mh 652t 09/07/11 pahintulot para sa telemental ......mh 652 09/07/11 pahintulot para sa telemental...

MH 652T09/07/11 PAHINTULOT PARA SA TELEMENTAL NA MGA SERBISIYONG PANGKALUSUGAN Pahina 2 ng 2

Impormasyon sa Telemental na Serbisyong Pangkalusugan

Ano ang Telemental na serbisyong pangkalusugan at kailan ginagamit ang mga ito?

Ang Telemental na serbisyong pangkalusugan ay ginagamit kapag ang tauhan sa kalusugangpangkaisipan ay hindi maaaring makasama mo upang tasahin ang iyong mga pangangailangan sakalusugang pangkaisipan at, kung naaangkop, magreseta ng mga gamot. Ang tauhan sa kalusugangpangkaisipan ay maaaring nasa ibang lokasyon at handang maglingkod sa iyo sa pamamagitan ngbagong magagamit na teknolohiya. Sa halip na makipag-usap sa isang tao, telepono sa ibanglokasyon, ang Telemental na serbisyong pangkalusugan ay gumagamit ng video camera at computerupang magpadala ng parehong boses at personal na imahe (mga larawan) sa pagitan mo at ng tauhansa kalusugang pangkaisipan upang hindi lamang kayo maaaring makapag-usap, pero magkikita rinninyo ang isa’t-isa. Pinapahintulutan nito ang tauhan ng kalusugang pangkaisipan na mas mahusay natasahin ang iyong mga pangangailangan.

Paano gumagana ang Telemental na mga serbisyong pangkalusugan?

Ikaw ay nasa isang pribadong silid mag-isa, may kasamang miyembro ng pamilya, o tauhan. Ang siliday may computer at video camera. Ang tauhan sa kalusugang pangkaisipan ay nasa isang pribadongsilid din pero sa ibang lokasyon na may parehong uri ng kagamitan. Kapag handa nang magsimulaang sesyon, bubuksan ng tauhan ng klinika ang computer at camera upang magkita at makapag-usapkayo ng tauhan ng kalusugang pangkaisipan. Kapag tapos na ang sesyon, papatayin ng tauhan ngklinika ang kagamitan.

Paano ito naiiba sa regular na sesyon sa tauhan ng kalusugang pangkaisipan?

Maliban sa iyo at sa tauhan ng kalusugang pangkaisipan na hindi magkasama sa iisang silid, kakauntilamang ang pagkakaiba sa sesyon. Ang tauhan ng kalusugang pangkaisipan ay magtatanong at itatalaang mga klinikal na impormasyon na iyong ibinahagi sa kanya, magpapadala ng anumang mga resetana inutos sa parmasya para iyong kuhanin kung nagreseta ng mga gamot, itatala ang serbisyongipinagkaloob, at titiyakin na ang dokumento ay kasama sa iyong talaan sa klinika para sa pagsanggunidito sa hinaharap.

Ano ang mangyayari kung pipiliin ko na hindi bigyang pahintulot ang Telemental namga serbisyong pangkalusugan?

Kung iyong pipiliin na hindi magbigay pahintulot sa Telemental na serbisyong pangkalusugan,hindi kami makakapagkaloob sa iyo ng madali at handang magamit na mga serbisyo at angiyong mga serbisyo ay babaguhin ang takdang araw at lugar para sa ibang petsa at/o ibanglugar.

Ang kompidensyal na impormasyong ito ay ipinagkaloob sa iyo alinsunod samga batas at regulasyon ng Estado at Pederal kabilang ang, nguni’t hindilimitado sa naaangkop na Welfare and Institutions code (Kodigo saKapakanan at Mga Institusyon), Civil Code (Kodigong Sibil) at HIPAA PrivacyStandards (Mga Pamantayan ng HIPAA sa Pagkapribado). Ang paggawa ngkopya ng impormasyong ito para sa karagdagang pagsisiwalat ayipinagbabawal nang walang paunang nakasulat na pahintulot ng kliyente/maypahintulot na kinatawan na may kinalaman maliban kung iba angpinapahintulot ng batas. Ang pagsisira sa impormasyong ito aykinakailangan matapos matugunan ang ipinahayag na layunin ng orihinal nakahilingan.

Pangalan: Numero ng IS:

Ahensiya: Numero ng Tagapagkaloobng Serbisyo:

County ng Los Angeles – Kagawaran ngKalusugang Pangkaisipan

PAHINTULOT SA TELEMENTAL NA MGA SERBISYONG PANGKALUSUGAN

MH 65209/07/11 PAHINTULOT PARA SA TELEMENTAL NA MGA SERBISIYONG PANGKALUSUGAN Pahina 1 ng 2

Aking nauunawaan na:

1. Ako ay may opsyon na bawiin ang pahintulot sa anumang oras. Maaari kong bawiin ang pahintulot na ito anumangoras kasama ang panahon na isinasagawa ang isang sesyon. Hindi nakakaapekto sa aking karapatan o sapanghinaharap na pag-aalaga. Ang pagpigil o pagbawi sa pahintulot ay hindi ilalagay sa panganib ang mgakapakinabangan ng programa na may karapatan ako..

2. Ang potensyal na kapakinabangan ng Telemental na mga serbisyong pangkalusugan ay makakausap ko ang tauhan sakalusugang pangkaisipan ngayon mula sa lokal na lugar na ito para sa pagtatasa ng aking mga pangangailangan. Kapagnaaangkop, ako ay makakalahok sa mga serbisyo ng kalusugang pangkaisipan, masimulan ngayon ang gamot, o ipagpatuloyang aking mga kasalukuyang gamot nang hindi humihinto.

3. Ang potensyal na panganib ng Telemental na mga serbisyong pangkalusugan ay isang bahagya o kumpletong hindipaggana ng kagamitan na ginagamit na maaaring magresulta sa kakulangan sa kakayahan ng tauhan ng kalusugangpangkaisipan na kumpletuhin ang pagtatasa, mga serbisyo sa kalusugang pangkaisipan, at/o proseso ng pagrereseta.

4. Walang permanenteng video o narekord na boses na pananatilihin sa sesyon ng Telemental na mga serbisyongpangkalusugan.

5. Ilalapat ang lahat ng kasalukuyang ipinapatupad na proteksyon sa pagiging kompidensyal.

6. Lahat ng mga umiiral na batas hinggil sa paraang makuha ng kliyente ang impormasyon sa kalusugan at mga kopya ngmga rekord sa kalusugang pangkaisipan ay ilalapat.

7. Ang pamamahagi sa magpapakilala sa kliyente na imahe o impormasyon na mula sa Telemental na interaksyong pangkalusuganpapunta sa mga mananaliksik o iba pang mga entitidad ay hindi magaganap nang wala ang pahintulot ng kliyente.

Ako, si ________________________________, ay nagpapahintulot sa Telemental na serbisyong pangkalusugan sa mgapangyayari kung saan ang tauhan sa kalusugang pangkaisipan na angkop sa aking mga pangangailangan ay hindi kaagadmakakapunta sa aking lugar. Tinalakay sa akin ng aking tagapagkaloob ng pangangalaga sa kalusugang pangkaisipan angimpormasyong ipinagkaloob sa itaas. Nagkaroon ako ng pagkakataon na magtanong ukol sa impormasyong ito, at lahat ngaking mga katanungan ay nasagot. Nauunawaan ko ang nakasulat na impormasyon na ipinagkaloob sa itaas.

