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Informed Consent for Assessment (Web)

Community & Family Resources
Phone 515-576-7261
Fax 515-955-7628
 Client Information
  First Name:  * Last Name:  *  
           
  Date of Birth:  * Birth Sex: 
* 
         
  Address: City:  
  State: Zip Code :  
  Phone No:  
Date
Medicaid #
Medicare #
I understand that as a client of Community & Family Resources/The Richmond Center, I am eligible to receive a range of services. The type and extent of services that I will receive will be determined following an initial assessment and thorough discussion with me. The goal of the assessment process is to determine the best course of treatment for me. Typically, treatment is provided over the course of several weeks. Some of the care that CFR/TRC provides will be via telemedicine.  This care is provided by a clinician from a remote site to your local site. At your first appointment you will be provided an orientation to the system and how to trouble shoot the system if needed. A nurse will also be available to answer any questions you may have regarding specific instructions from the clinician.

If you are receiving an OWI assessment, please be informed of the following:
Your initial assessment, initial recommendation, and all subsequent recommendations must be completed prior to any information being submitted to the Department of Transportation (DoT). All assessment and treatment fees must be paid in full.
Please notify our support staff when all of these criteria are met. Filing to the DoT will occur at that time. A copy of your completion letter can be provided to you.

Additionally:
I authorize Community and Family Resources/The Richmond Center to release necessary protected health information to my health insurance company or third-party payor for authorization and assignment of insurance benefits for the course of my treatment.   I understand that Federal Law including the The Health Insurance Portability and Accountability Act of 1996 ("HIPAA") and/or 45 C.F.R. pts 160 & 164, and/or 42 CFR Part 2 (for alcohol/Drug abuse), and/or State Law (Iowa Code Ch. 228) for Mental Health, prohibit information disclosed from records protected by these laws from being redisclosed, even to the client, without the specific written consent of the client or as otherwise permitted by such law and/or regulations.    I understand it is my ongoing responsibility to provide CFR/TRC with my most current insurance information.   I am responsible for all co-pays and deductibles related to my insurance benefits and any remaining financial balance not covered by my insurance. Co-pays are due at time of service.  I agree to inform CFR/TRC if I do not wish to have any treatment services filed with my insurance company.

As a courtesy to other potential consumers, CFR/TRC has opted to implement a policy in regards to appointments that are not attended.  Should I not attend an appointment; a CFR/TRC staff member will make contact with me within 24 hours and offer assistance to help me consistently attend appointments.   If I miss three appointments within a 90 day period, my appointments will be cancelled and I will need to access same day appointments.   In the unfortunate event that I miss four appointments in a 90 day period, I will not be eligible for services for 90 days.  I agree to this policy so that I am able to consistently attend appointments and work towards completing treatment successfully.  If I am unable to attend an appointment, I agree to notify CFR 24 hours or more in advance so that someone else in need may take my appointment time.

I understand that some of the communication with entities that I have given written consent to release of information may be in the form of electronic communication (email, fax, and phone).

I understand that I will receive the opportunity to provide feedback by filling out surveys throughout my treatment.  I have indicated how I would like to receive those surveys.

I understand that as part of the Quality Assurance and Training programs of Community and Family Resources/The Richmond Center, audio and/or video recording equipment may be used during my treatment sessions for the sole purpose of the professional development, training of CFR clinical staff, or by interns as required by their school.

I consent to random drug, alcohol, gambling, and weapons screenings and/or searches.

My signature or the signature of a guardian in my place indicates that this consent form has been explained to me in a language that I can understand, and that I or my guardian agree with the above.
* Is the client willing and able to sign in agreement?
Yes  
No  
If not, explain:
* Signature of Client:
Signer Type:  
  Client (Please click "Sign with Touch" and oversee / assist the Client in signing.)
  Other (Please enter the Name of the signer below and indicate relationship with the Client then click "Sign with Touch" and oversee / assist the signing. For example: Jane Doe, mother)
   
Name:
 
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Signature of Legally Authorized Representative:
Signer Type:  
  Client (Please click "Sign with Touch" and oversee / assist the Client in signing.)
  Other (Please enter the Name of the signer below and indicate relationship with the Client then click "Sign with Touch" and oversee / assist the signing. For example: Jane Doe, mother)
   
Name:
 
Sign with Touch
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