UNITED SERVICES, INC.

CONSENT FOR TREATMENT, PAYMENT AND OPERATIONS

Client’s Name:____________________________
                                           Please Print

Subject to the statements printed on the back, I, the undersigned client, hereby authorize United Services to use my medical information, including, if applicable, protected drug and/or alcohol abuse, confidential HIV related and psychiatric information ("Protected Health Information") for treatment, payment and health care operations purposes.

United Services Notice of Privacy Practices further explains how we may use and disclose your Protected Health Information. I understand that I have the right to review such notice before signing this consent. I also understand that United Services reserves the right to change its privacy practices described in its Notice, and that if I wish to receive notification of any changes to the notice, I may contact the Privacy Officer or check United Services’ web page at www.unitedservicesct.org

I understand that I have the right to request that United Services restrict how Protected Health Information about me is used or disclosed for treatment, payment or health care operations, and that United Services is not required to agree to this restriction. If United Services does agree to restriction I request, United Services will be bound by our agreement.

This consent will be valid for a period of one year from the date below. I understand that I have the right to revoke this consent by notifying the Privacy Officer in writing, at United Services, Inc., 1007 North Main Street, Dayville, CT 06241, except where United Services has already taken action in reliance on this consent.

I have had the opportunity to have all my questions answered regarding United Services Notice of Privacy Practices.

__________________________________________       _________________
Client Signature or                                                               Date
(If client is under 18, parent, guardian or legal representative’s signature)

_________________________________________
Print Name

Note: If you are signing as the parent, guardian, or legally authorized representative of the client, please indicate your relationship to the client here (this should demonstrate your authority to consent to health care for the client):______________________________________________

 

US/CR135/Revised 4-03

 

 

Consent for Treatment, Payment and Operations

Any information released by United Services to authorized persons is subject to the following notices:

Psychiatric Information:

                     In the event that information released constitutes confidential psychiatric
                     information  protected under Connecticut law:

This information has been disclosed to you from records whose confidentiality is protected by state law. State law prohibits you from making further disclosure of it or of using it for any purpose other than that indicated above without the specific written consent of the person to whom it pertains, or as otherwise permitted by said law.

Drug and Alcohol Abuse Information:

In the event that information released is protected by the HHS Confidentiality of Alcohol and Drug Abuse Client Records regulations:

This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR Part 2). The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse client.

HIV Related Information:

In the event that information released constitutes confidential HIV related information protected under Connecticut law:

This information has been disclosed to you from records whose confidentiality is protected by state law. State law prohibits you from making any further disclosure of it without the specific written consent of the person to whom it pertains, or as otherwise permitted by said law. A general authorization for the release of medication or other information is NOT sufficient for this purpose.