Welcome to Ocean Partnership for Children (OPC)! You have received a Welcome Packet, which outlines what to expect from OPC, including key agency policies and procedures, important contacts, and available crisis resources. The next few pages will guide you through providing important information, such as demographic and contact details, and completing required consents and acknowledgments. This helps us ensure we have everything needed to support you and your family throughout your time with us.

ADDITIONAL SUPPORTS (if applicable)

CONSENT FOR PARTICIPATION IN OPC PROGRAMS AND SERVICES: I voluntarily agree to receive care management services through the agency and understand that I may refuse or end these services at any time. I acknowledge that the agency operates in partnership with the New Jersey Department of Children and Families (DCF) - Children's System of Care (CSOC) and its Contracted System Administrator, PerformCare. The agency complies with all applicable federal and state laws and regulations governing New Jersey's Children's System of Care. I understand and agree that the agency will coordinate both clinical and non-clinical services for myself or my child(ren), and that agency staff may access my child's records as necessary to support the delivery of these services.

• CONSENT FOR EMERGENCY MEDICAL/PSYCHIATRIC TREATMENT: If youth experiences an accident, injury, or illness while on an outing with an employee, I authorize the agency to take necessary action and provide consent on my behalf.
• CONSENT FOR PARTICIPATION IN SUPERVISED SPORTS & RECREATIONAL ACTIVITIES: I give consent for the youth to participate in supervised sports and recreational activities that are part of the program, including those that take place outside the home and may involve transportation beyond Ocean County. I understand that these activities may carry unanticipated risks that could result in injury to the youth, damage to property, or harm to others. I acknowledge and accept these risks associated with participation in activities both within and outside the home.
• CONSENT/WAIVER OF RESPONSIBILITY FOR PERSONAL PROPERTY, PROPERTY DAMAGE, & PERSONAL INJURY: I understand and acknowledge that participation in activities or programs supervised by Ocean Partnership for Children, Inc. (OPC) staff may involve certain risks, including but not limited to personal injury, property damage, or loss of personal belongings. I voluntarily agree to allow participation in OPC activities and agree to assume full responsibility for any risks arising out of participation, including transportation or recreational activities, to the extent permitted by law. I release and agree to indemnify, defend and hold harmless Ocean Partnership for Children, Inc., its employees, agents, volunteers, and affiliated organizations from liability for any personal injury (fatal or otherwise), property damage, or loss that may occur during participation, except in cases of gross negligence or intentional misconduct.
• CONSENT FOR TRANSPORTATION: I hereby give my consent for youth to be transported by Ocean Partnership For Children, Inc., as needed.
• CONSENT FOR PROGRAM EVALUATION, RESEARCH, AND FOLLOW-UP: I consent to the use of data collected during my enrollment with the agency for research and program evaluation to assess the effectiveness of services. Findings may be shared publicly, but no names or identifying information will be disclosed without my explicit permission. I understand that the agency may contact me during and after services end to request feedback for internal quality improvement purposes.

CONSENT TO UTILIZE TECHNOLOGY SYSTEMS: OPC utilizes various technology systems as part of our coordination of care. I understand that using technology to communicate comes with risks that may be outside of anyone's control, including the possibility that information may be misdirected, intercepted, or shared unintentionally. I acknowledge that the OPC is not responsible for the privacy of devices or systems used by Child-Family Team members, and that each team member is responsible for keeping youth and family information confidential. I also understand that OPC is not responsible for any personal costs related to my use of technology. I agree to promptly inform OPC of any changes to my contact information.

• EMAIL/TEXTING: I give my consent to utilize the email addresses and phone numbers provided to OPC for communication purposes related to care management activities. This may include (but is not limited to) communication between OPC staff and myself/youth, communication with Child and Family Team members, and for primary source verification purposes. Additionally, I understand that I may receive emails/texts about current events and resources from OPC.
• TELEHEALTH: I understand that telehealth allows care management services to be delivered remotely using technology and may improve access by removing travel barriers and time constraints. I understand that the use of telehealth for the provision of care management services may depend on authorization by the Department of Children and Families (DCF) and the Centers for Medicaid Services (CMS I may withdraw my consent at any time without impacting my right to future services or benefits.

