Agreement for TeleHealth/Health 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 mine and/or my family’s services. Participant(s) and provider will agree upon a video program.
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. Identifying 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: By starting telehealth services, I give permission for my provider to communicate with PerformCareNJ (state insurance), CSOC of Care Management Organization-CMO and Mobile Response-MRSS (authorizing agency) and/or my private insurance (authorizing agency). JIS providers also meet with supervisors within this agency and/or supervision associated to this agency.
Specific Release of information Form: 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.]
Court Release of Information Form 📝: In other situations, someone may contact the Jersey Innovative Services provider for a clinical summary or participation in services. Parent(s)/Adults would use this form to release information about their services.
Press submit. Information sent confidentially.
Consent is valid (until one year from today)
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working with families self-efficacy scales