Subpoenas to Release Records: 96-14
Attachments:
Attachment: A. Subpoena Review Checklist
Attachment: B. Sample Cover Letter for Forwarding Records per Appropriate Subpoena and Release
Attachment: C. Sample Letter When No Release Accompanies Subpoena and All Documents Are Being Returned
Attachment: D. Sample Letter for Returning Subpoena Previously Responded To
Restrictions on Use or Disclosure of Protected Health Information (PHI), Client Request: 03-08
Attachments:
Attachment: A. Request for Special Restriction on Use or Disclosure of Protected Health Information
Attachment: B. Response to Request for Special Restriction on Use or Disclosure of Protected Health Information
Notice of Privacy Practices Policy: 03-02
Attachment A: Summary of Privacy Practices: English | Spanish | Chinese | Tagalog | Tongan | Russian
Attachment B: Consent to Treatment & Acknowledgement of Receipt of Notice of Privacy Practices: English | Tagalog | Spanish | Tongan | Chinese | Tagalog | Russian
Disclosures of Protected Health Information (PHI) with Client Authorization: 03-06
ATTACHMENTS:
See Policy 03-01:
Confidentiality/Privacy of Protected Health Information
(PHI)
• Attachment B: Authorization for Use or Disclosure of Protected
Health Information
• Attachment C: Authorization for the Verbal Release of Client
Information
Disclosure of Protected Health Information (PHI), Minimum Necessary: 03-04
Attachments:
Attachment: B. Routine Requests and the Degree of Disclosure Allowed
Attachment: C. Management Information System (MIS) – Outline of Access by Function
Attachment: A. Individuals and the Conditions of their Minimum Necessary Access by Workforce Class
Confidentiality/Privacy of Protected Health Information (PHI): 03-01
Attachments:
A. Declaration of Notice of Confidentiality
B. Authorization for Use or Disclosure of Health Information (Mental Health): English | Spanish | Chinese | Tagalog | Tongan | Russian
C. Authorization for the Verbal Release of Client Information (Mental Health): English | Spanish | Chinese | Russian | Tagalog | Tongan
F. Exchange of Information: Principles and Definitions
G. Exchange of Information: Guide to Sharing
H. Authorization for Use or Disclosure of Protected Health Information (AOD Services): English | Spanish | Chinese | Russian | Tagalog | Tongan
Application for Services and Consent to Treatment: 96-15
Attachments:
Application for Services and Consent to Treatment: 96-15, Attachment A, Treatment Consent & Notice of Privacy Practices: English
Application for Services and Consent to Treatment: 96-15, Attachment A, Treatment Consent & Notice of Privacy Practices: Spanish
Application for Services and Consent to Treatment: 96-15, Attachment A, Treatment Consent & Notice of Privacy Practices: Tagalog
Application for Services and Consent to Treatment: 96-15, Attachment A, Treatment Consent & Notice of Privacy Practices: Tongan
Application for Services and Consent to Treatment: 96-15, Attachment, B. Minor Client Legal Status and Implications for Consent
Application for Services and Consent to Treatment: 96-15, Attachment, C. GGRS Clients Mentally Incapable of Giving Consent
Amendment of Protected Health Information (PHI), Client Request: 03-09
Attachments:
Attachment: A. Request to Amend Protected Health Information
Attachment: B. Response to Request To Amend Protected Health Information
Attachment: C. Statement of Disagreement/Request to Include Amendment Request and Denial with Future Disclosures
Attachment: D. Notification of Amendment to Protected Health Information
Policy 22-04: Documentation Requirements or all SMHS, DMC, and DMC-ODS Services: Policy
Obsoleted by 19-01 June 24,
2019
Obsoleted by 19-01 June 24,
2019
Change of Clinician/Provider Request, including Charitable Choice: 98-01
Attachments:
Change of Clinician Request: 98-01, Attachment: A. Request for Change of Provider – English
Change of Clinician Request: 98-01, Attachment: B. Request for Change of Provider – Spanish
Change of Clinician Request: 98-01, Attachment: C. Request for Change of Provider – Tagalog
Change of Clinician Request: 98-01, Attachment: D. Request for Change of Provider – Chinese
Policy 99-04: Waiver/Registration in Lieu of License
Attachment A: Request for Waiver of Licensure
Attachment B: Verification of Notice Registration, Waiver of License or Licensin
Attachment C: Procedures re Verification of Licensing and Registrations
Attachment D: Mental Health Professional Licensing Waiver Request
Policy 99-04.1: Waiver/Registration in Lieu of License - Grace Period Temporary Policy
Attachment E: Employee Attestation of Temporary Policy
Assaults on Clients: Suspected or Reported: 01-03
Attachments:
Attachment A. Dependent Adult or Elder Abuse Reporting Agreement (for Employees)
Attachment B. Child Abuse Reporting Agreement (for Employees)
Attachment C. Table - Mandated Reporting of Dependent Adult and Elder Abuse
Attachment D. Emergency and Mandated Phone Numbers for Reporting Dependent Adult/Elder
Attachment E. Police Phone Numbers for Reporting Purposes (Non Emergency)
Attachment J. Community Resources Crisis Lines
Attachment K. Instructions for Residential Care Facilities
Client Access to Protected Health Information (PHI): 00-06
Attachements:
Attachment A. Request for Access to Protected Health Information
Attachment A. Request for Access to Protected Health Information, Spanish
Attachment A. Request for Access to Protected Health Information, Tagalog
Attachment B. Log of Requests for Access to Protected Health Information