____________________________________________ _________________Lagda ng Kliyente* Petsa

___________________________________________ __________________ _________________Lagda ng Responsableng Mayor de Edad** Kaugnayan sa Kliyente Petsa

____________________________________________ _________________Lagda ng Saksi/Tagapagsalin-wika *** Petsa

Ang Pahintulot na ito ay isinalin-wika sa ____________________ para sa kliyente at/o responsableng nasa hustong gulang.Kung ang isang nakasalin-wika na bersyon ng Pahintulot na ito ay nilagdaan ng kliyente at/o responsableng nasa hustonggulang, nakalakip dapat ang isinaling bersyon sa Ingles na bersyon.

Binigyan ang lumagda hindi binigyan ng kopya ng Pahintulot na ito noong ______________ sa ________.Petsa Mga Inisyal

Ang bahaging ito ay dapat kumpletuhin ng Mga Tauhan kung nilagdaan ng Menor de Edad o kung walang lagda ng kliyente at/o responsableng nasa hustong gulang .

Ang kliyente ay handang tanggapin ang Telemental na mga serbisyong pangkalusugan, pero ayaw lagdaan angPahintulot na ito.

Nakumpleto ko o ipinakumpleto ang form sa Pahintulot sa Menor de Edad para sa kahit na sinong kliyente sa pagitan ngedad na 12-18 na lumagda sa itaas nang walang pahintulot ng magulang/tagapag-alaga at aking pinatotohanan nanatutugunan ng kliyente ang lahat ng pangangailangan sa pagiging karapat-dapat tulad nang naitala sa Form saPahintulot sa Menor de Edad upang tumanggap ng gamot o panggamot nang walang pahintulot ng legal na kinatawan.

____________________________________________ _________________Lagda ng Tauhan Petsa

* Ang menor de edad na kliyenteng tumatanggap ng mga serbisyo sa ilalim ng kaniyang sariling lagda ay dapat na may nilagdaang Form na Pahintulot sa Menor de Edad na nasa file ngtalaan ng klinika.

** Responsableng Nasa Hustong Gulang = Tagapag-alaga, Konserbator o Magulang ng menor de edad kung kinakailangan.*** Saksi/Tagasalin-wika = Ang taong nakasaksi sa paglalagda ng form (maaaring tauhan o iba pang tao) o ang tagapagsalin-wika ng form na ito sa iba pang wika para sa kliyente (kailangang

kasama ang wika kung saan ito isinalin).

Ang kompidensyal na impormasyong ito ay ipinagkaloob sa iyo alinsunod sa mga batas atregulasyon ng Estado at Pederal kabilang ang, nguni’t hindi limitado sa naaangkop naWelfare and Institutions code (Kodigo sa Kapakanan at Mga Institusyon), Civil Code(Kodigong Sibil) at HIPAA Privacy Standards (Mga Pamantayan ng HIPAA sa Pagkapribado).Ang paggawa ng kopya ng impormasyong ito para sa karagdagang pagsisiwalat ayipinagbabawal nang walang paunang nakasulat na awtorisasyon ng kliyente/awtorisadongkinatawan na may kinalaman maliban kung iba ang pinapahintulot ng batas. Ang pagsira saimpormasyong ito ay kinakailangan matapos matugunan ang ipinahayag na layunin ngorihinal na kahilingan.


Ahensiya: Numero ng Tagapagkaloobng Serbisyo:

County ng Los Angeles – Kagawaran ng KalusugangPangkaisipan

PAHINTULOT SA TELEMENTAL NA MGA SERBISYONG PANGKALUSUGAN

MH 732 3/8/19

CONSENT FOR SECURE TEXT MESSAGING / VIDEO CHAT

Page 2 of 2

Secure Text Messaging and Video Chat Information

What is Secure Text Messaging/Video Chat?

Secure Text Messaging/Video Chat involves the use of a Los Angeles County Department of Mental Health (DMH) - approved text messaging and video chat application that allows authorized DMH providers to securely send and receive encrypted pictures, exchange text, audio and video messages securely, and conduct secure video conferences with clients. This method is secure, encrypted, and compliant with all laws related to the protection/security of Protected Health Information (PHI).

How can Secure Text Messaging/Video Chat be beneficial?

Secure text messaging/video chat allows clients and an authorized DMH mental health provider to quickly and efficiently communicate by sending and receiving text messages and video chats. The use of secure text messaging provides another avenue for clients to communicate with mental health providers should both parties decide that secure text messaging is an appropriate method of communication.

What happens if I choose not to consent to using LACDMH’s Secure Texting Messaging / Video Chat Application?

Without the consent for using the DMH-approved secure text messaging/video chat application, DMH workforce members will not initiate text messaging with clients or offer text messaging to clients as a mode of communication. If a client initiates text messaging with a DMH workforce member, staff will respond to the client via other means of communication (e.g. telephone call or mail).


Page 1 of 2

The undersigned understands:

1. Secure Text Messaging/Video Chat should not be used for emergency or urgent situations. The undersigned should discuss how to best contact the provider after normal business hours or during any emergency or urgent situation.

2. It is important for the undersigned to keep one’s mental health provider informed of current contact information should it change at any time.

3. Consenting to the use of Secure Text Messaging/Video Chat is at the undersigned’s request. 4. Secure Text Messaging/Video Chat will never be used for diagnostic purposes and requests to be assessed through either

method will not be honored. 5. The LACDMH Approved Secure Text Messaging / Video Chat Application is the only option for sending and receiving texts

and video chat with LACDMH Workforce Members. 6. LACDMH assumes no liability for the undersigned’s cellular device. If installation of the LACDMH Approved Secure Text

Messaging / Video Chat Application causes any conflict, malfunction, or damage, LACDMH will not be held responsible. 7. The undersigned is fully responsible for the handling, operating, and maintaining of his/her cellular device as well as any

applications and information including but not limited to Protected Health Information (PHI). Should the undersigned’s device be compromised, lost, or stolen, LACDMH will not be held responsible for the disclosure of information which was residing on the device at the time of or after the incident.

8. The undersigned is responsible for contacting his/her cell phone provider regarding any data usage or texting fees as a result of using Secure Text Messaging/Video Chat.

9. The undersigned has the option to withhold or withdraw consent at any time, without affecting the right to future care or treatment or risking the loss or withdrawal of any program benefits to which the undersigned would otherwise be entitled. This consent may also be revoked by the provider at any time.

I, ________________________________, consent to using the LACDMH Secure Text Messaging / Video Chat Application with _______________________________. My mental health care provider has discussed with me the information provided above. I have had an opportunity to ask questions about this information, and all of my questions have been answered. I understand the information provided above.

____________________________________________ __________________ __________________ Signature of Client* Phone number for text messaging Date

___________________________________________ __________________ _________________ Signature of Responsible Adult** Relationship to Client Date

____________________________________________ _________________ Signature of Witness/Interpreter *** Date

____________________________________________ _________________ Signature of Authorized Workforce Member Date

This Consent was interpreted in ____________________ for the client and/or responsible adult. If a translated version of this Consent was signed by the client and/or responsible adult, the translated version must be attached to the English version.

