APPLICATION CHECKLIST

Application ______ CHC Application Form ______ CHC Medical Intake Form Consent Forms (Must be filled out completely, do not send back blank signed forms) ______ Informed Consent for Assessment and Treatment ______ Consent for Medical Care ______ Publicity Clearance/Use Consent Form ______ Transition and Aftercare Authorization to Release Information Release of Information (Must be filled out completely, do not send back blank signed forms) ______ CHC Request for Records ______ Notice of Privacy Practices-Protected Health Information ______ Acknowledgment of Receipt for Notice of Privacy Practices – Protected Health Information Required Documentation ______ Birth Certificate (photocopy) ______ Social Security Card (photocopy) ______ Immunization Records (current copy) ______ Insurance Card (photocopy of front and back, enlarged)

______ Court Records (adjudication, disposition)-must include school district of origin and court order for placement at CHC

Other Materials ______ School Records/Transcripts (including IEP if applicable) ______ Psychological Testing (if applicable) ______ Social Summary/Predisposition Reports (including an outline of child’s developmental background as well as current and past information on family functioning) ______ Reports from other agencies having had contact with child (treatment programs, therapists, probation officer, etc.) ______ Physical Examination Record (if completed within past 30 days)

APPLICATION

Application must be filled out COMPLETELY; all information must be complete upon admittance to our program. Information will be kept confidential.

Please take a moment to tell us how you heard about CHC:

__________________________________________________________________________________________

CLIENT’S IDENTIFYING INFORMATION

Child’s name : (Last, First, Middle)

M F DOB:

Address:

Social Security Number:

Name of Legal Guardian: Adjudication:

Weight: Height: Hair: Eyes:

Race: Ethnicity: Religion:

Identifying features and relevant cultural variables:

REFERRING AGENCY INFORMATION

Referring Agency:

Caseworker:

Address:

Office Phone: Cell Phone:

Fax Number: Email Address:

Preferred Method of Contact:

Office Phone Cell Phone Email Fax Standard Mail

What problems has the child been having? (Please include problems at home, school or in the community and indicate when the problems began. You may attach additional information to this application)

Previous Treatment/Therapy (Please list if the child has been treated by a psychiatrist, psychologist, social worker, or mental health agency)

Dates Reason Agency/Location

Previous Out of Home Placements

Dates Reason Agency/Location

GUARDIAN AD LITEM (GAL)

GAL:

Address:

Office Phone: Cell Phone:

Fax Number: Email Address:

Preferred Method of Contact:

Office Phone Cell Phone Email Fax Standard Mail

FAMILY INFORMATION

Father:

Biological Step Adoptive Foster

Name: DOB:

Address:

Phone Numbers

Home:

Work:

Cell:

Does this parent have: Email Address:

Parental Rights? Y / N Preferred Method of Contact: Home Phone Work Phone Cell Phone Email Standard Mail

Educational Rights? Y / N Is contact restricted with this parent? Yes No

If “yes” please explain:

Mother:

Biological Step Adoptive Foster

Name: DOB:

Address:

Phone Numbers

Home:

Work:

Cell:

Does this parent have: Email Address:

Parental Rights? Y / N Preferred Method of Contact: Home Phone Work Phone Cell Phone Email Standard Mail

Educational Rights? Y / N Is contact restricted with this parent? Yes No

If “yes” please explain:

Other legal guardian: Relationship to client: __________________

Name: DOB:

Address:

Phone Numbers

Home:

Work:

Cell:

Does this person have: Email Address:

Parental Rights? Y / N Preferred Method of Contact: Home Phone Work Phone Cell Phone Email Standard Mail

Educational Rights? Y / N Is contact restricted with this person? Yes No

If “yes” please explain:

Name DOB Bio, 1/2 , Step This sibling resides with:

Siblings

MEDICAL INSURANCE INFORMATION

A COPY OF THE CHILD’S BIRTH CERTIFICATE, SOCIAL SECURITY CARD, AND INSURANCE CARDS IS REQUIRED

ARE REQ

Does the child have Medicaid (Title XIX)? Yes No

Medicaid Number:

Does the child have private insurance? Yes No

Name of Insurance Company:

Address:

Phone:

This insurance covers (check all that apply): Medical Dental Vision

Name of Insurance Holder:

Date of Birth of the Insured: Social Security # of the Insured:

Address:

Daytime Phone: Cell Phone:

Do you have an original birth certificate and social security card in your possession? Yes No

SSI

Does the child receive SSI (Supplemental Security Income)? Yes No

*If the child is receiving SSI you must provide documentation of benefits*

Who is the payee representative?

Address:

Office Phone: Cell Phone:

Fax Number: Email Address:

Preferred Method of Contact:

Office Phone Cell Phone Email Fax Standard Mail

ADDITIONAL DOCUMENTAION

Please attach copies of the following documentation to the completed application.

