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. (www.HHS.gov).

Protected Health Information (PHI) − protection applies to information collected from the individual or received by other team members agreed participants (www.PerformCareNJ.org). 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.

Goals Program 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.

2. Increase POSITIVE FAMILY COLLABORATION.
Youth will work collaboratively with family, provider and team.

3. Increase POSITIVE FAMILY COMMUNICATION.
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.

JERSEY INNOVATIVE SERVICES
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.]

TeleHealth Treatment for Youth (First name Last name)(required)

I hereby give my consent for this youth to participate in services through(required)

NJ Children’s System of Care and PerformCareNJ Health Insurance

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

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

Care Manager or Case Manager(required)

Hospital/Psychiatric Emergency Screening- PESS (name/phone number *if none, type or n/a)(required)

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

InHome provider outside JIS (name/phone number *if applicable or n/a)(required)

Relative/Friend/Neighbor (name/relationship to them/phone number *if applicable or n/a)(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)

Youth's street address and town(required)

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

Your personal email address(required)

TeleHealth Therapist or BA name (required)

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

Contact: info@workingwithfamilies.com

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