Signature was given declined a copy of this Consent on ______________ by ________. Date Initials

This section must be completed by Staff if consent is withdrawn.

Client had previously provided Consent but now wishes to withdraw Consent as of _____________ (date)

_______________________________________ ___________________________________ _______________ First Name and Last Name of Staff Signature of Staff Date

* A minor client receiving services under his/her own signature must have the signed Consent of Minor form on file in the clinical record. ** Responsible Adult = Guardian, Conservator, or Parent of minor when required. *** Witness/Interpreter = Person who either witnessed the signing of the form (may be staff or other person) or the person who interpreted this form into another language for the

client (must include the language it was interpreted into).

This confidential information is provided to you in accord with State and Federal laws and regulations including but not limited to applicable Welfare and Institutions code, Civil Code and HIPAA Privacy Standards. Duplication of this information for further disclosure is prohibited without prior written authorization of the client/authorized representative to whom it pertains unless otherwise permitted by law. Destruction of this information is required after the stated purpose of the original request is fulfilled.

Name: ID#:

Agency: Provider #:

Los Angeles County – Department of Mental Health


MH 7323/8/19

CONSENT FOR GROUPS OR FAMILY SESSIONS CONDUCTED VIA TELEHEALTH OR TELEPHONE

CONSENT FOR GROUPS OR FAMILY SESSIONS CONDUCTED VIA TELEHEALTH OR TELEPHONE

MH 739 3/18/2020

In order to minimize the spread of COVID-19, DMH is temporarily using telehealth (interactive audio and video telecommunication) and telephone to continue to provide group and family sessions to our clients. The purpose of this consent is to provide the client with information that is important for him/her to consider when deciding whether to participate in group or family sessions by means of telehealth or telephone.

Put your initials next to each element to confirm that you have discussed with the client:

________ ________

Group and/or family sessions will be conducted using approved secure platforms, but there is no way to guarantee that this software is completely failure-proof. As with any technology, there is a chance that information may be shared that would affect the privacy of your personal information. Since you will be participating in sessions in a remote location, we cannot guarantee your privacy. To strengthen privacy and confidentiality controls for yourself and other group/family members, we request that you:

Are in a private area with no others in the room with you and where disruptions (e.g., others coming into the room or hearing what you say in another room) are minimized as much as possible

Use headphones to limit the possibility of other people overhearing confidential information

Refrain from using last names of other group/family members ________

All existing confidentiality rules for group and family sessions apply. However, given that other clients or family members will also be participating from a remote location, it is possible that your confidentiality could not be maintained if other members are not in a private area.

________

These sessions will not be recorded by us (DMH). You are also not to use any recording software during the sessions.

________

You have the right to withhold or withdraw your consent to participate in group/family sessions via telehealth or telephone at any time during the course of your care and it will not affect your right to other care/treatment.

Client understands the above advisements and has verbally consented to accept Group/Family Sessions via

Telehealth and Telephone but is not signing this Consent due to procedures in place in response to the COVID-19 public health crisis. This Consent was interpreted in ____________________ for the client and/or responsible adult. _____________________________________ _________________ Signature of Practitioner Obtaining Consent Date This confidential information is provided to you in accord with State and Federal laws and regulations including but not limited to applicable Welfare and Institutions Code, Civil Code and HIPAA Privacy Standards. Duplication of this information for further disclosure is prohibited without prior written authorization of the client/authorized representative to who it pertains unless otherwise permitted by law.

Name: DMH #: Agency: Prov. #:


MH 708 CONSENT FOR EMAIL Page 1 of 2 08/15/12

The undersigned client* or responsible adult** consents to and authorizes LAC-DMH Authorized Workforce members at:

_______________________________________________________________ Name of Facility and/or Program

to use secure email to communicate with me for the following purposes: Scheduling appointments Sending reminders of appointments and/or treatment instructions Relaying factual mental health information that was previously discussed with me.

The undersigned understands:

1. Email should never be used for emergency purposes. The email system does not have a 24-hour monitoring services nor can the system guarantee delivery of email messages in a timely manner. In the case of an emergency, please dial 911.

2. Consenting to the use of secure email is at the undersigned’s request.

3. Email will never be used for diagnostic or treatment purposes and requests to be assessed or treated through email will not be honored.

4. Email is not an instant messaging system. There will likely be a delay, up to several days, between the time I submit an email and the point at which my treating provider reads and responds to the email. I will not know if the information in the email has been seen, and I cannot anticipate when I will receive a response.

5. By signing this consent, I agree to allow the Los Angeles County – Department of Mental Health (LAC-DMH) staff to send information about my mental health condition and care via secure email.

6. Information sent via email may assist mental health staff in treatment and scheduling.

7. The ability to use email may be rescinded by me or mental health staff at any point in which I or mental health staff believe email is not the most appropriate means of communication for me.

8. Any unauthorized use of email should be reported to mental health staff as soon as possible.

9. Although the email will be sent through a secure means, there is a risk that an email intended for me may be inadvertently sent to the wrong email address.

I have read this document carefully and understand the above information. By signing below, I acknowledge and consent to use of email for communication for the purposes described above.

____________________________ ______________________ _____________________ __________________ First Name and Last Name of Client Signature of Client* Email Address Date

____________________________ ______________________ _____________________ __________________ First Name and Last Name of Signature of Responsible Adult** Relationship to Client Date

Responsible Adult This Consent was interpreted by ________________________________ (name of interpreter) in ________________________ (language) for the client and/or responsible adult. If a translated version of this Consent was signed by the client and/or responsible adult, the translated version must be attached to the English version.

The above information including email address has been confirmed to be legible by ____________________________ First Name and Last Name of DMH Staff

Signatory was given / declined a copy of this two-page Consent on ______________ by ________. Date Initials

This section must be completed by Staff if consent is withdrawn.

Client had previously provided Consent but now wishes to withdraw Consent as of _____________ (date) _______________________________________ ___________________________________ _______________ First Name and Last Name of Staff Signature of Staff Date

* A minor client receiving services under his/her own signature must have the signed Consent of Minor form on file in the clinical record. ** Responsible Adult = Guardian, Conservator, or Parent of minor when required.

This confidential information is provided to you in accord with State and Federal laws and regulations including but not limited to applicable Welfare and Institutions code, Civil Code and HIPAA Privacy Standards. Duplication of this information for further disclosure is prohibited without prior written authorization of the client/authorized representative to whom it pertains unless otherwise permitted by law. Destruction of this information is required after the stated purpose of the original request is fulfilled.

Name: IS#:

Agency: Provider #:


CONSENT FOR EMAIL

MH 708 08/15/12

SECURE EMAIL IMFORMATION Page 2 of 2

What is secure email and why is it used? Regular email is sent as clear text that could potentially be intercepted by an unauthorized source and result in a security breach. Typically, senders encrypt messages to prevent important or confidential information from getting into the wrong hands. Encryption is the process of transforming information using a special computer program that will make it unreadable to anyone except those that are intended to and have authorization to access the confidential data. Often, when individuals or organizations send encrypted email, they want to protect confidential information for the benefit of the recipient. In some cases, senders are required to maintain confidentiality because of government regulations or statutes. The Health Insurance Portability and Accountability Act (HIPAA) includes email security and privacy regulations requiring all individually identifiable health care information be protected to ensure privacy and confidentiality when stored, maintained or transmitted electronically. Any email containing electronic Protected Health Information (ePHI) sent via email over the Internet must be secured. DMH Secure Email will enable clients to communicate easily and securely with LAC-DMH workforce

members. There is no cost for DMH clients associated with DMH Secure Email.

