Teri's Health Services

Information and Informed Consent for Telemental Health Treatment Telemental health is live two - way audio and/or video electronic communications that allows therapists and clients to meet outside of a physical office setting.

Client Understanding

• I understand that telemental health services are completely voluntary and that I can withdraw this consent at any time.
• I understand that none of the telemental health sessions will be recorded or photographed.
• I agree not to make or allow audio or video recordings of any portion of the sessions.
• I understand that the laws that protect privacy and the confidentiality of client information also apply to telemental health, and that no information obtained in the use of telemental health that identifies me will be disclosed to other entities without my consent.
• I understand that telemental health is performed over a secure communication system that is almost impossible for anyone else to access.
• I understand that any internet based communication is not 100 % guaranteed to be secure.
• I agree that the therapist and practice will not be held responsible if any outside party gains access to my personal information by bypassing the security measures of the communication system.
• I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties.
• I understand that I or my therapist may discontinue the telemental sessions at any time if it is felt that the video technology is not adequate for the situation.
• I understand that if there is an emergency during a telemental health session, then my therapist may call emergency services and/ or my emergency contact.
• I understand that this form is signed in addition to the Notice of Privacy Practices and Consent to Treatment and that all office policies and procedures apply to telemental health services.
• I understand that if the video conferencing connection drops while I am in a session, my therapist will contact me back. During the evaluation process at times your therapist will complete an evaluation over the phone. All therapists who call from Teri's Health Services are held to the same practice procedures as in office therapists. All therapists over telemental health services are mandated reporters by law. If you report you might harm yourself or someone else or hang up the phone during session and you have stated risk of harm your therapists is permitted by Arizona law to break confidentiality to get you help or someone else in foreseeable harms way. In addition, if you are in crisis and you hang up the phone and your therapists is unable to contact again 911 or the nonemergency line will be contacted to respond for help

Patient Rights

PURPOSE:

The purpose of this policy is to ensure that all patients of Teri’s Health Services (THS) are aware of their rights and are treated with dignity, respect and consideration.

II. POLICY

This policy shall be posted conspicuously in the patient lobby on the premises. At the time of admission, the patient or the patient’s representative will receive a copy of this policy.

All THS personnel shall ensure that each patient is treated with dignity, respect, and consideration.

III. DEFINITIONS“Informed consent” means:

(i) advising a patient or a patient’s representative of a proposed treatment, surgical procedures, psychotropic drug medication, opioid, or diagnostic procedure; alternatives to the treatment, surgical procedure, psychotropic drug medication, opioid, or diagnostic procedure; and associated risks and possible complications; and

(ii) obtaining documented authorization for the proposed treatment, surgical procedure, psychotropic drug medication, opioid or diagnostic procedure from the patient or the patient’s representative. “Medical record” means communications related to a patient’s physical or mental health or condition that are recorded in any form or medium and that are maintained for purposes of patient diagnosis or treatment, including medical records that are prepared by a health care provider or by other providers. Medical records do not include materials that are prepared in connection with utilization review, peer review or quality assurance activities, including records that a health care provider prepares pursuant to A.R.S. §§ 36-441, 36-445, 36-2402 or 36-2917.

Medical records do not include recorded telephone and radio calls to and from a publicly operated emergency dispatch office relating to requests for emergency services or reports of suspected criminal activity but include communications that are recorded in any form or medium between emergency medical personnel and medical personnel concerning the diagnosis or treatment of a person.“Patient” means an individual receiving physical health services or behavioral health services from a health care institution.“Patient’s representative” means any of the following:

• A patient’s legal guardian;
• If a patient is less than 18 years of age and not an emancipated minor, the patient’s parent;
• If a patient is 18 years of age or older or an emancipated minor, an individual acting on behalf of the patient with written consent of the patient or a patient’s legal guardian; or
• A surrogate as defined in A.R.S. § 36-3201.

