TeleHealth Consent – PerformCareNJ during COVID19

Agreement for TeleHealth Services
Family centered 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. ( 

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 my family from a private office to promote confidentiality of my family’s services. Family and provider will agree upon a video program.

GoalsProgram Goals:
1. COPING SKILLS: Learn appropriate ways to manage difficult situations, feelings, conflicts, and behaviors. Provider will talk with youth/family identifying needs and work towards goals and strategies of stabilization.

Youth will work collaboratively with family, provider and team.

Youth will work on communication needs and positive interactions with family.

4. Linkage(s) to the Community. Team will identify local resources and linkages in the community  for the family and identified person’s needs.

General / Specific Consents

General Release of information: The NJ Children’s System of Care (CSOC) provider is a part of a team. By starting telehealth services, I give permission for my provider to communicate with PerformCareNJ (state insurance) and Care Management Organization-CMO and/or Mobile Response-MRSS (authorizing agency). JIS providers also meet with supervisors within this agency and/or supervision associated to this agency.

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

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


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