REQUIRED REQUESTED

Birth Certificate School Transcripts

Social Security Card Individualized Education Program (if applicable)

Insurance card (copy of front and back) Psychological Evaluation (if done)

Documentation of SSI Benefits (if applicable)

Immunization Record

Court Order (or Minute Order if not available)

Signed Consent Forms

MEDICAL INTAKE FORM

All questions contained in this questionnaire are strictly confidential and will become part of the child’s medical record.

Child’s name (Last, First, M.I.):

M F DOB:

Previous or referring doctor: Date of last physical exam:

CHILD HEALTH HISTORY

Childhood illness: Measles Mumps Rubella Chickenpox Rheumatic Fever Date(s) or age:

Immunizations and dates (please attach an up to date immunization record):

Tetanus HPV (Guardasil)

Hepatitis Chickenpox

Influenza MMR Measles, Mumps, Rubella

List any medical problems that other doctors have diagnosed

Surgeries

Year Reason Hospital

Other hospitalizations

Year Reason Hospital

Has the child ever had a blood transfusion? Yes No

List the child’s prescribed drugs and over-the-counter drugs, such as vitamins and inhalers

Name the Drug Strength Frequency Taken

Allergies to medications or substances

Name the food, drug, or substance Reaction the child had

Does the child have an allergy and/or medical identification tag? Yes No

HEALTH HABITS AND PERSONAL SAFETY

ALL QUESTIONS CONTAINED IN THIS QUESTIONNAIRE WILL BE KEPT STRICTLY CONFIDENTIAL.

Optometric Date of most recent eye exam:

Name of provider:

Does the child wear glasses or contacts? (please check all that apply) Please list any vision issues:

glasses contacts

Dental Date of most recent exam:

Name of provider:

Please list any dental and/or orthodontic issues:

Diet Does the child have any special dietary needs or restrictions? Yes No

If yes, is he/she on a physician prescribed medical diet? Yes No

Please describe:

Alcohol Does the child drink alcohol? Yes No

If yes, what kind?

How many drinks per week?

Tobacco Does the child use tobacco? Yes No

Cigarettes – pks./day Chew - #/day

# of years Or year quit

Drugs Has the child used recreational or street drugs? Yes No

Has he/she ever injected street drugs with a needle? Yes No

FAMILY HEALTH HISTORY

AGE SIGNIFICANT HEALTH PROBLEMS AGE SIGNIFICANT HEALTH PROBLEMS

Father Children M F

Mother M F

Siblings M F

M F

M F

M F

M F

Grandmother Maternal

M F

Grandfather Maternal

M F

Grandmother Paternal

M F

Grandfather Paternal

MENTAL HEALTH

Has the child been seen by a psychologist or psychiatrist? Yes No

Date of last session:

Name and address:

Reason for treatment:

What problems has the child been having? (Please include problems at home, school, or in the community and indicate when the problems began):

DEAFNESS/HEARING LOSS

Is the child deaf or does the child have hearing loss? (If no, skip to next section) Yes No

Age when first discovered:

Discovered by whom?

Family history of deafness or hearing loss? Yes No

If yes, please explain:

Does the child wear hearing aides? Yes No

All the time? Yes No

Bilateral? Yes No

Please explain type of device:

Date of last fitting and audiogram:

Childs’s preferred language:

Is the child comfortable with use of an interpreter? Yes No

Parent’s preferred language:

If either child or parent uses SIGN, what method?

OTHER PROBLEMS

Check if the child is under care for a current condition in any of the following areas and briefly explain.

Skin Chest/Heart Recent changes in:

Head/Neck Back Weight

Ears Intestinal Energy level

Nose Bladder Ability to sleep

Throat Bowel Other pain/discomfort:

Lungs Circulation

Person Completing Form: Date:

INFORMED CONSENT FOR ASSESSMENT AND TREATMENT

NAME: ___________________________________ Date of Birth: _________________ As a client of Cathedral Home for Children (CHC) you will receive a range of services that will be determined following an initial assessment and thorough discussion with your counselor and treatment team. The goal of the assessment process is to determine the best course of treatment. Typically, treatment is provided over the course of several months. The purpose of treatment is to get help with problems in your life that are bothering you or that are keeping you from being successful in important areas of your life. You may be ready to talk to a counselor or therapist about these problems. Or, you may be here because your parent, guardian, doctor or teacher had concerns about you. When you meet with your counselor and treatment team, you will discuss these problems. They will ask questions, listen to you and suggest a plan for improving these problems. It is important that you feel comfortable talking about the issues that are bothering you. Sometimes these issues will include things you don’t want your parents or guardians to know about. For most people, knowing that what they say will be kept private helps them feel more comfortable and have more trust in their counselor and treatment team. Under the Health Insurance Portability and Accountability Act (HIPAA), Cathedral Home for Children is required by law to maintain the privacy of protected health information (PHI). Most of the information you share with the staff at CHC is confidential and no information will be released outside the agency without written consent from your parent or guardian if you are under 18 years of age, or by yourself if you are an adult. There are, however, important exceptions to this rule that are important for you to understand before you share personal information in therapy. Confidentiality cannot be maintained when:

You tell someone you plan to cause serious harm or death to yourself. Steps must be taken to inform a parent or guardian of what you have disclosed and how serious this threat is believed to be. We must make sure that you are protected from harming yourself.