IV. PROCEDURE

All THS personnel shall ensure that a patient is not subjected to:

a. Abuse;b. Neglect;c. Exploitation;d. Coercion;

Title: PATIENT RIGHTS

Section:

Patient’s Rights

f. Sexual abuse;g. Sexual assault;h. Restraint or seclusion, except as allowed in A.A.C. R9-10-1012

(B) (THS does not provide restraint or seclusion of patient’s as a matter of policy);i. Retaliation for submitting a complaint to the Department or another entity; orj. Misappropriation of personal and private property by a THS personnel member, employee, volunteer, or student.

All THS personnel shall ensure that a patient or the patient’s representative:a. Except in an emergency, either consents to or refuses treatment;b. May refuse or withdraw consent for treatment before treatment is initiated;c. Except in an emergency, is informed of alternatives to a proposed psychotropic medication or surgical procedure and associated risks and possible complications of a proposed psychotropic medication or surgical procedure;d. Is informed of the following:i.

THS’ policy on health care directives CR 500.01, andii. The patient complaint process QP 200.00;e. Consents to photographs of the patient before a patient is photographed, except that a patient may be photographed when admitted to an outpatient treatment center for identification and administrative purposes; andf. Except as otherwise permitted by law, provides written consent to the release of information in the patient’s:i. Medical record, orii. Financial records.

All patients have the following rights:

1. Not to be discriminated against based on race, national origin, religion, gender, sexual orientation, age, disability, marital status, or diagnosis;

2. To receive treatment that supports and respects the patient’s individuality, choices, strengths, and abilities;

3. To receive privacy in treatment and care for personal needs;

4. To review, upon written request, the patient’s own medical record according to A.R.S. §§ 12-2293, 12-2294, and 12-2294.01;

5. To receive a referral to another health care institution if the outpatient treatment center is not authorized or not able to provide physical health services or behavioral health services needed by the patient;

6. To participate or have the patient's representative participate in the development of, or decisions concerning, treatment;

7. To participate or refuse to participate in research or experimental treatment; and

8. To receive assistance from a family member, the patient’s representative, or other individual in understanding, protecting, or exercising the patient’s rights.TitleV. RELATED POLICIESRC 300.04 – Medical Records PolicyQP 200.00 – Grievance and Complaints

Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Purpose Teri’s Health Services is required by law to maintain the privacy of your health information in accordance with federal and state law. This Notice of Privacy Practices ("Notice") outlines our legal duties and privacy practices with respect to health information. We are required by law to provide you with a copy of this Notice and to notify you following a breach of your unsecured health information. We will abide by the terms of the Notice. We reserve the right to make changes to this Notice as permitted by law. We reserve the right to make the new Notice provisions effective for all health information we currently maintain, as well as any health information we receive in the future. If we make material or important changes to our privacy practices, we will promptly revise our Notice. Each version of the Notice will have an effective date listed on the first page.

If we change this Notice, you can access the revised Notice on our website (terishealthservices.org) or from the receptionist at any Teri’s Health Service location.Uses and Disclosures of Your Health InformationThe following categories describe the ways that we may use and disclose your health information without your written authorization. Treatment. We may use and disclose your health information to provide you with medical treatment and services. For example, your health information may be disclosed to physicians, nurses, or other health care providers who are involved in your care to coordinate or manage your health care services or to facilitate consultations or referrals as part of your treatment. If you are in a group home or facility we will coordinate care with these entities and provide your information of treatment to the home staff and owners. We will provide your documentation for the facility or group home to have a copy and place in their state file, use for their licensing requirements, placing your notes in their state file in house.

Payment. We may use and disclose your health information to obtain payment for the services we provide to you. For example, we may disclose your health information to seek payment from your insurance company or from another third party. We may also inform your insurance company about a treatment you are going to receive so that we obtain prior approval for the treatment or in order to determine whether your insurance company will cover the cost of the treatment.Advise of Appointments. We will call or email within 48 hours prior to appointment on the phone and email you provided.

Health Care Operations. We may use and disclose your health information to conduct certain of our business activities, which are called health care operations. These uses and disclosures are necessary to run our business and make sure our patients receive quality care. For example, we may use your health information for quality assessment activities, necessary credentialing, and for other essential activities. We may also disclose your health information to third party "business associates" that perform various services on our behalf, such as transcription, billing, and collection services. In these cases, we will enter into a written agreement with the business associates to ensure they protect the privacy of your health information.

