I UNDERSTAND THAT MY PROTECTED HEALTH INFORMATION MAY BE USED AND DISCLOSED TO CARRY OUT TREATMENT, FOR PAYMENT OF SERVICES, OR FOR HEALTH CARE OPERATIONS TO IMPROVE THE QUALITY OF CARE BY SAGE. I ACKNOWLEDGE RECEIPT OF THE SAGENOTICE OF PRIVACY PRACTICES AND I UNDERSTAND THAT I HAVE THE RIGHT TO REVIEW THE NOTICE BEFORE SIGNING THIS CONSENT. I UNDERSTAND THAT ANY CHANGES IN THE NOTICE WILL BE POSTED AT ALL SAGE SITES AND ARE AVAILABLE TO ME UPON REQUEST. I UNDERSTAND THAT THIS AUTHORIZATION IS IN EFFECT FOR ONE CALENDAR YEAR FROM THE DATE ON THIS FORM.
THE CONFIDENTIALITY OF ALCOHOL AND/OR DRUG ABUSE CLIENT RECORDS MAINTAINED BY SAGE IS PROTECTED BY FEDERAL LAW AND REGULATIONS. EXCEPT UNDER SPECIAL CIRCUMSTANCES, SAGE MAY NOT ORALLY DISCLOSE TO A PERSON OUTSIDE THE PROGRAM THAT A CLIENT ATTENDS THE PROGRAM. SAGE ALSO MAY NOT DISCLOSE ANY INFORMATION IDENTIFYING THE CLIENT’S HISTORY OF ALCOHOL AND/OR DRUG ABUSE UNLESS: BY WRITTEN AUTHORIZATION BY THE CLIENT; BY WRITTEN COURT ORDER; OR THE DISCLOSURE IS MADE TO MEDICAL PERSONNEL IN A MEDICAL EMERGENCY OR TO QUALIFIED PERSONNEL FOR RESEARCH, AUDIT, OR PROGRAM EVALUATION PROCESS. (FEDERAL LAW REFERENCES 42 U.S.C. 290 DD-3 –FEDERAL REGULATION REFERENCE CFR, PART 2)
ON JUNE 5, 2017, AN ARIZONA PUBLIC HEALTH STATE OF EMERGENCY WAS DECLARED BY ARIZONA GOVERNOR DOUG DUCEY REGARDING THE OPIOID EPIDEMIC IN THE STATE OF ARIZONA. AS PART OF THIS EMERGENCY ORDER, THE ARIZONA DEPARTMENT OF HEALTH SERVICES (ADHS) IS GATHERING DATA REGARDING SUSPECTED OR CONFIRMED OPIOID RELATED DEATHS OR OVERDOSES. SAGE COUNSELING, INC. IS LICENSED BY THE ADHS AND IS REQUIRED TO RELEASE INFORMATION REGARDING ANY KNOWN, SUSPECTED, OR CONFIRMED OPIOID RELATED DEATHS OR OVERDOSES OF CLIENTS ENROLLED WITH THIS AGENCY. IF IT IS REPORTED TO SAGE THAT YOU HAVE EXPERIENCED AN OPIOID RELATED OVERDOSE (SUSPECTED OR CONFIRMED) OR IF YOU ARE THE VICTIM OF AN OPIOID RELATED DEATH (SUSPECTED OR CONFIRMED), SAGE COUNSELING, INC. MUST RELEASE THE REQUIRED INFORMATION THAT PERTAINS TO YOUR CASE TO ADHS. MY SIGNATURE BELOW ACKNOWLEDGES SAGE COUNSELING, INC.’S RESPONSIBILITY TO REPORT SUSPECTED OR CONFIRMED OPIOID RELATED DEATH OR OVERDOSE TO THE ARIZONA DEPARTMENT OF HEALTH SERVICES.
I UNDERSTAND THAT I HAVE THE RIGHT TO REQUEST IN WRITING THAT SAGE RESTRICT HOW MY PROTECTED HEALTH INFORMATION IS USED TO CARRY OUT TREATMENT, PAYMENT, OR HEALTH CARE OPERATIONS. I UNDERSTAND THAT SAGE IS NOT REQUIRED TO COMPLY WITH MY REQUEST.
I UNDERSTAND THAT I HAVE THE RIGHT TO REVOKE THIS CONSENT AT ANY TIME, AND I MUST SUBMIT THIS REVOCATION IN WRITING. SAGE COUNSELING, INC. WILL NOT DISCLOSE MY PROTECTED HEALTH INFORMATION AFTER A WRITTEN REQUEST FOR REVOCATION HAS BEEN RECEIVED, EXCEPT TO THE EXTENT THAT SAGE COUNSELING, INC. HAS ALREADY TAKEN ACTION PRIOR TO THE RECEIPT OF THE REVOCATION. IF NOT PREVIOUSLY REVOKED, THIS CONSENT WILL TERMINATE ON THE DATE THE RELEASE EXPIRES, AS DETAILED ABOVE.
I UNDERSTAND THAT UPON REQUEST, I HAVE THE RIGHT TO OBTAIN A LIST OF ENTITIES THAT RECEIVED MY INFORMATION WITHIN THE PREVIOUS TWO YEARS UNDER A GENERAL DESIGNATION CONSENT. A REQUEST OF THIS NATURE MUST BE MADE IN WRITING. THE RESPONSE WOULD NEED TO INCLUDE THE NAME OF THE RECIPIENT ENTITY, THE DATE OF THE DISCLOSURE, AND A BRIEF DESCRIPTION OF THE INFORMATION DISCLOSED. SAGE COUNSELING, INC. WILL RESPOND IN 30 OR FEWER DAYS FOLLOWING THE RECEIPT OF THE WRITTEN REQUEST.
DEAR PCP, MENTAL HEALTH OR MEDICARE PLAN/PROVIDER:
THE ABOVE BEHAVIORAL HEALTH PROVIDER IS WRITING TO REQUEST INFORMATION THAT CONCERNS ONE OF YOUR PATIENTS FOR THE PURPOSE OF COORDINATING CARE. THE QUALITY OF CARE THAT THIS PERSON RECEIVES IS DEPENDENT ON YOUR TIMELY RESPONSE TO THIS REQUEST. CONFIDENTIALITY LAWS DO NOT REQUIRE A SEPARATE AUTHORIZATION TO RELEASE THIS INFORMATION (PROTECTED HEALTH INFORMATION PERTAINING TO ALCOHOL, DRUG AND HIV/COMMUNICABLE DISEASE INFORMATION REQUIRES SEPARATE AUTHORIZATION ACCORDING TO A.R.S. § 36-664 AND 42 CFR PART 2. FOR MORE INFORMATION SEE PM SECTION 4.1 DISCLOSURE OF BEHAVIORAL HEALTH INFORMATION). IF YOU HAVE QUESTIONS REGARDING THIS REQUEST, PLEASE CONTACT THE ABOVE REFERENCED PERSON.