You tell someone you plan to cause serious harm or death to someone else who can be identified. Steps must be taken to inform a parent or guardian of what you have disclosed and we must inform the person who you intend to harm.

You are doing things that could cause serious harm to you or someone else, even if you do not intend to harm yourself or another person. In these situations, we will need to use professional judgment to decide whether a parent or guardian should be informed.

You tell someone you are being abused - physically, sexually, or emotionally - or that you have been abused in the past. In this situation, we are required by law to report the abuse to the Wyoming Department of Family Services.

You are involved in a court case and a request is made for information about your therapy. If this happens, we will not disclose information without your written agreement unless a court requires us to do so. If we are required by the court to disclose information, our attorney will review the validity of this request.

Permitted uses listed in Cathedral Home for Children’s Notice of Privacy Practice Act

There may be times when your counselor and/or treatment team feel that it would be important for your parents to know what is going on in your life. In these situations, we will encourage you to tell your parent/guardian and will help you find the best way to tell them. Also, when meeting with your parents, we may sometimes describe problems in general terms, without using specifics, in order to help them know how to be more helpful to you.

Services The mental health services we provide include individual, family, and group therapy, and any testing that is pertinent to treatment. Psychotherapy is not easily described in general statements. It varies depending on the personalities of the counselor and client, and the particular problems you are experiencing. There are many different methods we may use to deal with the problems that you hope to address. Psychotherapy calls for an active effort on your part. In order for therapy to be most successful, you will have to work on things we talk about both during sessions and at home. Psychotherapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings. On the other hand, psychotherapy has also been shown to have many benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress, but there are no guarantees of what you will experience. Your counselor and treatment team will offer you some sense of what therapy will entail and how they will work with you to address your concerns. If you have questions about your program, you should discuss them with your counselor whenever they arise. You have the right to ask for the rationale for any aspect of your treatment or to decline any part of your treatment. When you participate in testing, you have the right to an explanation of what the test or tests being administered are for and how they contribute to your treatment program, and you may decline participation at any time. You also have the right to a summary (which may be either verbal or written) of any test results. This testing gives us the basis for knowing you and how to get you through your treatment program as quickly as possible. Individual counseling appointments are generally for 50 minutes and are typically scheduled once per week. Therapy group usually meet once a week for approximately 60 minutes. Before joining a group you must meet with one of the counselors to discuss your participation in the group and any questions or concerns you may have. A range of mental health professionals, some of whom are in training, provide services at CHC. All professionals-in-training are supervised by licensed staff, as required by Wyoming Medicaid Standards. While psychotherapy and/or medication, may provide significant benefits, it may also pose risks. Psychotherapy may elicit uncomfortable thoughts and feelings, or may lead to the recall of troubling memories. Medications may have unwanted side effects. As part of your program at CHC you may participate in recreation and/or wilderness therapy activities and travel on trips both in and out of state. Research has shown that these types of activities provide significant benefits for physical, emotional, and psychological health. There are risks inherent in these activities, and while every precaution is taken to minimize these risks, the potential exists for unintended outcomes or injury. Some of these unanticipated outcomes are reportable events to our accrediting agency (Joint Commission). If you have a safety or quality of care concern that is not resolved by our administration, we encourage you to call the Commission at 630-792-5264. You may also call our licensing agency, Wyoming Department of Mental Health at 307-777-7094. Professional Records The laws and standards of our profession, and the HIPAA Privacy Rules require that we keep Protected Health Information (PHI) about you in your clinical record. You clinical record includes information about your reasons for placement at CHC, a description of the ways in which your problem affects your life, your diagnosis, the goals for treatment, your progress toward those goals, your medical and social history, your treatment history, results of clinical tests, any past treatment records that we receive from other providers, reports of any professional consultations, and copies of any reports that have been sent to anyone. Because these are professional records, they can be misinterpreted and/or upsetting to read. If you wish to review them, we will arrange for you to review them in the presence of your therapist or Director, or have them forwarded to another mental health professional with whom you can discuss the contents. Your clinical record serves as a:

basis for planning your care and treatment

means of communication among the health professionals who may contribute to your care legal document describing the care you received means by which you or a third-party payer can verify that services billed were actually provided