Family Members and Friends for Care and Payment and Notification. If you verbally agree to the use or disclosure and in certain other situations, we may make the following uses and disclosures of your health information. We may disclose certain health information to your family, friends, and anyone else whom you identify as involved in your health care or who helps pay for your care; the health information we disclose would be limited to the health information that is relevant to that person's involvement in your care or payment for your care. We may also make these disclosures after your death as authorized by Arizona law unless doing so is inconsistent with any prior expressed preference. We may use or disclose your information to notify or assist in notifying a family member, personal representative, or any other person responsible for your care regarding your location, general condition, or death. We may also use or disclose your health information to disaster-relief organizations so that your family or other persons responsible for your care can be notified about your condition, status, and location.

Required by Law. We may disclose your health information when required by law to do so.Public Health Reporting. We may disclose your health information to public health agencies as authorized by law. For example, we may report certain communicable diseases to the state’s public health department.

Reporting Victims of Abuse or Neglect. We may disclose health information to the appropriate government authority if we believe you have been the victim of abuse, neglect, or domestic violence. We only make this disclosure if you agree or when we are required or authorized by law to make the disclosure. Licensed professionals are required report abuse and neglect, breaking confidentiality to ensure safety.Health Care Oversight. We may disclose your health information to authorities and agencies for oversight activities allowed by law, including audits, investigations, inspections, licensure and disciplinary actions, or civil, administrative, and criminal proceedings, as necessary for oversight of the health care system, government programs, and civil rights laws.

Legal Proceedings. We may disclose your health information in the course of certain administrative or judicial proceedings. For example, we may disclose your health information in response to a court order.Law Enforcement. We may disclose your health information to a law enforcement official for certain specific purposes, such as reporting certain types of injuries. In addition, if you report you are in danger or are going to endanger someone else we may send police to complete a welfare check or attend to the threats to others.Deceased Persons. We may disclose your health information to coroners, medical examiners, or funeral directors so that they can carry out their duties.

Organ and Tissue Donation. We may use and disclose your health information to organizations that handle procurement, transplantation, or banking of organs, eyes, or tissues.Research. Under certain circumstances, we may disclose your health information to researchers who are conducting a specific research project. For certain research activities, an Institutional Review Board (IRB) or Privacy Board may approve uses and disclosures of your health information without your authorization.

To Avert a Serious Threat to Health or Safety. If there is a serious threat to your health and safety or the health and safety of the public or another person, we may use and disclose your health information in a very limited manner to someone able to help lessen the threat.

Specialized Government Functions. In certain circumstances, HIPAA authorizes us to use or disclose your health information to authorized federal officials for the conduct of national security activities and other specialized government functions.Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may disclose your health information to the correctional institution or law enforcement official to assist them in providing you health care, protecting your health and safety or the health and safety of others, or providing for the safety of the correctional institution.

Minors: If you are a minor (17 years old or younger) your guardian has full rights to your charts including all documentation by any provider who provides treatment to you. We are also required to have your guardians sign all paperwork for you to receive treatment and continue treatment, to take medications, to make changes to your treatment, and discharge planning.

Workers’ Compensation. We may disclose your health information as necessary to comply with laws related to workers’ compensation or other similar programs. Please be aware that Arizona and other federal laws may have additional requirements that we must follow or may be more restrictive than HIPAA on how we use and disclose certain of your health information. If there are specific more restrictive requirements, even for some of the purposes listed above, we may not disclose your health information without your written permission as required by such laws. For example, we will not disclose your mental health or alcohol or drug abuse treatment records without obtaining your written permission, except as permitted by Arizona and federal law. We may also be required by law to obtain your written permission to use and/or disclose your HIV, STD, or other communicable disease related information, developmental disability information, or your genetic test results.

Other Uses and Disclosures specific written authorization. Some examples include:• Psychotherapy Notes: We will not use and disclose your psychotherapy notes without your written authorization except as otherwise permitted by law.

Marketing: We will not use or disclose your health information for marketing purposes without your written authorization except as otherwise permitted by law.