How does a secure email look and how can it be read? When a secure email is sent, the recipient will receive the following files:

1. Notification email message: The notification message indicates that someone has sent a secure, encrypted message in the form of a Registered Envelope. The notification also includes links to information about Registered Envelopes and Cisco Registered Envelope Service.

2. Encrypted message file attachment: The notification message includes an encrypted message

file attachment. The file attachment is named “securedoc.html.” This file contains both the Registered Envelope and the encrypted content. To view the Registered Envelope, the file attachment must be saved to the local drive. Opening this attachment will allow the recipient to self-enroll and create an account that will not only allow the recipient to read encrypted email, but to send or reply to emails in a secure and encrypted format. For complete instructions on how to access, read or respond using secure email please see link below. http://file.lacounty.gov/dmh/cms1_180460.pdf

What happens if I choose not to consent to the use of secure email? Without the consent for email, LAC-DMH workforce members will not initiate emails with clients or offer client’s their email address as a mode of communication. If a client initiates email with a LAC-DMH workforce member, the staff will respond to the client via other means of communication (e.g., telephone or mail).

http://file.lacounty.gov/dmh/cms1_180460.pdf

MH 500T

PAHINTULOT PARA SA MGA SERBISYO Binago noong 02/11/11

Ang nakalagdang kliyente* o responsableng nasa hustong gulang** ay nagbibigay pahintulot sa at pinapayagan ang mga serbisyo ng kalusugang pangkaisipan ng:

_______________________________________________________________________________ Pangalan ng Pasilidad at/o Programa

Ang mga serbisyong ito ay maaaring kabilangan ng sikolohikal na pagsusuri, psychotherapy/pagpapayo, mga serbisyo ng rehabilitasyon, medikasyon, pamamahala sa kaso, mga pagsusuri sa laboratoryo, mga pamamaraan sa pagkikilala ng sakit (diagnostic), at iba pang naaangkop na mga serbisyo. Habang ang mga serbisyong ito ay maaaaring ibigay sa ibang lokasyon, ang mga serbisyong ipinagkakaloob sa loob ng sistema ng kalusugang pangkaisipan ng County ng Los Angeles ay aayusin ng mga tauhan ng nag-iisang ahensiya.

Naunawaan ng nakalagda na:

1. Siya ay may karapatan magkaroon ng kaalaman at sumali sa pamimili ng alinman sa mga serbisyong ipinagkakaloob tulad nang nakasaad sa itaas.

2. Siya ay may karapatang tumanggap ng alinman sa mga serbisyong nakasaad sa itaas nang hindi hinihiling na kumuha ng iba pang serbisyo mula sa sistema ng Kalusugang Pangkaisipan ng County ng Los Angeles.

3. Ang lahat ng nakasaad sa itaas na serbisyo ay kusang-loob at siya ay may karapatan na humiling ng pagbabago sa tagapagkaloob ng serbisyo (ahensiya o tauhan) o bawiin ang pahintulot na ito anumang oras.

4. Lahat ng tauhan ng ahensiya, bilang kondisyon sa kanilang pagtatrabaho, ay lumalagda taun-taon sa isang sumpa ng pagiging kompidensyal na nagbabawal sa kanila mula sa pagbabahagi ng mga impormasyon ng kliyente maliban kung pinahintulutan sa ilalim ng Pederal, Pang-estado, at Pang-kagawaran na mga batas, patakaran, at pamamaraan hinggil sa pagiging kompidensyal.

5. Anumang impormasyon na ipinahayag sa mga tauhan at kanilang napagpasyahan bilang mahalagang pangalagaan, ay itatala sa talaan ng klinika upang tiyakin na ang mga tauhan na nakikitungo ay may nakahandang mga pinakakumpletong impormasyon tungkol sa kliyente kapag nagpapasya kung aling paggagamot ang pinaka-angkop sa mga pangangailangan ng kliyente at para sa kalidad ng pag-aalaga.

6. Ang lahat ng pangalan ng kliyente ay ipinapasok sa isang sistema ng impormasyon na nasa computer na kumikilala sa (mga) programa na nagkakaloob ng mga serbisyo sa kliyente. Ang impormasyong ito ay handang makuha kahit na walang awtorisasyon ng kliyente sa kahit na sinong miyembro ng mga manggagawa ng sistema ng ahensiya na direktang pinamamahalaan o naka-kontratang serbisyo ng Kagawaran.

7. Ang impormasyon na mula sa talaan ng klinika ng kliyente na may kaugnayan sa mga pangangailangan sa paghahatid ng serbisyo ay maaaring ibahagi sa loob ng ahensiyang ito at sa sistema ng kalusugang pangkaisipan ng County ng Los Angeles (mga ahensiya na direktang pinamamahalaan at naka-kontrata) kahit hindi kumukuha ng awtorisasyon mula sa kliyente.

____________________________________________ __________________ Lagda ng Kliyente* Petsa

____________________________________________ __________________ _________________ Lagda ng Responsableng Nasa Hustong Gulang** Kaugnayan sa Kliyente Petsa

____________________________________________ _________________ Lagda ng Saksi/Tagapagsalin-wika *** Petsa

Ang Pahintulot na ito ay isinalin-wika sa ____________________ para sa kliyente at/o responsableng nasa hustong gulang. Kung ang isang nakasalin-wika na bersyon ng Pahintulot na ito ay nilagdaan ng kliyente at/o responsableng nasa hustong gulang, nakalakip dapat ang nakasaling bersyon sa Ingles na bersyon.

Binigyan ang lumagda hindi binigyan ng kopya ng Pahintulot na ito noong ______________ ni/ng ________. Petsa Mga Inisyal

Ang bahaging ito ay dapat kumpletuhin ng Mga Tauhan kung nilagdaan ng Menor de Edad o kung walang lagda ng kliyente at/o responsableng nasa hustong gulang.

Ang kliyente ay handang tanggapin ang mga serbisyo, pero ayaw lagdaan ang Pahintulot na ito.

Nakumpleto ko o ipinakumpleto ang form sa Pahintulot sa Menor de Edad na para sa kahit na sinong kliyente sa pagitan ng edad na 12-18 na lalagda sa itaas nang walang pahintulot ng magulang/tagapag-alaga.

____________________________________________ _________________ Lagda ng Tauhan ng ahensiya Petsa

* Ang menor de edad na kliyenteng tumatanggap ng mga serbisyo sa ilalim ng kanyang sariling lagda ay dapat na may nilagdaang form sa Pahintulot sa Menor de Edad na nasa talaan ng klinika.

** Responsableng Nasa Hustong Gulang = Tagapag-alaga, Konserbator o Magulang ng menor de edad kung kinakailangan. *** Saksi/Tagapagsalin-wika = Ang taong nakasaksi sa paglalagda ng form (maaaring tauhan ng ahensiya o iba pang tao) o ang tagapagsalin-wika ng form na ito

sa iba pang wika para sa kliyente (kailangang kasama ang wika kung saan ito isinalin).

