TeleHealth Consent – Outpatient NJ during COVID19

Agreement for TeleHealth Services
Adult outpatient services with Jersey Innovative Services

Privacy Practices: The HIPAA (Health Insurance Portability and Accountability Act) Privacy Rule − requires appropriate safeguards to protect the privacy of personal health information and sets limits and conditions on the uses and disclosures that may be made of such information without client authorization. (www.HHS.gov).

Protected Health Information (PHI) − protection applies to information collected from the individual or received by other team members agreed participants. Jersey Innovative Services follows Federal, 42 CFR Part 2, State and HIPAA regulations to protect your confidentiality and asks permission to release information on you or your family.

Limits to Privacy: Federal law authorizes disclosure of information when there is: harm to self, harm to another or harm from someone. It is our obligation to protect you and others around you.

I understand my services are conducted by video, phone, computer, in the community and/or inHome. By starting counseling with a provider, I agree to this type of interaction. The provider agrees to interact with me from a private office to promote confidentiality of my services. Individual and provider will agree upon a communication venue.

Goals Program Goals:
1. COPING SKILLS: Learn appropriate ways to manage difficult situations, feelings, conflicts, and behaviors. Provider will talk with individual identifying needs, increase awareness and work towards goals and/or strategies of stabilization.

2. Linkage(s) to the Community. Identification of local resources and linkages in the community for the identified person’s needs.

JERSEY INNOVATIVE SERVICES
General / Specific Consents

General Release of information: By starting telehealth services, I give permission for my provider to communicate with my insurance company for billing purposes. The information on this form is not stored on the Internet or on this website. The information will be transmitted immediately to Jersey Innovative Services in a secured email platform.

Specific Release of information: In some cases, the Jersey Innovative Services provider will need to contact others outside this unit. To authorize the phone call or the use of video conferencing, I will authorize with this release information below for my provider. [When filling out this release a response is “required“, not authorization. If you do not authorize this provider to contact , type n/a.]

TeleHealth/In Person Treatment for (First name Last name)(required)

I hereby give my consent for participation in services through(required)

My Health Insurance

Insurance Company(required)

Insurance Group/Number (email copy/picture of card)

My street address and town(required)

Date of Birth(required)

As part of the counseling services, Jersey Innovative Services may contact individuals/agencies outside of your home. I give permission for Jersey Innovative Services to contact: Primary Care Physician (name/phone number *if applicable or n/a)(required)

Clinician/Psychologist/Psychiatrist (name/phone number *if applicable or n/a)(required)

Care Manager or Case Manager (name/phone number *if none, type n/a)(required)

Hospital/Psychiatric Emergency Screening - PESS (name/number *if applicable or n/a)(required)

Youth's school (school/phone number), add Child Study Team/Special Education representative in known (First name Last name)(required)

DCPP case worker (formally DYFS) type (name/number *if applicable or n/a)(required)

Legal system: Court, Probation/Parole, FCIU, Shelter, Detention Center (name/number *if applicable or n/a)(required)

Type your name (First name Last name) *consent is valid until one year from today(required)

Your personal email address(required)

Phone Number(required)

TeleHealth Therapist /BA name or n/a(required)

How did you hear about Jersey Innovative Services?(required)

Press submit. Information sent confidentially.
Consent is valid (until one year from today)

Contact: info@workingwithfamilies.com

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