with Alaska Behavioral Health, or until I revoke this consent, whichever occurs earlier. If I revoke this authorization, I must do so in writing and present my written revocation to Alaska Behavioral Health for general medical records. This revocation will not apply to information that has already been released in response to this authorization.

I understand that this Organization (Alaska Behavioral Health) trains undergraduate and advanced graduate students from the mental health profession who are not yet licensed in Alaska.

I understand that all students are supervised by a minimum of a Master’s prepared Clinical Supervisor. Supervision includes face-to-face supervision sessions, reviewing and co-signing treatment plans, progress notes, and signing off on all other documents that go into your clinical record.

With your permission we may ask to conduct live observation and/or audio/video record your session to provide quality feedback, supervision to your clinician and to improve overall quality of our care to you. Audio/video recordings are kept in a secure location until it has been reviewed by a supervisor and destroyed based on our record retention policy. I understand that my session with my therapist after obtaining my permission may be recorded for quality and training purposes.

I understand that I have the right to know the name of the Student Intern, their supervisor and how to contact her or him; the staff member you meet with will provide this information upon request.

Your signature below indicates: 1) you have read the information in this document and consent to services provided by the Organization’s Student Interns; 2) your Protected Health Information (PHI) is strictly confidential and is protected by Federal and State regulations (42 CFR Part 2; 45 CFR 160, 162, and 164; and 7 AAC 71.215).