Ang kompidensyal na impormasyong ito ay ipinagkaloob sa iyo alinsunod sa mga batas at regulasyon ng Estado at Pederal kabilang ang, nguni’t hindi limitado sa naaangkop na Welfare and Institutions code (Kodigo sa Kapakanan at Mga Institusyon), Civil Code (Kodigong Sibil) at HIPAA Privacy Standards (Mga Pamantayan ng HiPPA sa Pagkapribado). Ang paggawa ng kopya ng impormasyong ito para sa karagdagang pagsisiwalat ay ipinagbabawal nang walang paunang nakasulat na awtorisasyon ng kliyente/awtorisadong kinatawan na may kinalaman maliban kung iba ang pinapahintulutan ng batas. Ang pagsira sa impormasyong ito ay kinakailangan matapos matugunan ang ipinahayag na layunin ng orihinal na kahilingan.


Ahensiya: Numero ng Tagapagkaloob ng Serbisyo:

County ng Los Angeles – Kagawaran ng Kalusugang Pangkaisipan

PAHINTULOT SA MGA SERBISYO

LOS ANGELES COUNTY HEALTH AGENCY

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.

Effective date: May 30, 2017

________________________________________________

WHO WILL FOLLOW THIS NOTICE OF PRIVACY PRACTICES

This Notice describes the privacy practices followed by the workforce members of the County of Los Angeles Department of Health Services, Mental Health, and Public Health, collectively referred to as the Health Agency (Agency). Workforce members include doctors, nurses, residents, therapists, case managers, students, volunteers, and other health care staff who help with your care at an Agency facility.

OUR PLEDGE REGARDING YOUR HEALTH INFORMATION

The law requires the Agency to:

Keep your medical records and health information, also known as “protected health information," private and secure.

Give you this Notice which explains your rights and our legal duties with respect to your health information.

Tell you about our privacy practices and follow the terms of this Notice. Notify you if there has been a breach of the privacy of your health information.

USES AND DISCLOSURES OF YOUR HEALTH INFORMATION

The following categories describe the different ways that we may use or disclose your health information without obtaining your authorization. For each category of use or disclosure, we will explain what we mean and try to give some examples. Not every use or disclosure in a category is listed. However, all of the ways we may use and disclose information falls within one of the categories. Treatment: We may use and disclose your health information to provide you with medical treatment and related services. We may share your health information with doctors, medical staff, counselors, treatment staff, clerks, support staff, and other health care personnel who are involved in your care. We may also share your health

Los Angeles County Health Agency Notice of Privacy Practices

Page 2 of 8 Effective 5/30/17

information with treatment providers for your future care for other treatment reasons. In addition, we may use or share your health information in response to an emergency. Payment: We may use and disclose your health information to bill and receive payment for the treatment and services you receive. For billing and payment purposes, we may disclose your health information to your payment source, including insurance or managed care company, Medicare, Medicaid, or another third-party payer. For example, we may give your health plan information about the treatment you received so your health plan will pay us or refund us for the treatment or we may contact your health plan to confirm your coverage or to ask for prior authorization for a proposed treatment. Health Care Operations: We may use and share your health information for Agency business purposes, such as quality assurance and improvement actions, reviewing the competence and qualifications of health care professionals, medical review, legal services, audit roles, and general administrative purposes. For example, we may use your health information to review our treatment and services and to evaluate our staff’s performance in caring for you. We may combine health information about our patients to decide what added services the Agency should offer or whether new treatments are effective. The law may need us to share your health information with representatives of federal and State regulatory agencies that oversee our business. Business Associates: We may share your health information with our business associates so they can perform the job we have asked them to do. Some services provided by our business associates include a billing service, record storage company, or legal or accounting consultants. To protect your health information, we have written contracts with our business associates requiring them to safeguard your information. Health Information Exchange: We, along with other health care providers in the Los Angeles area, may participate in one or more Health Information Exchanges (HIE). An HIE is a community-wide information system used by participating health care providers to share health information about you for treatment purposes. Should you require treatment from a health care provider that participates in one of these exchanges who does not have your medical records or health information, that health care provider can use the system to gather your health information in order to treat you. For example, he or she may be able to get laboratory or other tests that have already been performed or find out about treatment(s) that you have already received. We will include your health information in this system. If you would prefer your information not be shared with the HIE (opt-out) or have previously opted out of HIE participation and would like to share your information with the HIE (opt-in), please notify your registration staff or the business office at the facility where you obtain health care. The staff can help you change your preference using the HIE Change of Sharing Status form. Hospital Directory: Our hospitals maintain a directory that lists patients admitted to the hospital so family and friends can call or visit you or so you can receive mail. If you do not object, we will include your name, location in the hospital, general condition (e.g., fair, stable, critical, etc.), and religious affiliation in the hospital directory. The directory



information, except for religious affiliation, will be released to people who ask for you by name, unless you have asked us not to include you or to limit this information. Providing your religious affiliation is your choice. If you decide to give us this information, it may be given to a member of the clergy, such as a priest or rabbi, even if they do not ask for you by name. Appointment Reminders: We may use and disclose your health information to contact you as a reminder that you have an appointment at one of our facilities via standard mail (postcard), telephone, email, or text messaging. Discuss Treatment, Alternatives and Other Health-Related Benefits and Services with You: We may use and disclose your health information to tell you about your health condition or to recommend possible treatment choices or alternatives. We may tell you about health-related benefits, medical education classes or services (such as eligibility for Medicaid or Social Security benefits), that may be of interest to you. To Individuals Involved in Your Care or Payment of Your Care: We may disclose your health information to a family member, a relative, a close friend, or other individual involved in your medical care or payment for your medical care if we obtain your verbal agreement, or if we give you an opportunity to object to such a disclosure, and you do not raise an objection. If you are unable to agree or object at the time we give you the opportunity to do so, we may decide that it is in your best interest, based on our professional judgment, to share your health information, such as if you are incapacitated or during an emergency. Disaster Relief Purposes: We may disclose your health information to an organization assisting in a disaster relief effort so that your family can be notified about your condition, status, and location. We will give you the opportunity to agree to this disclosure or object to this disclosure, unless we decide that we need to disclose your health information in order to respond to the emergency circumstances.

Public Health Purposes: We may disclose health information about you for public health activities. These activities generally include the following:

To prevent or control disease, injury or disability; To report births and deaths; To report child abuse or neglect; To report reactions to medications or problems with products; To notify people of recalls of products they may be using; To notify a person who may have been exposed to a disease or may be at risk for

contracting or spreading a disease or condition; To notify the appropriate government authority if we believe you have been the

victim of abuse, neglect, or domestic violence.



