Advance Directives Acknowledgement Form

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Advance Directives Acknowledgement Form

It is your right to have a written direction about their mental/health treatment, known as an advanced directive, if you ever lose your ability to make decisions. This plan basically describes how you want to be cared for in case you ever become unable to decide or speak for yourself. You also have the right to revoke the consent at any time.

You may also include a “health-Care Proxy”. This lets you name another person to make decisions about your care if you become unable to do so. For assistance preparing these plans, we recommend that you speak to someone you trust. For example, one of our agency staff, a family member or a minister. If you choose through informed consent, the LMHP will further explain available community-based resources for the completion of an advance directive. You may also contact an advocacy agency for assistant and/or support in completing an advanced directive. The following is advocacy contact information:

The Advocacy Center: (800) 711-1696

or

visit the website for a center in your area at www.dhh.louisiana

The agency has explained what advance directive is and its purpose. I understand the plan and at this time I am signing this acknowledgement form and also choose:

Consent for Treatment

In signing this document, I am stating that I have read and agree to the following conditions regarding services rendered by INSERT AGENCY NAME:

1. I consent to and authorize treatment through INSERT AGENCY NAME.
2. I authorize the collection of necessary administrative data regarding me. I understand that such data shall be computerized for statistical, programming, and billing purposes.
3. I understand information regarding me shall be collected responsibly and maintained in a confidential clinical record. Any such records or information shall remain confidential except in the following incidences:
   1. Information required by third-party payers and parties giving INSERT AGENCY NAME authorization to provide said services shall be forwarded to them.
   2. Records shall be open to INSERT AGENCY NAME as needed and to appropriate state mental health officials.
   3. Information may be exchanged if I sign a written release form indicating the nature of the information to be released.
   4. Information which indicates a severe threat to the life or safety of another person or to myself shall be forwarded to the threatened parties or appropriate agencies to the extent necessary to protect life and safety.
   5. Information will be released if required under a court subpoena.
   6. Suspected abuse, neglect, or exploitation shall be thoroughly investigated, documented, and reported as indicated in the agency’s policies and procedures.
   7. State and Federal law prohibits the disclosure of any information identifying a recipient as receiving alcohol/drug services unless the recipient consents in writing, the disclosure is allowed by court order, or the disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit, or program evaluations.
   8. Federal law does not protect any information about a crime committed by a recipient either at the program or against any person who works for the program, or about any threat to commit such a crime.
4. I understand that all services will be provided regardless of gender, color, national origin, sexual orientation, religious preference, or level of disability.
5. If there is a medical or psychiatric emergency, I give permission for staff to seek emergency care on my behalf.
6. INSERT AGENCY NAME staff may share information, with my consent, with other associated facilities such as group homes, the Department of Social Services, Court Services, and Area Programs if a recipient is seen in two or more of these agencies.
7. I agree to satisfy my financial obligation with INSERT AGENCY NAME. I understand payment is due at the time services are rendered unless payment arrangements are made.

Consent for Treatment