Minors If you are under 18 years of age, please be aware that the law may provide your parents the right to examine your treatment records. Before giving parents any information we will discuss this with you, if possible, and do our best to handle any objections you may have with what we are prepared to discuss. Conclusion Your signature below indicates you have read this information and agree to abide by its terms during your placement at Cathedral Home. *Informed consent is explained to the client by their clinical therapist upon intake and they electronically sign this document within the agency’s electronic record keeping system.* ________________________________________________ ____________________________ Signature of Parent or Guardian Date ________________________________________________ ____________________________ Referring Agency Signature (if applicable) Date

CONSENT FOR MEDICAL CARE

I hereby authorize the Cathedral Home for Children (CHC) to obtain any necessary medical treatment for the following

client ______________________________________ from the following individuals (1-8), unless any of these

individuals has been marked through with a line and is followed by my initials:

1. CHC Nursing Staff

2. CHC Medical Director

3. Client's designated physician, nurse practitioner, dentist, eye care provider, and

audiologist.

4. CHC designated physician, nurse practitioner, dentist, eye care provider, and

audiologist.

5. Emergency room personnel.

6. Psychiatrist

7. Psychologist

8. Hospital Personnel

I understand that the term, necessary medical treatment, pertains to the following items (1-10), and I give consent for each

of these items, unless individual items are marked through with a line and followed by my initials:

1. Comprehensive history and physical exam

2. Screening exams that are deemed necessary during or after the history and

physical

3. Required Vaccines: childhood immunizations, meningitis, and annual Influenza *

4. Acute illness care

5. Chronic illness management

6. Emergency medical treatment

7. Hospitalization, including psychiatric

8. Dental and eye care

9. Psychiatric mental assessment and testing

10. Administration of prescribed medications

I can be reached at (phone) ____________________ and understand that I will be notified should emergency treatment be

necessary and before any non-routine medical care (e.g. surgery, orthodontics, treatment of a new major medical illness)

is initiated. I also understand and acknowledge that the resident may need prescription medications to be ordered and

administered to the resident while at CHC. These prescription medications may include psychotropic medications which

are prescribed and monitored by a psychiatrist. I give consent for the resident to be prescribed and administered all

medications. I understand I will be notified of all prescribed medications, as well as any prescribed changes in medication

regime and/or management.

________________________________________________ ___________________

Signature of Client (if over 18yrs. of age) Date

________________________________________________ ____________________

Signature of Parent or Guardian Date

________________________________________________ ____________________

Referring Agency Signature (if applicable) Date

* For information regarding immunization, please visit:

http://www.health.wyo.gov/familyhealth/immunization/SchoolResourcesSchoolImmRecs.html

PUBLICITY CLEARANCE/USE CONSENT FORM

PHOTOGRAPH, VIDEO, ARTWORK, AND WRITINGS (OF CLIENT)

I, _____________________ , the parent or legal guardian of ________________ , (hereafter “client”), grant to Cathedral

Home for Children, Laramie, Wyoming, its successors and assigns, the right to use and publish for advertising,

promotional and fundraising purposes, photographic portraits or any photographic likeness or picture of client. Client may

be included in the portraits, any photographic likeness or pictures in whole or in part, in composite or other form, in color

or otherwise, make and published through any medium, including but not limited to print, video and web based means.

I waive on behalf of client any right to inspect or approve the finished product or the copy that may be used in connection

therewith or the use to which it may be applied.

I release and discharge on behalf of such client such photographers, videographers or web based “page designers” and

Cathedral Home for Children, their successors and assigns, and all persons acting under their permission or authority from

any liability by virtue of any blurring, distortion, alteration, optical illusion, or use in composite form whether intentional

or otherwise, that may occur or be produced in the taking of the pictures or videos, or in any processing tending toward

the completion of the finished product.

In addition to the rights granted herein, I further grant to Cathedral Home for Children the non-exclusive right to

reproduce or publish original works of authorship (graphic and/or text) of client, for the exclusive purposes of advertising,

promotion and fundraising purposes, provided, however, this grant shall not be considered an assignment of copyrights

whatsoever in said original works of authorship.

Additionally, I and the client have been made aware that client has the right to rescind consent for use of film,

photographs, likenesses, artwork, etc. within thirty days of intake. Client may do so by submitting a letter or a verbal

request addressing reasons for rescind of consent to the Marketing Director for review.

*Please note, when client is participating in public events (i.e. Jubilee Days and Cheyenne Frontier Days Parades, University of

Wyoming Athletic venues, graduation parties, etc.) Cathedral Home relinquishes control of outside parties utilizing photographic

portraits or any photographic likeness or picture of client in outside mediums.

______________________________ _________________________ _________________

Signature of Client Signature of Parent/Guardian Date (Must be 18 years of age or older.)

