COVID-19 OUTPATIENT TREATMENT RESPONSE

 

THIS TWO SECTION DOCUMENT HAS BEEN CREATED TO MINIMIZE BARRIERS FOR TREATMENT DURING THE COVID-19 HEALTH CRISIS BY ALLOWING THE PARTICIPANT TO CONSENT TO TREATMENT AND AUTHORIZE USE OF THIRD PARTY FUNDING AS REQUIRED FOR “PART 2” PROGRAMS. THIS FORM IS INTENDED FOR USE ONLY DURING THE HEALTH CRISIS.  

SECTION 1: CONSENT TO TREATMENT

I authorize Bridges Professional Treatment Services to provide treatment and services based on my treatment needs, as deemed necessary by Bridges Professional Treatment Services staff and as identified in assessment tools. I authorize the diagnosis of substance use disorder(s) and agree to participate in applicable treatment.

Date:

Participant Signature:

SECTION 2: RELEASE OF INFORMATION - THIRD PARTY BILLING AUTHORIZATION

IMPORTANT NOTE

Special kinds of health information have specific laws and rules that have to be followed before that information can be disclosed. HIV, Alcohol and Drug, and Mental Health Treatment: These records are protected under federal or state law and cannot be disclosed without your written authorization unless otherwise provided. Re-disclosure of these records are not allowed, except in compliance with state or federal law or with your written permission. All HIV test information released must be labeled with a statement that: “This information may not be disclosed to anyone without the specific written authorization of the individual.”

INFORMATION TO BE RELEASED/OBTAINED/EXCHANGED

Type of information you are authorizing to be exchanged:

☒ANY AND ALL INFORMATION REQUIRED FOR BILLING PURPOSES

THE ABOVE STATED INDIVIDUAL IS AUTHORIZING

NAME/ PROGRAM/AGENCY/OFFICE NAME:

Bridges Professional Treatment Services

PHONE NUMBER:

916-450-0700

FAX NUMBER/EMAIL:

916-450-0703

* By checking here, you agree and understand that Bridges Professional Treatment Services is a multi-disciplinary team. This release includes all Bridges Professional Treatment Services programs as follows: Bridges Outpatient, Bridges STARS, Promise House SLE, Bridges Men’s SLE, Bridges Women and Children SLE, Bridges DDP PC1000, and Bridges DUI. Also included is Redwood toxicology.

PLEASE CHECK THE APPROPRIATE SELECTION

☒ TO EXCHANGE INFORMATION WITH …

NAME OF THIRD PARTY BILLING AGENCY:

 

PURPOSE(S) FOR WHICH INFORMATION WILL BE RELEASED OR OBTAINED

☒ AT THE REQUEST OF THE INDIVIDUAL FOR BILLING PURPOSES

EXPIRATION OF RELEASE

THE AUTHORIZATION EXPIRES ON _AUTOFILL FOR 12 MONTHS FROM DATE SIGNED (not to exceed 12 months).

I may revoke this authorization to obtain, use and disclose my information at any time in writing.

By signing this form, I am allowing protected health information (PHI) to be obtained, disclosed and used. I understand revocations do not affect information that has already been shared. I understand that this authorization is voluntary; that my health information may be protected under federal or state confidentiality laws. I understand that federal privacy laws protecting my health information may not apply to the recipient and may not prohibit the recipient from disclosure.

Participant Name:

Date:

Participant Signature: