{"id":3,"date":"2026-07-08T17:06:56","date_gmt":"2026-07-08T17:06:56","guid":{"rendered":"http:\/\/web_external.stonebelt.org\/milestones\/?page_id=3"},"modified":"2026-07-16T15:25:22","modified_gmt":"2026-07-16T19:25:22","slug":"patient-forms","status":"publish","type":"page","link":"https:\/\/web_external.stonebelt.org\/milestones\/index.php\/patient-forms\/","title":{"rendered":"Patient Forms"},"content":{"rendered":"\n
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Client HandBook<\/span><\/span><\/span><\/a><\/div>\n<\/div>\n <\/div><\/div>\n\n\n\n
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Referral Form<\/span><\/span><\/span><\/a><\/div>\n<\/div>\n\n\n\n
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Patient\/Client Agreement<\/span><\/span><\/span><\/a><\/div>\n<\/div>\n\n\n\n
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Consent for Services<\/span><\/span><\/span><\/a><\/div>\n<\/div>\n\n\n\n
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Release of Information<\/span><\/span><\/span><\/a><\/div>\n<\/div>\n <\/div><\/div>\n\n\n\n
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HIPPA Privacy Notice<\/div><\/span><\/span><\/span><\/div>
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THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.<\/strong><\/p>\n\n\n\n

OUR LEGAL DUTY<\/strong>
We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect April 14, 2003, and will remain in effect until we replace it.<\/p>\n\n\n\n

We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make changes to our privacy practices and the new terms of our Notice, effective for all health information we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request.<\/p>\n\n\n\n

You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.<\/p>\n\n\n\n

USES AND DISCLOSURES OF HEALTH INFORMATION<\/strong>
We use and disclose your health information for treatment, payment, and healthcare operations. For example: <\/p>\n\n\n\n

Treatment:<\/strong> We may use or disclose your health information to a physician or other healthcare provider providing treatment to you when you give us written permission.<\/p>\n\n\n\n

Payment:<\/strong> We may use and disclose your health information to obtain payment for services we provide to you.<\/p>\n\n\n\n

Medicaid Waiver:<\/strong> In accordance with state regulations, we are required to give copies of your Behavior Support Plan, Functional Behavior Assessment, and Quarterly Progress Reports to the Bureau of Development Disabilities. To this end, these documents are uploaded into the BDDS Portal, and may be accessed by others on your Medicaid Waiver treatment team or other state agency staff. These documents contain information regarding your psychiatric care and
treatment.<\/p>\n\n\n\n

Health Care Operations:<\/strong> We may use and disclose your health information for our health care operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or
qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing, or credentialing activities.<\/p>\n\n\n\n

Your Authorization:<\/strong> In addition to our use of your health information for treatment, payment, or health care operations, you may give us written authorization to use your health information to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice.<\/p>\n\n\n\n

To Your Family and Friends:<\/strong> We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to a family member, friend, or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so.<\/p>\n\n\n\n

Persons Involved in Care:<\/strong> We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative, or another person responsible for your care, of your location, your general condition, or death. If you are present, we will provide you with an opportunity to object to the use or disclosure of your health information before it occurs. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment, disclosing only health information that is directly relevant to the person\u2019s involvement in your healthcare. We will also use our professional judgment and experience with common practice to make reasonable inferences about your best interests in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information.<\/p>\n\n\n\n

Marketing Health-Related Services:<\/strong> We will not use your health information for marketing communications without your written authorization.<\/p>\n\n\n\n

Required by Law:<\/strong> We may use or disclose your health information when we are required to do so by law.<\/p>\n\n\n\n

Abuse or Neglect:<\/strong> We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.<\/p>\n\n\n\n

National Security: <\/strong>We may disclose health information of Armed Forces personnel to military authorities under certain circumstances. We may disclose health information to authorized federal officials for lawful intelligence, counterintelligence, and other national security activities. We may disclose protected health information of an inmate or patient to correctional institutions or law enforcement officials having lawful custody of the protected health information under certain circumstances.<\/p>\n\n\n\n

Appointment Reminders:<\/strong> We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters).<\/p>\n\n\n\n