• Risks and Confidentiality: I acknowledge that using telehealth comes with risks, including technical difficulties, potential confidentiality concerns, and limited effectiveness compared to in-person sessions. I agree to participate from a private location and understand that OPC is not responsible for privacy breaches or technical disruptions beyond its control.
• Technology Platforms and Liability: I understand that OPC use third-party, HIPAA- compliant platforms for telehealth services but is not liable for that platform's failure to protect my information. If I request to use a different platform that is not HIPAA- compliant, I accept the risks and agree to hold OPC harmless for any resulting loss or breach of confidentiality. OPC reserves the right to deny such requests but may offer alternatives.
• AUTOMATED NOTETAKING: OPC may use automated note-taking software during meetings and phone calls to help staff focus fully on you and your family without having to take notes in real time. This HIPAA-compliant, SOC 2 Type 2 certified technology temporarily records the session to generate a progress note, then deletes the recording automatically. Automated notetaking software improves documentation accuracy and allows care managers to be more present during visits and conversations with you.

*NOTE: OPC follows all applicable HIPAA privacy and security requirements when using technology to deliver services, including the use of encrypted systems and platforms to protect the confidentiality of youth and family information. As required by HIPAA, OPC has a Business Associate Agreement (BAA) in place with any third-party software provider, which ensures the provider is held to strict data privacy and security standards. OPC is not liable for any breach of information that occurs as a result of a business associate's failure to uphold these standards.

POLICY ON AUDIO/VIDEO RECORDING: I acknowledge that I have received information about OPC's recording policy in my welcome packet and understand that no conversations, meetings, or sessions may be recorded without the full knowledge and written consent of all parties involved. I understand that violations of this policy may result in serious consequences, including (but not limited to) transition from services.

NOTICE OF DUTY TO WARN AND MANDATED REPORTING: I understand that Ocean Partnership for Children staff are mandated reporters under New Jersey law. This means they are legally required to report any suspected abuse or neglect of a child to the New Jersey Department of Children and Families (DCF).

• I also understand that information shared with OPC staff is generally kept confidential; however, there are certain legal exceptions where information may be disclosed without consent. These include, but are not limited to, situations where:
  • There is suspected abuse or neglect of a child or vulnerable adult
  • There is a serious threat of harm to self or others
  • Disclosure is required by law or court order
• I understand that in accordance with New Jersey's "duty to warn" obligations, OPC staff may be required to notify appropriate parties if a serious threat to health or safety has been made, even without consent.
• I acknowledge that I/we have been informed of these limits to confidentiality and understand the agency's legal and ethical responsibilities.

ACKNOWLEDGMENT OF RIGHTS AND NOTICE OF PRIVACY PRACTICES: I acknowledge that I have received of a copy of Ocean Partnership For Children's Notice of Privacy Practices and Rights of Children/Families in my Welcome Packet. I understand the rights that have been communicated to me as well as the responsibilities as a participant with Ocean Partnership For Children.

• If I have any questions or concerns about these notices, I understand that I have the right to contact OPC's Privacy Officer and/or Ombudsman at (732) 202-1585.

DOCUMENTATION OF FAMILY INFORMATION: I understand that information I share with Ocean Partnership for Children (OPC) staff about my own health, background, or experiences may be documented in my child's care record if it is relevant to their treatment or service planning. This may include information about family history, dynamics, trauma, or other factors that help inform my child's care. I understand that this information will be treated as part of the youth's protected health information (PHI) and will only be used or shared in accordance with applicable federal and state privacy laws.