If you do not give consent please sign here: ________________________________________ _______________________

Date

If you have any questions regarding this form, please contact:

Marketing Department

Cathedral Home for Children

4989 N 3rd St.

Laramie, WY 82072

Phone (307) 745-8997

info@cathedralhome.org

CATHEDRAL HOME FOR CHILDREN

TRANSITION & AFTERCARE AUTHORIZATION TO RELEASE INFORMATION

4989 N 3rd St.

Laramie, WY 82072

(307) 721-1589

Fax: (307) 742-6146

Client Name:_______________________________

Social Security #:______________________________

Date of Birth:_________________________________

Authorization to Release Information FROM:

Cathedral Home for Children

4989 N. 3rd St.

Laramie, WY 82072

Please sign below each authorization statement; signature is required for each. No signature

indicates no authorization.

I authorize the release of immunization records, school transcripts, Cathedral Home for Children photo ID and letter

explaining placement at Cathedral Home for Children to obtain an original Social Security Card from the Social Security

Administration.

______________________________ _______________________________ ___________________ Printed Name of Signature of Date Legal Guardian/Referring Agency Worker Legal Guardian/Referring Agency Worker

I authorize the release of Cathedral Home for Children photo ID and letter explaining placement at Cathedral Home for

Children to obtain an original certified Birth Certificate.

______________________________ _______________________________ ___________________ Printed Name of Signature of Date Legal Guardian/Referring Agency Worker Legal Guardian/Referring Agency Worker

I authorize the release of Birth Certificate, Social Security Card, immunization records and letter explaining placement at

Cathedral Home for Children to obtain Wyoming State ID.

______________________________ _______________________________ ___________________ Printed Name of Signature of Date Legal Guardian/Referring Agency Worker Legal Guardian/Referring Agency Worker

CATHEDRAL HOME FOR CHILDREN

REQUEST FOR RECORDS

Client Name: ________________________

Social Security #: _____________________ Date of Birth: _________ Phone: ________ Address: ___________________________ City/State/Zip: _______________________

For Office Use Only

The request to access the health care record is approved

The request to access the health care record is denied for the following reason(s):

____________________________________________________________________ __________________________________ __________________________________ Signature of HIPAA Compliance Officer

________________________________________________________________________________ Authorization to Release Medical Information FROM: _________________________________________ Name of Practitioner _________________________________________ Name of Clinic/Hospital/Treatment Facility, etc. _________________________________________ Address _________________________________________ City, State, Zip

Please SEND my treatment information TO: _________________________________________ Name of Practitioner _________________________________________ Name of Clinic/Hospital/Treatment Facility, etc. _________________________________________ Address _________________________________________ City, State, Zip

________________________________________________________________________________ I authorize the release of the following records:

Medical (please specify): ____________________________________________________________ ________________________________________________________________________________ Educational (please specify): ________________________________________________________ ________________________________________________________________________________ Clinical* (please specify): ___________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ * I specifically authorize the release of information pertaining to drug and alcohol abuse records Purpose of this release is for: (check one or more)

( ) Billing and payment of bill ( ) Continuity of care and discharge planning ( ) Other: ________________________________________________________________

My consent may be revoked at any time. The only exception is when the information has already been released as instructed in the consent. If not previously revoked, this consent will terminate one (1) year after the date of my signing it. A photocopy or faxed copy of the release may be used in place of the original. __________________ _____________________________________ Date Signature

_____________________________________ Parent/Legal Guardian Signature (if needed)

________________________________________________________________________________

I specifically authorize the release of HIV/AIDS testing information, if this is a part of my record. __________________ _____________________________________ Date Signature

Cathedral Home for Children 4989 North 3rd Street Laramie, WY 82072

Notice of Privacy Practices-Protected Health Information

THIS NOTICE DESCRIBES HOW MEDICAL/MENTAL HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED

AND HOW YOU CAN GET ACCESS TO THE INFORMATION. PLEASE REVIEW IT CAREFULLY.

