To have your license reinstated, you must obtain a certificate of completion.
A certificate of completion can be obtained by:
a) Completing a substance abuse assessment at an authorized NC DWI Services provider
and
b.) Completing the recommended level of treatment or education at an authorized NC DWI Services provider.
for the purpose of evaluating and monitoring agencies for appropriateness of services and financial responsibility
[describe the purpose of the disclosure; as specific as possible]
I understand that my substance use disorder records are protected under the Federal regulations governing Confidentiality and Substance Use Disorder Patient Records, 42 C.F.R. Part 2, and the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 45 C.F.R. pts 160 & 164, and cannot be disclosed without my written consent unless otherwise provided for by the regulations.
I understand that I may revoke this authorization at any time except to the extent that action has been taken in reliance on it. Unless I revoke my consent earlier, this consent will expire automatically as follows:
[describe date/event/ condition upon which consent will expire; must be no longer than reasonably necessary to serve the purpose of this consent]
I understand that I might be denied services if I refuse to consent to a disclosure for purposes of treatment, payment, or health care operations, if permitted by state law. I will not be denied services if I refuse to consent to a disclosure for other purposes.
Notice Prohibiting re-disclosure of Substance Use Disorder Information: This information has been disclosed to you from records protected by federal confidentiality rules (42 CFR part2). The federal rules prohibit you from making any further disclosure of information in this record that identifies a patient as having or having had a substance use disorder either directly, by reference to publicly available information, or through verification of such identification by another person unless further disclosure is expressly permitted by the written consent of the individual whose information is being disclosed 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 (see §2.31). The federal rules restrict any use of the information to investigate or prosecute regarding a crime any patient with a substance use disorder, except as provided at §2.12(c)(5) and §2.65
[name or general designation of individual or entity making the disclosure]
I understand that my substance use disorder records are protected under the Federal regulations governing Confidentiality and Substance Use Disorder Patient Records, 42 C.F.R. Part 2, and the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 45 C.F.R. pts 160 & 164, and cannot be disclosed without my written consent unless otherwise provided for by the regulations. I understand that I may revoke this authorization at any time except to the extent that action has been taken in reliance on it. Unless I revoke my consent earlier, this consent will expire automatically as follows:
I understand that I might be denied services if I refuse to consent to a disclosure for purposes of treatment, payment, or health care operations, if permitted by state law. I will not be denied services if I refuse to consent to a disclosure for other purposes.
Notice Prohibiting re-disclosure of Substance Use Disorder Information: This information has been disclosed to you from records protected by federal confidentiality rules (42 CFR part2). The federal rules prohibit you from making any further disclosure of information in this record that identifies a patient as having or having had a substance use disorder either directly, by reference to publicly available information, or through verification of such identification by another person unless further disclosure is expressly permitted by the written consent of the individual whose information is being disclosed 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 (see §2.31). The federal rules restrict any use of the information to investigate or prosecute regarding a crime any patient with a substance use disorder, except as provided at §2.12(c)(5) and §2.65
I understand that my substance use disorder records are protected under the Federal regulations governing Confidentiality and Substance Use Disorder Patient Records, 42 C.F.R. Part 2, and the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 45 C.F.R. pts 160 & 164, and cannot be disclosed without my written consent unless otherwise provided for by the regulations.
I understand that I might be denied services if I refuse to consent to a disclosure for purposes of treatment, payment, or health care operations, if permitted by state law. I will not be denied services if I refuse to consent to a disclosure for other purposes.
Signature & Initials on this form authorizes A.R.C. Counseling and Consulting Services, PLLC (ARCCCS) to receive, release, and/or discuss specific information concerning the above-named Individual to the following individual or entity listed below:
A.R.C. COUNSELING AND CONSULTING SERVICES, PLLC
Print (Individual or Entity Name)
ADDRESS: 512 Harris Avenue
CITY: Raeford
STATE: NC
ZIP CODE: 28376
PHONE: (910) 960-7491
Individual/Legal Responsible Person (LRP) must initial each category to be disclosed. Enter N/A next to items not applicable.