For Health Oversight Purposes: We may disclose your health information to a health oversight agency for purposes allowed by law. For example, we may share your health information for audits, investigations, inspections, accreditation, licensure, and disciplinary actions. Research: Your health information may be provided to a researcher if you authorize the use of your health information for research purposes. In some situations, we may disclose your information to researchers preparing a research protocol or if our Institutional Review Board (IRB) Committee determines that an authorization is not necessary. The IRB Committee is charged with ensuring the protection of human subjects in research. We also may provide limited health information about you (not including your name, address, or other direct identifiers) for research, public health or health care operations, but only if the person or organization that receives the information signs an agreement to protect the information and not use it to identify you. Judicial and Administrative Proceedings: If you are involved in a lawsuit or a dispute, we may disclose your health information in response to a court or administrative order. We may also disclose your health information in response to a subpoena, discovery request, or other legal procedure by someone else involved in the dispute, but only if efforts have been made to tell you about the request (which may include written notice to you) or to obtain an order protecting the health information requested. Law Enforcement: We may disclose your health information to law enforcement agencies: If the police bring you to the hospital and document that exigent circumstances exist

to test your blood for alcohol or substance abuse; or If the police present a valid search warrant; or If the police present a valid court order; or To report abuse, neglect, or assaults as required or permitted by law; or To report certain threats to third parties or crimes committed on the premises; or To identify or locate a suspect, fugitive, material witness or missing person, if

required or permitted by law; or To report your discharge, if you were involuntarily detained after a peace officer

initiated a 72-hour hold for psychiatric evaluation and requested notification. Organ and Tissue Donation: If you are an organ donor, we may release your health information to an organization involved in organ and tissue donations. Coroners, Medical Examiners, Funeral Directors and Information About Decedents: When required by law, your health information may be released to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release limited health information to a funeral home. We may also give health information to family members or friends of a deceased person if they were involved in the person's care or paid for



that care prior to the death and the health information is relevant. However, we will not do this if the health information is not relevant to their involvement or if it is known to us that the deceased person would not have wanted us to share such information. To Prevent a Serious Threat to Health or Safety: We may use and disclose certain information about you when necessary to prevent a serious threat to your health and safety or the health and safety of others. Any such disclosure, however, would only be to the extent required or permitted by federal, State or local laws and regulations. Military Personnel: If you are a member of the armed forces, we may disclose your health information as mandated by military authorities or the Department of Veterans Affairs. Specialized Government Functions and National Security: We may disclose your health information to federal officials to conduct lawful intelligence, counterintelligence and other national security actions allowed by law. We may disclose your health information to federal officials who provide protection to the President, other people or foreign heads of state, or conduct an investigation. Workers’ Compensation: We may disclose your health information as allowed by workers’ compensation laws or related programs. For example, we may communicate your health information regarding a work-related injury or illness to claims administrators, insurance carriers, and others responsible for evaluating your claim for workers’ compensation benefits. As Required By Law: We will disclose your health information when required to do so by federal, State, or local laws. For example, the law requires us to report certain types of injuries. Breach Notification: We may use and disclose your health information to tell you in the event that there has been unlawful or unauthorized access to your health information, such as when someone not authorized to see your health information looks at your information or your health information is accidently lost or is stolen. We will also report these occurrences to State and federal authorities, and may need to use your health information to do so. If this happens, we will provide you with a written notice via first-class mail to your last known address. Special Rules for Disclosure of Psychiatric, Substance Abuse, and HIV-Related Information: For disclosures of health information about psychiatric conditions, substance abuse, or HIV-related testing and treatment, special rules may apply. In general, health information relating to care for psychiatric conditions, substance abuse or HIV-related testing and treatment may not be disclosed without your permission or a court order. There are exceptions to this general rule. For example, HIV test results may be disclosed to your provider of health care without written authorization. Inmates: If you are an inmate or under the custody of a law enforcement official, we may release your health information to the correctional institution or law enforcement



official. This release would be necessary for the institution to provide you with health care and for the safety and security of the correctional institution. Fundraising: We may use information about you to contact you to raise money for our hospitals or clinics. We will limit any information we release about you such as your name, address and telephone number and the dates you received treatment or services at our facilities. For example, we may send you a letter asking if you would like to make a donation. You can choose not to be contacted for our fundraising efforts. If we send you information about our fundraising efforts, we will include a simple way for you to request that we not contact you in the future for our fundraising efforts.

OTHER USES AND DISCLOSURES

Except as described in this Notice, or as allowed by State or federal law, we will not use or share your health information without your written authorization. For example, we cannot use or disclose your health information for marketing purposes, or sell your health information without your written authorization. If you sign an authorization and later change your mind, you can let us know in writing. This will stop any future uses and disclosures of your information but will not require us to take back any information we already disclosed.

YOUR RIGHTS ABOUT YOUR HEALTH INFORMATION You have the following rights about your health information, which you can exercise by submitting your request at the facility where you obtain health care. For your convenience, the applicable forms can be found on our websites at dhs.lacounty.gov, dmh.lacounty.gov or publichealth.lacounty.gov. Right to Request Restrictions of Your Health Information: You have the right to ask us to follow special restrictions when using or providing your health information for treatment, payment or health care operations. You may also ask for restrictions on the records we give out to someone who is involved in your care or the payment of your health care. For example, you might ask us to not to share certain information with your spouse. We are not required to agree to your request and will tell you if we cannot honor your request. However, if we do agree, we will comply unless the health information is needed to provide you emergency treatment. If we share your restricted health information with a health care provider for emergency treatment, we will ask the health care provider to not further use or disclose the information. Right to Ask for Restrictions When You Fully Pay Out-of-Pocket: You have the right to request a restriction on the disclosure of your health information to a health plan for purposes of payment or health care operations if you or someone else paid out-of-pocket, in full, for a health care item or service. We must agree to your request, unless the law requires us to share your information. If you paid out-of-pocket in full for a



health care item or service, and you wish to request this special restriction, you must submit your written request to the facility where you obtain health care. Right to Choose Someone to Act for You: If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure this person has the proper authority before we take any action. Right to Receive Confidential Communications: You have the right to ask that we communicate with you about your appointments or other matters related to your treatment in a specific way (e.g., only calling you at work). You must specify how or where we may contact you. We will grant all reasonable requests. Right to Access, Inspect, and Copy Your Health Information: With certain exceptions, such as records considered psychotherapy notes, you have the right to see and get a copy of the medical records we have of your care. To inspect and copy your medical records, you must make your request, in writing, to the facility where you obtain health care. If you request a copy of your medical record, we may charge a fee for the costs of copying, mailing, or supplies associated with your request. If we deny your request, we will provide you with a written decision. Right to Amend Your Health Information: If you feel that the health information contained in your medical record is incorrect or incomplete, you may ask us to correct or update the information. You have the right to request an amendment for as long as we keep the health information. To request an amendment, you must make your request, in writing, to the facility where you obtain health care. You must state why you believe your health information is wrong or incomplete. In certain cases, we may deny your request for an amendment. If we deny your request, we will give you a written reason. Right to Receive an Accounting of Disclosures of Health Information: You have the right to ask for an accounting of certain disclosures of your health information made by the Agency. This is a list of disclosures we made of your health information other than our own uses for treatment, payment and health care business. To ask for an accounting of disclosures, you must state a time period, but not longer than six years. The first accounting provided within a twelve-month period is free. We may charge you a fee for each future request. Before we process your request, we will tell you the cost so you may change or withdraw your request. Right to Obtain a Paper Copy of Notice: You have the right to receive a paper copy of this Notice at any time, even if you have already received a copy or have agreed to receive this Notice electronically. You may obtain a paper copy of this Notice from the facility where you obtain health care. An electronic copy of this Notice is also available on our websites: dhs.lacounty.gov, dmh.lacounty.gov or publichealth.lacounty.gov.