Sale of Your Health Information: We will not sell your health information without your written authorization except as otherwise permitted by law. If you change your mind after authorizing a use or disclosure of your health information, you may withdraw your permission by revoking the authorization. However, your decision to revoke the authorization will not affect or undo any use or disclosure of your health information that occurred before you notified us of your decision, or any actions that we have taken based upon your authorization.

To revoke an authorization, you must notify us in writing to:Teri’s Health Services14040 N. Cave Creek Rd. Suite 210 Phoenix, Az 85022

Fundraising. We do not utilize your information for any type of fundraising.

Your Right Regarding Your Health Information

This section describes your rights regarding the health information we maintain about you. All requests or communications to us to exercise your rights discussed below must be submitted in writing to:

Teri’s Health Services14040 N. Cave Creek Rd. Suite 210Phoenix, Az 85022

Right to Request Restrictions. You have the right to request restrictions on how your health information is used or disclosed for treatment, payment, or health care operations activities. However, we are not required to agree to your requested restriction, unless that restriction is regarding disclosure of health information to your health insurance company and:

(1) the disclosure is for the purpose of carrying out payment or health care operations and is not otherwise required by law; and

(2) the health information pertains solely to a health care item or service for which you or another person (other than your health insurance company) paid for in full. If we agree to your requested restriction, we will comply with your request unless the information is needed to provide you emergency treatment.

Right to Request Confidential Communications. You have the right to request that we communicate your health information to you in a certain manner or at a certain location. For example, you may wish to receive information about your health status through a written letter sent to a private address. We will grantreasonable requests. We will not ask you the reason for your request.Right to Inspect and Copy. You have the right to inspect and receive a copy of your health information.We may charge you a fee as authorized by law to meet your request. You may request access to your health information in a certain electronic form and format, if readily producible, or, if not readily producible, in a mutually agreeable electronic form and format. Further, you may request in writing that we transmit such a copy to any person or entity you designate. Your written, signed request must clearly identify such designated person or entity and where you would like us to send the copy. You will be required to sign a release of information for self before documentation will be released to you. We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to your health information, you may request that the denial be reviewed by a licensed health care professional chosen by us. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review. If you are in a facility or group home setting your request for documentation completed by Teri’s Health Services can only be requested and provided by Teri’s Health Services not directly by your group home or facility placement.Right to Amend. You have a right to request that we amend or correct your health information that you believe is incorrect or incomplete. For example, if your date of birth is incorrect, you may request that the information be corrected. To request a correction or amendment to your health information, you must make your request in writing and provide a reason for your request. You have the right to request an amendment for as long as the information is kept by or for us. Under certain circumstances we may deny your request. If your request is denied, we will provide you with information about our denial and how you can file a written statement of disagreement with us that will become part of your medical record.Right to an

Accounting of Disclosures. You have the right to request an accounting of disclosures we make of your health information. Please note that certain disclosures need not be included in the accounting we provide to you. Your request must state a time period which may not go back further than six years. You will not be charged for this accounting, unless you request more than one accounting per year, in which case we may charge you a reasonable cost-based fee for providing the additional accounting(s). We will notify you of the costs involved and give you an opportunity to withdraw or modify your request before any costs have been incurred.

Right to a Paper Copy of This Notice. You have the right to receive a paper copy of this Notice at any time, even if you previously agreed to receive this Notice electronically. A paper copy of this Notice can be obtained from the receptionist Teri's Health Services.

Complaints. You have the right to file a complaint if you believe your privacy rights have been violated. If you would like to file a complaint about our privacy practices, you can do so by sending a letter outlining your concerns to the leadership@terishealthservices.org. 

You also have the right to complain to the Secretary of the United States Department of Health and Human Services. You will not be penalized or otherwise retaliated against for filing a complaint.

 

You are receiving this notice because your healthcare provider participates in a non-profit, non-governmental health information exchange (HIE) called Health Current. It will not cost you anything and can help your doctor, healthcare providers, and health plans better coordinate your care by securely sharing your health information.

This Notice explains how the HIE works and will help you understand your rights regarding the HIE under state andHow does Health Current help you to get better care? In a paper-based record system, your health information is mailed or faxed to your doctor, but sometimes these records are lost or don't arrive in time for your appointment. If you allow your health information to be shared through the HIE, your doctors are able to access it electronically in a secure and timely manner. What health information is available through Health Current?