CLIENT RIGHTS<\/strong>
Access:<\/strong> You have the right to review or obtain copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you requested unless we cannot do so in practice. You must make a written request to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this Notice. We will charge you a reasonable cost-based fee for expenses such as copies and staff time. You may also request access by sending us a letter to the address at the end of this Notice. If you request copies, we will charge you $0.10 (ten cents) for each page, $10 per hour for staff time to locate and copy your health information, and postage if you want the copies mailed to you. If you request an alternative format, we will charge a cost-based fee for providing your health information in that format. If you prefer, we will prepare a summary or an explanation of your health information for a fee. Contact us using the information listed at the end of this Notice for a full explanation of our fee structure.<\/p>\n\n\n\n

Disclosure Accounting: <\/strong>You have the right to receive a list of instances in which our business associates or we disclosed your health information for purposes other than treatment, payment, healthcare operations, and certain other activities, for the last 6 years, but not before April 14th, 2003. If you request this accounting more than once in 12 months, we may charge you a reasonable, cost-based fee for responding to these additional requests.<\/p>\n\n\n\n

Restriction:<\/strong> You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).<\/p>\n\n\n\n

Alternative Communication: <\/strong>You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. (You must make your request in writing.) Your request must specify the alternative means or location and provide a satisfactory explanation of how payments will be handled under that alternative.<\/p>\n\n\n\n

Amendment:<\/strong> You have the right to request that we amend your health information. (Your request must be in writing, and it must explain why the information should be amended.) We may deny your request under certain circumstances.<\/p>\n\n\n\n

Electronic Notice:<\/strong> If you receive this Notice on our website or by electronic mail (email), you are entitled to receive this notice in written form.<\/p>\n\n\n\n

QUESTIONS AND COMPLAINTS<\/strong>
If you want more information about our privacy practices or have questions or concerns, please contact us. If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may
complain to us using the contact information listed at the end of this Notice. You may also submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request. We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.<\/p>\n<\/div><\/div><\/div>\n<\/div>\n<\/div>\n\n\n\n

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Patient Rights<\/div><\/span><\/span><\/span><\/div>
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You and\/or your child are entitled to specific rights regarding the administration of your care and treatment. You shall have impartial access to treatment, regardless of race, religion, gender, ethnicity, age, or disability. You and\/or your child are entitled to:<\/p>\n\n\n\n

Considerate, respectful, professional, humane care.<\/p>\n\n\n\n

An explanation of your\/child’s condition, the risks, benefits, and the nature of your treatment and continued care, unless such knowledge is judged to be detrimental to your wellbeing by your mental health provider.<\/p>\n\n\n\n

Confidentiality and personal privacy, except in cases of danger to self or others, and abuse reporting. <\/p>\n\n\n\n

Examination of your record.<\/p>\n\n\n\n

Examination and explanation of treatment fees.<\/p>\n\n\n\n

Give your informed consent to be photographed, audio, or videotaped, or to become involved in any research activity.<\/p>\n\n\n\n

Be informed of any proposed changes to the staff responsible for your services or any transfers.<\/p>\n\n\n\n

Request reassignment to a different provider.<\/p>\n\n\n\n

Request a second opinion from a consultant at your expense.<\/p>\n\n\n\n

Be informed of your rights in a language you can understand.<\/p>\n\n\n\n

The extent permitted by law, refuse specific medication or treatment procedures.<\/p>\n<\/div><\/div><\/div>\n<\/div>\n<\/div>\n\n\n\n

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Patient Responsibilities<\/div><\/span><\/span><\/span><\/div>
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To the degree possible, we request that patients:<\/p>\n\n\n\n

Arrive on time for appointments.<\/p>\n\n\n\n

Call and cancel appointments as soon as you know you are unable to attend. We have people on standby, waiting for cancellations, who want services.<\/p>\n\n\n\n

Silence cell phones in the waiting room and step outside if you must make or receive calls.<\/p>\n\n\n\n

Be honest with your doctor or therapist.<\/p>\n\n\n\n

Express your needs and preferences to your doctor or therapist as they relate to your services.<\/p>\n\n\n\n

Ask your doctor or therapist about anything you do not understand.<\/p>\n\n\n\n

Be Courteous.<\/p>\n\n\n\n

Respect the privacy of others receiving treatment.<\/p>\n\n\n\n

Participate to your highest ability in your treatment planning.<\/p>\n\n\n\n

Pay any agreed-upon fees at the time of service (if applicable).<\/p>\n\n\n\n

Notify Stone Belt clinical staff of any changes in address, phone, insurance coverage, and\/or guardianship.<\/p>\n<\/div><\/div><\/div>\n<\/div>\n<\/div>\n <\/div><\/div>\n\n\n\n

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