CHANGES TO THIS NOTICE We may change this Notice when the law or our practices change. We reserve the right to make the revised or changed Notice effective for health information we already have about you as well as any information we receive in the future. You will not automatically receive a new Notice. If we change this Notice, we will post the revised Notice in our facilities and on the above-mentioned websites. You may also obtain any revised Notice from the facility where you obtain health care.

HOW TO FILE A COMPLAINT If you believe your privacy rights have been violated by us, you may file a complaint with the facility where you obtain health care or any of the offices listed below. The law prohibits retaliation against an individual for filing a complaint.

County of Los Angeles Department of Health Services

Privacy Officer 313 N. Figueroa Street, Room 703

Los Angeles, CA 90012 (800) 711-5366

County of Los Angeles Department of Public Health

Privacy Officer 5555 Ferguson Drive, Suite 3033

Commerce, CA 90022 (888) 228-9064

County of Los Angeles

Department of Mental Health Director of Patients’ Rights Office

550 South Vermont Avenue Los Angeles, CA 90020

(800) 700-9996

You may also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights at (800) 368-1019 (TDD: 800-537-7697) or by sending a letter to: Region IX, Office for Civil Rights U.S. Department of Health and Human Services 90 7th St. Suite 4-100 San Francisco, CA 94103 You may also file a complaint at this link: www.hhs.gov/ocr/privacy/hipaa/complaints/

Los Angeles County Health Agency

ACKNOWLEDGEMENT OF RECEIPT

NOTICE OF PRIVACY PRACTICES

Effective Date: May 30, 2017 ACKNOWLEDGEMENT OF RECEIPT

By signing this form, you acknowledge receipt of the Notice of Privacy Practices of the Los Angeles County (LAC-Health Agency) Departments of Health Services, Mental Health, and Public Health, collectively referred to as the Health Agency. Our Notice of Privacy Practices provides information about how we may use and disclose your protected health information. We encourage you to review it carefully.

I acknowledge receipt of the Notice of Privacy Practices of LAC-Health Agency.

Signature: Date: __________________ (patient/parent/conservator/guardian)

INABILITY TO OBTAIN ACKNOWLEDGEMENT

To be completed only if no signature is obtained. If it is not possible to obtain the individual’s acknowledgement, describe the good faith efforts made to obtain the individual’s acknowledgement, and the reasons why the acknowledgement was not obtained:

Signature of Workforce Member: _______________________________ Date: ______________

Reasons why the acknowledgement was not obtained:

☐ Patient refused to sign.

☐ Other Reason or Comments:

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

e550733Text BoxMH 601ERevised 5/30/17

MH 602 (09/2016) Pahina 1 ng 2

KLIYENTE:

500.01 - Kalakip 1

KAGAWARAN NG KALUSUGANG PANGKAISIPAN NG COUNTY NG LOS ANGELES

PAHINTULOT PARA SA PAGGAMIT O PAGSISIWALAT NGPROTEKTADONG IMPORMASYONG PANGKALUSUGAN

Pangalan ng Kliyente /Dating Pangalan Petsa ngKapanganakan

Numero ng Kliyente

Pangalan ng Legalna Kinatawan

(Kung naaangkop)

Address ng Kalye Lunsod, Estado ZIP Code

PINAHIHINTULUTAN ANG:PAGGAMIT O PAGSISIWALAT NG PROTEKTADONGIMPORMASYONG PANGKALUSUGAN SA:

Pangalan ng Ahensya Pangalan ng Tagapagbigay ng Serbisyong PangangalagangPangkalusugan/Iba Pa

Address ng Kalye Address ng Kalye

Lunsod, Estado ZIP Code Lunsod, Estado ZIP Code

IMPORMASYONG ILALABAS:

Pagtatasa/Ebalwasyon Mga Resulta ng Sikolohikal na Pagsusuri Dayagnosis

Mga Resulta ng Laboratoryo Kasaysayan ng Medikasyon/Kasalukuyang Medikasyon Paggagamot

Kabuuang Rekord (Pangatwiranan):

Iba Pa (Tukuyin):

PAALALA: Ang mga rekord ay maaaring kabi langan ng impormasyongkaugnay ng paggamit ng alkohol o droga at HIV o AIDS. G a y u n m an , hindiisisiwalat ang mga rekord sa pagpapagamot sa mga pasilidad ng droga at alkohol omga resulta ng pagsusuri para sa HIV maliban kung partikular na hiniling.

Itsek ang lahat ng naaangkop: Mga Rekord sa Alkohol o Droga Mga Resulta ng Pagsusuri para sa HIV

Paraan ng paghahatid ng mga hiniling na rekord:Koreo Pickup Elektronikong Gamit (CD, USB)

LAYUNIN NG PAGGAMIT O PAGSISIWALAT: (Itsek ang angkop na kategorya)

K a h i l i n g a n n g K l i y e n t eIba Pa (Tukuyin):

Tatanggap ba ang ahensya ng anumang benepisyo para sa paggamit o pagsisiwalat ng impormasyon? Oo Hindi

Nauunawaan ko na ang aking Protektadong Impormasyong Pangkalusugan na ginamit o isiniwalatalinsunod sa Awtorisasyong ito ay maaaring hindi na protektado ng pederal na batas at maaaring gamitin oisiwalat pa ng tatanggap nang wala ang aking awtorisasyon. Nauunawaan ko rin na kapag ginamit oisiniwalat na ang aking impormasyon, hindi na maaari pa itong bawiin.

PETSA NG PAGKAWALA NG BISA: Ang Awtorisasyong ito ay balido hanggang / / .Buwan Araw Taon

I-clear Ang Buong Form

MH 602 (09/2016) Pahina 2 ng 2

500.01 - Kalakip 1

KAGAWARAN NG KALUSUGANG PANGKAISIPAN NG COUNTY NG LOS ANGELES

AWTORISASYON PARA SA PAGGAMIT O PAGSISIWALAT NGPROTEKTADONG IMPORMASYONG PANGKALUSUGAN

ANG IYONG MGA KARAPATANG MAY KINALAMAN SA AWTORISASYONG ITO:Karapatang Makatanggap ng Kopya ng Awtorisasyon – Nauunawaan ko na kapag sumang-ayonakong pirmahan ang Awtorisasyong ito, bagay na hindi ko kinakailangang gawin, dapat akong bigyan ngpinirmahang kopya ng form.

Karapatang Bawiin ang Awtorisasyon – Nauunawaan ko na mayroon akong karapatang bawiin angAwtorisasyong ito anumang oras sa pamamagitan ng pag-aabiso sa LACDMH nang nakasulat. Maaari konggamitin ang Pagbawi ng Awtorisasyon sa ibaba ng form na ito at ipadala sa koreo o ihatid ang pagbawi kay:

Taong Kokontakin Pangalan ng Ahensya

Address Lunsod, ZIP Code ng Estado

Nauunawaan ko rin na ang pagbawi ay hindi makakaapekto sa kakayahan ng LACDMH o anumangtagapagbigay ng serbisyong pangangalagang pangkalusugan na gamitin o isiwalat ang impormasyongpangkalusugan para sa mga dahilang may kaugnayan sa naunang pagtitiwala sa Awtorisasyong ito o kunginiaatas ng batas.