CONSENT TO CONDUCT BUSINESS ELECTRONICALLY & AUTHORITY TO CONSENT: OPC may utilize various electronic platforms to obtain signatures throughout my involvement. 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 of the consents and agreements I electronically sign. I acknowledge that using a keypad, mouse, or other device to select an item or perform a similar action constitutes my e-signature, and that no certification authority or third-party verification is required for its validity or enforceability. I further represent and warrant that:

• I have the authority to grant consent on behalf of myself/youth; and
• I am not party to a court order that requires consent for any of this to be agreed to by another person, including but not limited to another parent; and
• I will inform OPC if there is a change to the custodial requirements to the subject of this consent.

By signing below, I acknowledge that I have read and understand the above information. I understand that by signing, I accept and consent to the above terms. I understand that I may revoke or cancel any part of this consent at any time by providing written notice to my assigned Care Manager. I understand that revocation may affect OPC's ability to deliver services.

The confidentiality of my records is protected by Federal law, including 42 CFR Part 2 and HIPAA and the applicable regulations, as well as any applicable State law and regulations. My treatment records can only be used or disclosed with my written consent, except as permitted by 42 CFR Part 2, HIPAA, and applicable state law.

I understand that I have the right not to sign this form. OPC cannot provide care management without a signed authorization, as services depend on the ability to coordinate care with other agencies and providers. Refusal to sign may result in ineligibility for services.

By my signature on this form, I hereby authorize Ocean Partnership for Children (OPC) to RELEASE, OBTAIN, and DISCUSS my protected health information under HIPAA, including my substance use disorder (SUD) records under 42 CFR Part 2, for the purposes of treatment, payment, and health care operations (TPO), as defined under HIPAA and 42 CFR Part 2 with:

ACKNOWLEDGMENT OF RIGHTS AND CONSENT TO RELEASE INFORMATION

I understand that by signing this form, I authorize the release and use of protected health information, including mental health and substance use disorder (SUD) treatment records, as needed to support treatment, payment, and care coordination for my child or family.

This information may be shared with individuals and agencies involved in the development and delivery of services and may become part of their confidential records. All parties are expected to protect the privacy and confidentiality of this information in accordance with federal and state law, including the New Jersey Department of Children and Families.

This authorization has been explained to me in a language that I understand. I understand that information released to organizations covered by HIPAA may be redisclosed in accordance with HIPAA privacy regulations, except for uses and disclosure for civil, criminal, administrative or legislative proceedings against me. I acknowledge that there is a potential for the records used or disclosed pursuant to this authorization to be subject to redisclosure by the recipient and no longer protected by 42 CFR Part 2.

I understand that:

• I may revoke all or part of this authorization at any time in writing, except to the extent that action has already been taken based on it. Revocation requests must be submitted to your assigned Care Manager.
• I have the right to request limits on the type of information shared or the individuals or agencies who may receive it. If I would like to place any limitations on this authorization, I understand that I should discuss my request with my Care Manager before signing. Any agreed-upon limitations will be documented and honored to the extent permitted by law and program requirements.
• This authorization will expire automatically at the time of transition from OPC, unless continued use is permitted by law for quality improvement, evaluation, or as otherwise authorized by me.
• OPC may contact me/us after services have ended to request feedback or input for internal quality improvement or program evaluation purposes. I authorize such contact by phone, email, or mail, using the contact information I have provided. I understand that participation in any post-discharge feedback is voluntary and does not affect eligibility for future services.
• I may request a copy of this signed authorization.
• I understand that I have the right to request access to or copies of my or my child's records, in accordance with federal and state law. A reasonable fee may be charged for copies of records or for mailing, as allowed by law.

By signing below, I acknowledge that I have read and understand the above information. I understand that by signing, I accept and consent to the above terms. I understand that I may revoke or cancel any part of this consent at any time by providing written notice. I understand that revocation may affect OPC's ability to deliver services.

42 CFR PART 2 PROHIBITS UNAUTHORIZED USE OR DISCLOSURE OF THESE RECORDS.