Cathedral Home for Children (CHC) is required by law to maintain the privacy of protected health information, to provide individuals with notice of its legal duties and privacy practices with respect to protected health information, and to notify affected individuals following a breach of unsecured protected health information. We will require you to acknowledge receipt of this notice in writing. We create records concerning your medical and/or mental health treatment, etc. to maintain a record to comply with certain legal requirements. Protected Health Information (PHI) is defined as individually-identifiable information regarding a patient’s health care history; mental or physical condition; or matters related to treatment. Some examples of PHI may include, but are not limited to: date of birth and treatment, treatment records, enrollment and claims records and other matters as provided by law. CHC is required by law to maintain the confidentiality of your PHI. CHC will receive, use and disclose your PHI to provide care for you, to obtain payment for services provided to you and as otherwise permitted or required by law. Any other disclosure of your PHI without your authorization is prohibited. We must follow the privacy practices described in this notice, but also comply with any stricter requirements under federal or state law which may apply. EFFECTIVE DATE: This notice became effective February 28, 2004, and was amended on April 23, 2013, and will remain in effect until amended. We will abide by the most current privacy notice. In the event of an amendment, we will post the updated notice on our website and redistribute to you within the time provided by law. You may request a copy of this notice anytime by contacting the address or phone number at the end of this notice. You should receive a copy of this notice at the time of enrollment as a CHC client and upon your request. Permitted Uses and Disclosures of Your PHI We are permitted to use or disclose your PHI without your prior authorization under controlling law, including, but not necessarily limited to the purposes described below. Permitted uses and/or disclosures include uses and/or disclosures for purposes of health care treatment, payment of claims and other health care operations. If your health benefit plan is sponsored by an employer or another party, we may provide PHI to your employer or that sponsor, as provided by law. Such uses and disclosures may include but are not limited to: processing your claims, collecting enrollment information and premiums, reviewing the quality of care you received, customer service, resolving grievances, and sharing payment information with insurers. FOR TREATMENT: We may use your PHI to provide you with medical/mental health treatment or services. We may disclose your PHI to doctors, nurses, psychotherapists, or other professionals who are involved with or managing your care. Examples: Immunization records will be sent to schools, other doctors’ offices upon request, and placed on the Wyoming Vaccine Registry. If you are receiving medical/mental health treatment at CHC, the professional providing treatment needs to be informed of therapy progress for medication management. Therapists must be informed of diagnoses and recommendations from the psychiatrist to develop the appropriate therapy plan. We may also share your PHI with other health care providers to aid in treating you. FOR PAYMENT: We may use and disclose your PHI information for payment purposes. Examples: You are treated at CHC for a medical issue. We need to give your health insurance carrier or other payor the information about the diagnosis and treatment you received so your health plan will pay us or repay you for services paid for. We may also tell your health insurance carrier about treatment you may receive for approval or to determine if your plan will pay for the treatment. FOR HEALTH CARE OPERATIONS: We may also use and disclose your PHI for our health care operations. This may include measuring and improving quality, evaluating associate performance, conducting training programs, and obtaining the accreditation, certificates, licenses and credentials we need to provide you with quality health care. Example: Our facility is being audited by an external agency (i.e. Title XIX). Certain portions of your medical/mental health information may be examined for quality control purposes. ADDITIONAL USES AND DISCLOSURES: We may use and disclose your PHI without your authorization for the following additional purposes:

We may disclose PHI to third parties that perform services for CHC regarding your care or related matters. These parties are required by law to sign a contract agreeing to protect the confidentiality of your PHI. These affiliates are required to implement privacy policies and procedures and comply with applicable federal and state law. We are also permitted to use and/or disclose your PHI to comply with a valid authorization, to a personal representative, and to report victims of abuse, neglect, or domestic violence. You have a right to revoke any authorization you provide to us, but any disclosures made in reliance on the authorization prior to the revocation remain unaffected. Other permitted uses and/or disclosures are for purposes of health oversight by government agencies, judicial, administrative, or other law enforcement purposes, information about decedents to coroners and medical examiners, certain research purposes, to avert a serious threat to health or safety, specialized government functions such as military and veterans activities, workers’ compensation purposes, and use in creating summary information that can no longer be traced to you. Additionally, with certain restrictions, we may be permitted to disclose your PHI for insurance underwriting purposes. We are also permitted to incidentally use and/or disclose your PHI during the course of a permitted use and/or disclosure, but must be kept to a minimum. We use administrative, technical, and physical safeguards to maintain the privacy of your PHI and must limit the use and/or disclosure of your PHI to the minimum amount necessary to accomplish the purpose of the use and/or disclosure. As required by law; various state or federal statues or rules may require us to release PHI. Family/Friends Involved: We are allowed to release protected health information to your close friends and/or family members who are directly involved in your care. These persons are allowed to receive protected health information concerning you, unless you object. If you object, then you should inform us and we will then coordinate with you to determine what information can be disclosed and what steps are needed to assure for your continued effective treatment and care. Court orders, Judicial and Administrative Proceedings: Under certain circumstances we may disclose PHI in response to a court or administrative order, subpoena, discovery request, or other lawful process. Example, we may share the PHI of an inmate or other person in lawful custody with a law enforcement official or correctional institution. Public Health Activities: We may disclose your PHI to public health or other authorities charged with preventing or controlling disease, injury or disability, including child abuse or neglect, as required by law. We may disclose your PHI to persons subject to jurisdiction of the Food and Drug Administration for the purpose of reporting adverse events associated with product defects or problems, to enable product recalls, repairs or placements, to track products, or to conduct activities required by the Food and Drug Administration. Example, when authorized by law, we may also notify a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition. Victims of Abuse, Neglect, or Domestic Violence or Threats of Same: We may disclose PHI to appropriate authorities if we have reason to believe that you are a possible victim of abuse, neglect or domestic violence or the possible victim of other crimes. Example, we may share your PHI if it is necessary to prevent a serious threat to your health or safety or the health or safety of others. Workers’ Compensation: When authorized and necessary to comply with laws relating to workers’ compensation or other similar programs, we may disclose your PHI. Health Oversight Activities: We may disclose PHI to an agency providing health oversight or oversight activities authorized by law. Examples, audits, civil, administrative, or criminal investigations or proceedings, inspections, licensure or disciplinary actions, or other authorized activities. Law Enforcement: Under certain circumstances, we may disclose your PHI to law enforcement officials. We may share certain PHI concerning a suspect, fugitive, material witness, crime victim or missing person. Examples, include reporting required by certain laws, complying with a legal process (e.g. subpoena or court order), reporting limited information concerning identification and location (e.g. missing person), reports regarding suspected victims of crimes, reporting death, crimes on our premises, or to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. Personal Representative: This is a person who, under applicable law, has authority to represent you in making decisions related to your care (e.g., parents, guardians, etc.) Under the privacy laws, a personal representative has the same right to obtain protected health information as the person being treated.

