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DATE: February 12, 2015
TO: SUD Provider Network – Safe and Sober Housing Providers
FROM: Business Psychology Associates Provider Network Management
SUBJECT: Client Record Requirements for RSS Providers
BPA began implementing the Recovery Support Services audit in July 2014 as part of their
contract with the state. As we have visited Safe and Sober Housing RSS providers in each
region, we have found that the documents kept on file can vary. We want to clarify what
documents at a minimum are required by IDAPA to be maintained for each client either in hard
copy or electronic version. As part of the annual RSS audits Regional Coordinators will review
agency client files for these specific elements.
Signed Release of Information (ROI) forms: Providers who offer services to clients in SUD
treatment need to have a signed Release of Information on file. These providers must have an
IDHW ROI on file as well as an ROI for any other agency the RSS provider may be
communicating with regarding clients. Recommended forms are attached.
Statement of Clients Rights: All alcohol and substance use recovery support services programs
must have written policies and procedures to protect the fundamental human, civil,
constitutional, and statutory rights of each client. Each client must be given a written
statement of client rights, which includes who the client may contact with questions, concerns
or complaints regarding services provided. Copies of the program's client rights statement must
be posted in conspicuous places at all sites.
Sign in Sheets: Safe & Sober Housing providers must also have daily sign-in sheet to document
which clients utilized the facility on a daily basis.
PC-108-02/12/2015
If you have any questions, please contact your Regional Coordinator below:
Region 1 Region 2 Nancy Irvin, LMSW & ACADC Dean Allen, LCPC [email protected] [email protected] 208 964-4868 208-305-4439
Region 3 & 4 Region 5 LaDessa Foster, LCPC, MAC, NCC Kim Dopson, M.Ed., LCPC, MAC [email protected] [email protected] 208-284-4511 208-539-5090
Region 6 & 7 Address:
Doug Hulett, LPC, ACADC 380 E. Parkcenter Blvd., Suite 300 [email protected] Boise, ID 83706 208-921-8923
BPA: We are committed to providing real and human solutions that make lives better,
organizations more effective and communities stronger.
PC-108-02/12/2015
BPA Required Form DHW Release General Rev. Date 9-06 Client ID:___________
Idaho Substance Abuse Treatment and Recovery Support Services Direct any and all questions or concerns to: __________________________________________
Consent for Release of Information
I, _____________________________ am requesting substance abuse services from Idaho’s publicly funded substance abuse system of care. As such I voluntarily authorize Business Psychology Associates (BPA), those Substance Abuse Treatment and Recovery Support Services (RSS) providers who are contracted to provide Treatment and RSS under Idaho’s publicly funded substance abuse system of care, and the Department of Health and Welfare (Department) to disclose my name, all necessary treatment information and my social security number to each other and the Department. This information will be disclosed for the following purposes: 1) To assist with referring me to appropriate types of care and guiding my treatment and recovery support; 2) To be entered into the Department’s common client database so that I will have one client number for any services received from the Department; 3) To process payment of costs for my treatment and recovery support services; 4) For monitoring compliance in the program; 5) For program audit and research including independent peer reviewers, contract monitors or researchers appointment by the Department Furthermore, I authorize the disclosure of personal substance abuse treatment and recovery outcomes data collected by contracted Substance Abuse Treatment and RSS Providers, BPA and the Department to the Federal Center for Substance Abuse Treatment and its contracted data collection agents._____ Client Initials
Informed and Voluntary Consent for Treatment The purpose of my participation, as a client, in the Idaho publicly funded substance abuse treatment program is to acquire knowledge, skills and attitudes supportive of a sober and more satisfying lifestyle. In addition to the potential positive outcomes likely to occur as a result of my participation, the following reasonably foreseen risks may occur, as they would in any other alcohol and drug treatment program: breach of confidentiality; negative reactions of group members; emotional stress from requirements of group interaction, self-disclosure; stress to relationships resulting from open discussion of issues, past traumas; and, stress to relationships resulting from participant behavioral changes, positive or negative, need to attend recovery support meetings, spend time in group and doing assignments. Providers will take steps to minimize or protect participants against potential risks by adhering to standards of confidentiality found both in Federal and State Code, and by informing and verifying client understanding of group rules. And, by intervening in and guiding appropriate disclosure, confrontation and resolution in group and in family conflict. Providers will assist clients in accessing sober support services and self help groups where acceptance and stress reducing support is available. ___________ Client Initials
Revocation Clause
This release may be revoked at any time either orally or in writing, except to the extent that action has already been taken in reliance on the release. I acknowledge that some information may include material that is protected by State and Federal regulations including Confidentiality of Alcohol and Drug Abuse Patient Records, 42 C.F.R. Part 2 and the Health Information Portability and Accountability Act (HIPAA). Unless revoked as stated above, this consent expires automatically on:____________________________________. _________ Client Initials
I have read the above Consent to Release of Information, Informed and Voluntary Consent for treatment and the Revocation Clause. I agree I have been given the opportunity to question the above disclosures and consent for care and hereby do agree to the above identified Disclosures and Consent to Treatment. _________________________________________________________________________________________ Client Printed Name Client Signature Date _________________________________________________________________________________________ Parent/Guardian Printed Name Parent/Guardian Signature Date _________________________________________________________________________________________ Witness Printed Name Witness Signature Date
PC-108-02/12/2015
PR-50-04/05/2012 BPA Recommended Form Revised 4/5/2012
Any Agency CONSENT TO RELEASE AND EXCHANGE OF INFORMATION
I, ____________________________________, hereby authorize Any Agency to request and/or (PARENT/GUARDIAN OF CLIENT OR CLIENT NAME)
disclose information, verbal or written, of (NAME OF CLIENT)
to ____________________________________________________________________________ (NAME OF AGENCY OR INDIVIDUAL – INCLUDE RELATIONSHIP) (CONTACT INFORMATION)
____________________________________________________________________________ (St Address) (City) (State) (Zip)
Please initial next to all applicable items requested below The records requested are for the following services:
Substance/Alcohol Abuse Services Mental Health Services
Case Management
HIV/AIDS Related Information
RSS Services (Other)
Legal Services
Please initial next to all applicable items requested below Specific Information Requested:
The purpose of the disclosure authorized herein is to:
(Purpose of disclosure, as specific as possible)
I understand that my records are protected under the federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 CFR Part 2, as well as the Health Information Portability and Accountability Act (HIPAA) of 1996, 45 CFR Parts 160 and 164 Subparts A and E, and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I also understand that I may revoke this consent any time, by either written or verbal notification, except to the extent that action has been taken in reliance on it, and that in any event this consent expires automatically as follows: I also understand that this authorization is voluntary and that I may refuse to sign this authorization. I understand
that this agency may not condition treatment, payment, enrollment or eligibility for benefits whether or not I sign this authorization, unless allowed by law. I understand that I may inspect or copy any information used or disclosed under
this authorization.
Client Signature___________________________________ Date Parent/Guardian___________________________________ Date Agency Representative_____________________________ Date
GAIN Assessment
Admission/Discharge Summary
Psychiatric Evaluation
Court Related Information
Social/Medical History
Case Management Plans/Progress
History & Physical Exam
Treatment Plans
Laboratory Data (Drug Testing)
Probation/Parole Progress Reports
Admission/Discharge Summary
Exchange Information
Medication Records
Other _______________________
PC-108-02/12/2015
