Consent & Confidentiality Release Consent & Confidentiality Release Client's Name * Client's Name First Name First Name Last Name Last Name Date of Birth * Home Zip Code * Parent/Guardian's Name * Parent/Guardian's Name First Name First Name Last Name Last Name Parent/Guardian Phone * **Check each box, sign and date at the bottom CONSENT FOR TREATMENT * I/ We (parent/legal guardian) voluntarily consent to be treated by Palmer Addiction Recovery Services. My consent to receive treatment does not waive my legal rights under the Oklahoma and Federal Law. CONFIDENTIALITY * I understand the confidentiality of alcohol and drug abuse patient records maintained by this program is protected by Federal Law and Regulations 42 CFR Section 2.22. I understand that my protected health information is confidential and that any disclosure made regarding my protected health information will be pursuant to Palmer Notice of Privacy Practices. GRIEVANCE RIGHTS AND PROCEDURES * I understand that if I have any complaints or grievances regarding respect of my consumer rights or the treatment that I receive at Palmer, I have several individuals to whom I may submit my complaint. GRIEVANCE RIGHTS AND PROCEDURES 2 * I understand that my initial complaint should be submitted in writing to Palmer’s Program Director. They will investigate my complaint and respond back to me in writing within five (5) working days. GRIEVANCE RIGHTS AND PROCEDURES 3 * I understand that I may request and receive at any time additional copies or explanation about any of the information mentioned in this document. GRIEVANCE RIGHTS AND PROCEDURES 4 * I also understand that I may revoke any of these consents given to Palmer at any time without affecting treatment or services received by Palmer. HIV/AIDS/STD/HPV/HEP C EDUCATION, CONSULTING, AND TESTING * I acknowledge that education for STI’s is available by Palmer staff including information to testing sites at any time during services. CLIENT FINANCIAL OBLIGATION AND MEDICAL INSURANCE * I understand that services provided by Palmer Continuum of Care are at no charge and staff will not ask for any payment. If services are recommended and attended outside of school in office setting, I will provide insurance information if my child is on Soonercare. AGENCY CODE OF ETHICS * I acknowledge that Palmer staff abides by a code of ethics to do “no harm” to any client or family member receiving services. Palmer staff will conduct themselves in a professional manner, pursue a high standard of conduct and honesty in all situations, treat all individuals with respect and dignity, deliver quality client care, carry out responsibilities with a spirit of teamwork, protect confidentiality of clients, adhere to standards of practice, and respect all laws. Signature of Parent/Legal Guardian * signature keyboard Clear Date * Signature of Client * signature keyboard Clear Signature of Palmer Employee * signature keyboard Clear Submit If you are human, leave this field blank.
