I, the undersigned below, am requesting treatment from Core Recovery and the treatment team at Core Recovery. As a condition of that treatment, I acknowledge the following items and agree with them.
Consent for Treatment Services
I hereby consent to health care, therapy, self-learning and coaching services provided by the employees and independent contractors of Core Recovery for the benefit of myself and my family.
I understand that some of the Therapists, Coaches, Physicians, support staff, and mentors may be independent contractors or business associates and not employees of Core Recovery.
Right to Refuse Treatment
I understand that I have the right to refuse any or all parts of the recommendations for my treatment except emergency treatment designed to protect the health and safety of others and myself.
The treatment team and management believe that the outpatient treatment strategies the program uses to provide a useful intervention for chemical dependence problems; however, no specific outcome can be guaranteed.
Release of Liability
I recognize that there are inherent risks associated with the activities described herein and I assume full responsibility for personal injury to myself and my family members. I further release and discharge Core Recovery, contractors, 3rd party providers, business associates and any referring, accrediting or regulator parties including State Governments and their agencies for injury, loss or damage arising out of my or my family’s use of the programs, treatment protocols, self-learning modules or other resources of Core Recovery, whether caused by the fault of myself, my family, Core Recovery or other members of my treatment team.
I agree to indemnify and defend Core Recovery, contractors, 3rd party providers, business associates and any referring, oversight parties including State Governments and their agencies against all claims, causes of action, damages, judgments, cost or expenses, including attorney fees and other litigation costs, which may in any way arise from my or my family’s use of the programs, treatment protocols, self-learning modules or 3rd party resources provided by Core Recovery.
Consent for release of information to 3rd party coaches
I hereby consent for a limited release of information to 3rd party coaches, who will be providing Intentional coaching™ as a part of my treatment team.
Clarification of the Separate Roles of Licensed Therapists and Intentional Coaches
I understand that Intentional Coaches are not Licensed Therapists and will not provide therapy. I agree to keep my medical information private and not share with Intentional Coaches except as needed to accomplish my Intentional goals.
Your Consent for Communicating Protected Health Information
I understand that I have the right to give or withdraw consent for communicating my Protect Health Information (PHI.) Every request must be made in writing using the online or paper “Release of Information” (ROI) form. Your verbal instructions cannot be followed without a written confirmation. Your initial request is included in this agreement for the purpose of determining your appropriateness to our programs and to coordinate payment. I understand that I must give written consent for future release to and from my spouse, family, attorney, court, parole officer, doctor, family member, trusted person or others before Core Recovery can communicate with them.
Release of Information to Insurance Companies and 3rd Party Payors
I hereby give my written permission to share my assessment, diagnosis and clinical notes as needed with insurance companies and 3rd party payors for obtaining treatment authorizations and/or claim reimbursements.
Privacy of Information
Core Recovery is required by law to make and keep records of the Member’s medical treatment. The Facility safeguards those records, and it uses and discloses such records and the information they contain only in accordance with State and Federal privacy laws.
Clarification of Record Keeping
Records generated as a part of my self-learning modules will not be construed as medical records and will not be stored or protected under Core Recovery’s privacy statement.
3rd Party Resources and Programs
Electronic Health Record
I understand that as a Member, an electronic file will be developed for my treatment and that I may have a copy of all records upon request.
With my written consent hereby given by signature below, I understand that my therapist or supervising clinical staff may make treatment referrals or request professional consultation outside of Core Recovery for the sole purpose of my care.
Video Conference Treatment
I understand that all treatment and coaching will be by secure video conference or telephone. I understand that privacy is required and that I will follow all program rules during treatment including the privacy of my location.
I understand that Core Recovery does not make recordings of any session. Instead, for program quality and training purposes, I do give my consent for an authorized observer to attend any group meeting that I may be attending.
Confidentiality of Group Sessions
All information disclosed in private and group sessions is strictly confidential and may not be revealed to anyone outside the program staff without the written permission of the other Members.
Exceptions to Privacy
The exceptions are when disclosures are required or permitted by law. Those situations typically involve (1) insurance claim processing, (2) when you display a substantial risk of physical harm to yourself or to others and (3) suspected abuse of children or the elderly.
I understand that I can be discharged from the program/treatment if deemed therapeutic by my therapist/counselor or for disobeying program rules.
Accomplishing treatment goals also requires the cooperation and active participation of myself and my family. If the lack of cooperation by myself and family interferes with the program’s ability to render services effectively, I understand that I can be discharged from the program.
Other Member Privacy
I understand that as a Member of the Core Recovery IOP program I may become aware of information relating to other Members. I understand that I cannot reveal or discuss any information regarding Members with anyone outside Core Recovery. This privacy protection is for my welfare and the welfare of others in treatment.
Federal Confidentiality Regulations 42 CRF Part 2 prohibits me from making any disclosures without the specific written consent of the person to whom which disclosure pertains. A general authorization for the release of information (a general, medical or clinical) would not be sufficient.
I further understand that Act 63 contains no criminal penalties for breach of confidentiality. However, Federal Regulations cover such breaches and provide for the fine of $500.00 for the first offense. For each subsequent offense, the fine may be as high as $5,000.00.
I understand that when I interact online with Core Recovery systems and websites that my typed name becomes my electronic signature instead of written signatures. I also understand that faxed or scanned copies of documents with my signature are to be considered original signatures.
By signing below, I acknowledge that I have read, understand and commit to abide by these terms and conditions.
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