Mga Kondisyon Nauunawaan ko na maaari akong tumangging pirmahan ang Awtorisasyong ito nang hindinaaapektuhan ang aking kakayahang makakuha ng paggagamot. Gayunman, maaaring gawing kondisyon ngLACDMH sa pagbibigay ng paggagamot na kaugnay ng pananaliksik ang pagkuha ng awtorisasyonupang gumamit o magsiwalat ng protektadong impormasyon na nilikha para sa paggagamot nakaugnay ng pananaliksik na iyon. (Sa ibang salita, kung ang Awtorisasyong ito ay kaugnay ng pananaliksik nakinabibilangan ng paggagamot, hindi mo matatanggap ang paggagamot na iyon maliban kung pinirmahan mo angform ng Awtorisasyon na ito.)

Nagkaroon ako ng pagkakataong suriin at unawain ang nilalaman ng form ng Awtorisasyon na ito. Sa pagpirma saAwtorisasyon na ito, kinukumpirma ko na tumpak nitong sinasalamin ang aking mga kahilingan.

✘ ✘

Pirma ng Kliyente /Legal na Kinatawan Petsa

Kapag pinirmahan ng iba pang tao maliban sa kliyente, ipahayag ang

relasyon at awtoridad:✘

PAGBAWI NG AWTORISASYON

Pangalan ng Kliyente

Pirma ng Kliyente/Legal na Kinatawan Petsa

Kung pinirmahan ng ibang tao maliban sa kliyente, i-print ang pangalan at ipahayag ang relasyon at awtoridad.

Naka-print na Pangalan:

Relasyon at Awtoridad:

Consent for Telemental Health Service_TagalogConsent for Secure Text Messaging and Video ChatMH739_Consent for Groups or Family Sessions conducted via Telehealth or TelephoneConsent for Email_EnglishConsent for Service _TagalogNotice of Privacy Practices_EnglishAcknowledgement of receipt_Engilsh.pdfAuthorization for Use or Disclose PHI_Tagalog

pangyayari kung saan ang tauhan sa kalusugang pangkaisipan na angkop sa aking mga pangangailangan ay hindi kaagad: Lagda ng Kliyente: Kaugnayan sa Kliyente: Lagda ng Responsableng Mayor de Edad: Petsa_2: Lagda ng SaksiTagapagsalinwika: Petsa_3: Kung ang isang nakasalinwika na bersyon ng Pahintulot na ito ay nilagdaan ng kliyente ato responsableng nasa hustong: hindi binigyan ng kopya ng Pahintulot na ito noong: OffPetsa_4: Mga Inisyal: Ang kliyente ay handang tanggapin ang Telemental na mga serbisyong pangkalusugan pero ayaw lagdaan ang: OffNakumpleto ko o ipinakumpleto ang form sa Pahintulot sa Menor de Edad para sa kahit na sinong kliyente sa pagitan ng: OffLagda ng Tauhan: Petsa_5: Text17: Text18: Text19: SSG/Asian Pacific Counseling & Treatment CentersSignature of Client: Signature of Responsible Adult: Date-0: Signature of WitnessInterpreter: Date-1: Signature of Authorized Workforce Member: Date-2: declined a copy of this Consent on: Offdeclined a copy of this Consent on-0: by: I: Client had previously provided Consent but now wis: OffClient had previously provided Consent but now wis-0: Signature of Staff: Date-3: Text5: Text6: SSG-APCTCText7: Text8: Textfield: Textfield-0: Textfield-1: Textfield-2: Textfield-3: Client understands the above advisements and has v: OffThis Consent was interpreted in: Signature of Practitioner Obtaining Consent: Date: Client Name: Agency: DMH #: Name of Facility andor Program: language for the client andor responsible adult: If a translated version of this Consent was signed by the client andor responsible adult the translated version must be attached to the English version: First Name and Last Name of DMH Staff: was given: Offdeclined a copy of this twopage Consent on: OffDate_3: Initials: Client had previously provided Consent but now wishes to withdraw Consent as of: Offdate client withdraw consent: First Name and Last Name of Staff: Date_4: Name of Responsible Adult: Email Address: Relationship to Client: Name of Client: IS #: Agency Name: Provider #: Pangalan_ng_Pasilidad_ato_Programa: Lagda_ng_Kliyente: Petsa: Lagda_ng_Responsableng_Nasa_Hustong_Gulang: Kaugnayan_sa_Kliyente: Petsa0: Lagda_ng_SaksiTagapagsalinwika: Petsa1: Ang_Pahintulot_na_ito_ay_isinalinwika_sa: lumagda: Offhindi_binigyan_ng_kopya_ng_Pahintulot_na_ito_noong: Offhindi_binigyan_ng_kopya_ng_Pahintulot_na_ito_noong0: ning: Ang_kliyente_ay_handang_tanggapin_ang_mga_serbisyo: OffNakumpleto_ko_o_ipinakumpleto_ang_form_sa_Pahintul: OffLagda_ng_Tauhan_ng_ahensiya: Petsa2: Text1: Text2: Text3: Text4: Text12: Special Service for Groups/Asian Pacific Counseling and Treatment CentersDate_2: Patient refused to sign: OffOther Reason or Comments: Off1: Pangalan_ng_Kliyente_Dating_Pangalan: Petsa_ng: Numero_ng_Kliyente: Pangalan_ng_Legal: Kung_naaangkop: Address_ng_Kalye: Lunsod_Estado_ZIP_Code: Pangalan_ng_Ahensya: Pangalan_ng_Tagapagbigay_ng_Serbisyong_Pangangalag: Address_ng_Kalye0: Address_ng_Kalye1: Lunsod_Estado_ZIP_Code0: Lunsod_Estado_ZIP_Code1: PagtatasaEbalwasyon: OffMga_Resulta_ng_Sikolohikal_na_Pagsusuri: OffDayagnosis: OffMga_Resulta_ng_Laboratoryo: OffKasaysayan_ng_MedikasyonKasalukuyang_Medikasyon: OffPaggagamot: OffKabuuang_Rekord_Pangatwiranan: OffKabuuang_Rekord_Pangatwiranan0: Iba_Pa_Tukuyin: OffIba_Pa_Tukuyin0: Mga_Rekord_sa_Alkohol_o_Droga: OffMga_Resulta_ng_Pagsusuri_para_sa_HIV: OffKoreo: OffPickup: OffElektronikong_Gamit_CD_USB: OffKahllingan_ng_Kliyente: OffIba_Pa_Tukuyin1: OffIba_Pa_Tukuyin2: Hindi: OffChkBox: OffPETSA_NG_PAGKAWALA_NG_BISA_Ang_Awtorisasyong_ito_a: Taong_Kokontakin: Pangalan_ng_Ahensya0: Address: Lunsod_ZIP_Code_ng_Estado: x: x0: x1: Nakaprint_na_Pangalan: Relasyon_at_Awtoridad: Pangalan_ng_Kliyente:

mh 652t 09/07/11 pahintulot para sa telemental ......mh 652 09/07/11 pahintulot para sa telemental...

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