Note: The use or disclosure of PHI is governed by state and federal law, and the situation set forth herein are meant to provide you examples of the general instances of where we may use or disclose your PHI without your authorization. Whether PHI will be used and disclosed will be considered under the circumstances at the time, in accordance with state and federal law in effect at the time. PSYCHOTHERAPY NOTES: Special rules relate to psychotherapy notes. Psychotherapy notes refers to notes recorded (in any medium) by a mental health professional documenting or analyzing the content of conversation during a private, group, joint, or family counseling session and are separated from the rest of the individual’s medical record. Psychotherapy notes exclude medication prescription and monitoring, session start and stop times, modalities and frequencies of treatment, results of clinical tests, and any summary of the following items: diagnosis, functional status, treatment plan, symptoms, prognosis, and progress to date. We create these notes pertaining to you for our personal use. Consequently, these notes may be of limited use to others, including you. You should understand that in certain circumstances we may decline to provide you your psychotherapy notes, as may be provided by law. Moreover, psychotherapy notes may not be disclosed without your written authorization except in certain limited circumstances. PERMITTED USES OR DISCLOSURES FOR PSYCHOTHERAPY NOTES: - Supervised mental health training programs for students, trainees, or practitioners; - By CHC to defend legal action, complaint, investigation or other proceeding brought by you or involving you; - For legal and clinical oversight of the psychotherapist who made the notes; and/or - To prevent or lessen a serious and imminent threat to the health or safety of you or the public. YOU HAVE THE RIGHT TO: You have the right to request an inspection of and obtain a copy of your PHI. You may access your PHI by contacting CHC in writing. You must include your name, address, telephone number and the PHI you are requesting. Note: we may charge you for labor costs, a per-page copying fee and the cost of any media used to give you your PHI (compact discs or flash drives). These charges pertain to paper and microfilmed charts. We may also charge you for postage. Please contact us with questions on our fee structures. You may not inspect or copy PHI compiled in reasonable anticipation of, or use in, civil, criminal, or administrative action or proceeding, or PHI otherwise not subject to disclosure under federal or state law. In some circumstances, you may have a right to have this decision reviewed. Please contact the privacy office as noted below if you have questions about access to your PHI. We may deny your request to inspect and/or to receive a copy in certain limited circumstances. If you are denied access to mental health information, you may have the denial reviewed by another licensed health care professional chosen by use. We will comply with the outcome of the review. You have the right to request a restriction of your PHI. You have the right to ask that we limit how we use and disclose your PHI. We will consider your request, but are not legally required to accept it unless the disclosure is for the purpose of carrying out payment or health care operations and is not otherwise required by law and the PHI pertains solely to a health care item or service for which you, or some person other than the health plan on behalf of you, has paid CHC in full. If we accept your request for a restriction, we will put any limits in writing and abide by them except in emergency situations. You may not limit the uses and disclosures that we are legally required or allowed to make. You have the right to amend, correct, or update your PHI. You may request an amendment of your PHI for as long as we maintain this information. In certain cases we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy. If your PHI was sent to us by another, we may refer you to that person to amend your PHI. Please contact the privacy office as noted below if you have questions about amending your PHI. You have the right to request or receive confidential communications from us by alternative means or at a different address. We will agree to a reasonable request if you tell us that disclosure of your PHI could endanger you. You may be required to provide us with a statement of possible danger, a different address, and a different method of contact or information as to how payment will be handled. Please make this request in writing to the privacy office as noted below. Reminder calls: We may contact the telephone number or e-mail address you have specified to remind you of an appointment at CHC. You have the right to receive an accounting of certain disclosures we have made, if any, of your PHI within certain time periods. This right does not apply to disclosures for purposes of treatment, payment, or health care operations or for information we disclosed after we received a valid authorization from you. Additionally, we do not need to account for disclosures made to you or family members or close friends involved in your care, or for notification purposes. We do not need to account for disclosures made for national security or intelligence reasons, for certain law enforcement or correctional purposes, disclosures made as part of a limited data set, incidental to a disclosure or use otherwise permitted by law, disclosures made prior to April 14, 2003, and for other