Signature & Initials on this form authorizes A.R.C. Counseling and Consulting Services, PLLC (ARCCCS) to receive, release, and/or discuss specific information concerning the above-named Individual to the following individual or entity listed below:
A.R.C. COUNSELING AND CONSULTING SERVICES, PLLC
Print (Individual or Entity Name)
ADDRESS: 512 Harris Avenue
CITY: Raeford
STATE: NC
ZIP CODE: 28376
PHONE: (910) 960-7491
Individual/Legal Responsible Person (LRP) must initial each category to be disclosed. Enter N/A next to items not applicable.
Reason ( All applicable) Continuity of Care / Referral Legal / Service Delivery / Other:
HIPAA (Privacy Notification)
This information shall be accessed only by those who have a need to know and only on a professional basis. All persons who are privileged to this information shall be bound by the Confidentiality and HIPAA Act. The doctrine of informed consent has been explained to me, and I understand the contents to be released and the need for the information. I understand ARCCCS may disclose information without consent that is outlined and further explained to me in the ARCCCS- Assurance of Confidentiality- Notification to Individual form. Once information is disclosed pursuant to this signed authorization, I understand that the federal health privacy law (42 C.F.R. Part 164) protecting health information may not apply to the recipient of the information and therefore, may not prohibit the recipient from re-disclosing it. Other laws, however, may prohibit re-disclosure. I also understand substance abuse records are covered under Federal Regulations (42 CFR, Part 2) and that there are statutes and regulations protecting the confidentiality of my information, and that the information cannot be re-disclosed. I further understand that the information released may include drug and/or alcohol use, and/or HIV/AIDS diagnosis only with my specified consent.
I hereby acknowledge that this consent is truly voluntary and is valid until 1- year from the signature date of this form. I further acknowledge that I may revoke this consent at any time by submitting a short written, signed & dated request, except to the extent that action based on this consent has already been taken. I understand I may request a copy of this consent or any other pertinent information regarding my Individual file by submitting a short written, signed and dated request. ARCCCS will respond to my written request(s) within 48 business hours of receipt.
Your Right to Medical Information Confidentiality:
HIPAA is an acronym that stands for Health Insurance Portability and Accountability Act that was made into law in 1996. By law, if you are 18 years or older, you have the right to strict confidentiality regarding your medical records. To release any information, you must consent to the authorized provider listed on this form.
Copy Clause:
I agree that a copy of this form may act as an original.
| Diagnostic/Assessment (MH/DD/SAS) | Substance Abuse Comprehensive Outpatient Treatment Program |
| Intensive In-Home Services | Substance Abuse Non-Medical Community Residential Treatment |
| Psychosocial Rehabilitation | Substance Abuse Medically Monitored Community Residential Treatment |
| Partial Hospitalization | Substance Abuse Halfway House |
| Professional Treatment Services in Facility-Based Crisis Programs | Detoxification Services |
| Outpatient Services | Non-Hospital Medical Detoxification |
| Medically Supervised or ADATC Detoxification/Crisis Stabilization | Other |
INTERDISCIPLINARY TEAM PROGRESS NOTE--(TEAM’S REVIEW & DISCUSSION OF THE ASSESSMENT/EVIDENCE OF INDIVIDUAL AND/OR FAMILY OR GUARDIAN OR THER CAREGIVERS’ PARTICIPATION IN DIAGNOSTIC ASSESSMENT):
SIGNATURES OF TEAM MEMBERS
This service has been determined medically necessary and is being billed Incident To:
I confirm and agree with my involvement in the development of this Treatment Plan. My signature means that I agree with the services/supports to be provided. I understand that I have the choice of service providers and may change service providers at any time, by contacting the person responsible for this PCP.