The following types of health information may be available:

• Hospital records
• Medical history
• Clinic and doctor visit information
• Health plan enrollment and eligibility
• Other information helpful for your treatment

Who can view your health information through Health Current and when can it be shared?

People involved in your care will have access to your health information. This may include your doctors, nurses, other healthcare providers, health plan and any organization or person who is working on behalf of your healthcare providers and health plan. They may access your information for treatment, care coordination, care or case management, transition of care planning and population health services.You may permit others to access your health information by signing an authorization form. They may only access the health information described in the authorization form for the purposes stated on that form.

Health Current may also use your health information as required by law and as necessary to perform services for healthcare providers, health plans and others participating with Health Current.

The Health Current Board of Directors can expand the reasons why healthcare providers and others may access your health information in the future as long as the access is permitted by law. That information is on theHealth Current website at healthcurrent.org/permitted-use.Does Health Current receive behavioral health information and if so, who can access it? Health Current does receive behavioral health information, including substance abuse treatment records. Federal law gives special confidentiality protection to substance abuse treatment records from federally-assisted substance abuse treatment programs. Health Current keeps these protected substance abuse treatment records separate from the rest of your health information.

Health Current will only share the substance abuse treatment records it receives from these programs in two cases.

One, medical personnel may access this information in a medical emergency.
Two, you may sign a consent form giving your healthcare provider or others access to this information.
How is your health information protected?
Federal and state laws, such as HIPAA, protect the confidentiality of your health information. Your information is shared using secure transmission. Health Current has security measures in place to prevent someone who is not authorized from having access. Each person has a username and password, and the system records all access to yourYour Rights Regarding Secure Electronic Information Sharing

Ask for a copy of your health information that is available through Health Current. Contact your healthcare provider and you can get a copy within 30 days.

1. Ask for a copy of your health information that is available through Health Current. Contact your healthcare provider and you can get a copy within 30 days.

2. Request to have any information in the HIE corrected. If any information in the HIE is incorrect, you can ask your healthcare provider to correct the information. Ask for a list of people who have viewed your information through Health Current. Contact your healthcare provider and you can get a copy within 30 days. Please let your healthcare provider know if you think someone has viewed your information who should not have.You have the right under article 27, section 2 of the Arizona Constitution and Arizona Revised Statutes title 3, section 3802 to keep your health information from being shared electronically through Health1. You may "opt out" of having your information available for sharing through Health Current. To opt out, ask your healthcare provider for the Opt Out Form. After you submit the form, your information will not be available for sharing through Health Current. Caution: If you opt out, your health information will NOT be available to your healthcare providers even in an emergency.2. You may exclude some information from being shared. For example, if you see a doctor and you do not want that information shared with others, you can prevent it. On the Opt Out Form, fill in the name of the healthcare provider for the information that you do not want shared with others. Caution: If that healthcare provider works for an organization (like a hospital or a group of physicians), all your information from that hospital or group of physicians may be blocked from view.3. If you opt out today, you can change your mind at any time by completing an Opt Back In Form thatyou can obtain from your healthcare provider.4. If you do nothing today and allow your health information to be shared through Health Current,you may opt out in the future.

IF YOU DO NOTHING, YOUR INFORMATION MAY BE SECURELY SHARED THROUGH HEALTH CURRENT.

Teri’s Health Services takes all complaints, grievances and concerns very seriously. It is our goal to ensure your compliant, grievance, or concern is addressed and resolved as quickly as possible. If you have concerns regarding your care by you clinical team (this is where you enter the information you current have one the form).

If you have concerns regarding any other care, services, or treatment render by THS, please go to our website and complete the complaint form. You may also email our Chief Strategy and Compliance Officer, Trevor Cooke, at Trevor.cooke@terishealthservices.org.  If you feel your complaint, grievance, or concern was not handled or addressed appropriately, you may file a complaint with the Arizona Department of Health Services. A written complaint can be mailed to them at:
Arizona Department of Health Services
Medical Licensing Department
150 N 18th Ave, Suite 450
Phoenix, Az 85007