disclosures as provided by law. Please contact us if you would like to receive an accounting or disclosures or if you have questions about this right. You have the right to get his notice by e-mail. You have the right to get a copy of this notice by e-mail. You also have the right to request a paper copy of this notice. You have a right to file a complaint. If, in your opinion, we have violated your privacy rights or if you object to a decision we have made about your PHI, you are entitled to file a written complaint with us at the address below or with the Secretary of the United States Department of Health and Human Services, 200 Independence Ave. S.W., Washington, D.C., 20201. We will not retaliate in any way if you choose to file a complaint. Contact information: If you have questions, want to request information about your PHI, exercise your rights with your PHI or to file a complaint, contact the following: HIPAA Compliance Officer Cathedral Home for Children 4989 N 3

rd St.

Laramie, WY 82072 Phone: (307) 745-8997 Fax: (307) 742-6146

Cathedral Home for Children 4989 N 3rd St.

Laramie, WY 82072

Phone: (307) 745-8997

Acknowledgment of Receipt

Notice of Privacy Practices-Protected Health Information By signing this form, you acknowledge receipt of the Notice of Privacy Practices of Cathedral Home for Children (CHC). Our Notice of Privacy Practices provides information about how we may use and disclose the client’s Protected Health Information (PHI). We encourage you to read it in full. Immunizations will be sent to schools, other doctor’s offices upon request, and placed on the Wyoming Vaccine Registry. The client’s PHI may also be used for treatment with other providers, receive payment from insurers, and to conduct normal health care operations such as quality assessment. Our Notice of Privacy Practices is subject to change and we have reserved the right to change it. If we change our notice, you may obtain a copy of the revised notice by contacting Cathedral Home for Children at the above address to obtain a current copy of the Notice of Privacy Practices.

***An electronic version of the Notice of Privacy Act can be found at: www.cathedralhome.org***

Client Name: _______________________________________________ Date of Birth: _______________ Parent/Guardian Signature: _______________________________________________________________ Relationship to Client: ________________________________________________ Date: ____________ Signature of Client, over 18 years old ____________________________________ Date: ____________

FOR OFFICE USE ONLY CHC attempted to obtain written Acknowledgement of Receipt of our Notice of Privacy Practices, but Acknowledgement was unable to be obtained due to: Reason: ______________________________________________________ Signature of CHC Representative: ________________________________________ Date: _____________

Wisdom Teeth Extraction Consent

As a client of Cathedral Home for Children (CHC) you will receive routine medical care including annual vision exams as well as dental visits. If the dentist determines it is appropriate, they may give a referral for a wisdom teeth extraction consultation. CHC clients are taken to Cheyenne Oral and Maxillofacial Surgery Associates (at their Laramie location) for wisdom teeth consultations. If the oral surgeons agree with the dentist’s initial assessment that the client should have their wisdom teeth removed CHC healthcare staff will arrange an appointment for the surgery.

Clients are educated on the importance of wisdom teeth extractions and the complications that can present later in life if wisdom teeth are left unattended. Clients are encouraged to work with CHC healthcare staff on moving forward with the surgery, but surgeries will not be scheduled against a client’s will or if the client still has serious concerns or reservations.

CHC healthcare staff works to train and educate cottage staff on providing post-operative care to clients following wisdom teeth extractions. Cottage staff routinely prepare soft foods, monitor Ibuprofen/Tylenol for pain management and swelling, and encourage rest and hydration to clients after their wisdom teeth procedures.

Please see the Cheyenne Oral and Maxillofacial Surgery consent form on the following page. The consent form outlines all the necessary information and disclosures for a wisdom teeth extraction. CHC healthcare staff is happy to answer any additional questions not satisfied in the surgeon’s consent form. Please read and initial EACH paragraph as well as sign and date the bottom. CHC would like to make it clear that by signing the following consent form it does not mean that the client is guaranteed to have their wisdom teeth extracted while at Cathedral Home. Including the consent form in the application packet is merely a way for CHC healthcare staff to ensure that scheduling wisdom teeth extractions move as smoothly as possible should that be a recommended procedure for the client. We will also notify the parent/guardian of the client after a client’s wisdom teeth consultation if extraction has been recommended so that they can be aware that the procedure is being scheduled.