ࡱ> \^[9 -bjbj@@ 7V*h*h ^^8<Zl&f&&&&&&&$(+<&u@<&^^Q&sss^^R&s&ssv#"j$`zT$&g&0&0$:},p},,j$},j$"s<&<&%N&}, X $: WELCOME TO RIVER REGION HUMAN SERVICES, INC.! These rights and responsibilities have been written to help protect each person receiving services. These forms were designed to help you know and understand what to expect from us and what it is we expect from you. We will be happy to answer any questions that you have at any time while you are receiving services and even after you leave River Region.   What to do if you think your rights have been violated? Ask any staff member for a complaint (grievance) form. If you need help filling out the form, you may ask any staff member or someone else to help you. HOW TO FORMALLY COMPLAIN OR FILE A GRIEVANCE TIME SCHEDULE FOR FILING COMPLAINTS OR GRIEVANCESSubmit your written complaint/grievance to the Program Supervisor within seven (7) days of when the issue occurred.You will be interviewed as a part of the investigation and the Program Supervisor will provide a written response within 14 days.If you do not agree with the response provided, you may ask for the Client Grievance Committee to review the complaint/grievance.Within seven (7) days, ask in writing for a review by the Client Grievance Committee.The Client Grievance Committee will review the complaint/ grievance and provide a written response within 14 days.If you do not agree with the response provided, you may ask for the Chief Executive Officer to review the complaint/grievance.Within seven (7) days, ask in writing for a review by the Chief Executive Officer.The Chief Executive Officer will review the compliant/grievance and provide a written response within 14 days.If this response is not acceptable, you may appeal to River Regions Board of Directors with a written notice.Within seven (7) days, ask in writing for a review by the Board of Directors.The Board of Directors will review the complaint/grievance and provide its written response as quickly as possible.If you are still not satisfied with the Board of Directors response. You have the right to contact your payer source.TO CALL THE CLIENT RELATIONS OFFICE OF THE DISTRICT SUBSTANCE ABUSE MENTAL HEALTH OFFICE, YOU MAY CALL 904-485-9583. TO CONTACT THE LOCAL FLORIDA ADVOCACY COUNCIL YOU MAY CALL 1-800-342-0825 IF YOU WANT TO CONTACT THE ABUSE REGISTRY, YOU MAY CALL 1-800-962-2873 RIVER REGIONS CLIENT PRIVACY NOTICE please review it carefully (Effective 4/14/2003). (THIS NOTICE DESCRIBES HOW MEDICAL, MENTAL HEALTH AND DRUG AND ALCOHOL RELATED INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.) Information regarding your services at River Region including how the services are paid for, is protected by two federal laws: the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 42 U.S.C. 1320d et.seq., 45 C.F.R. Parts 160 & 164, and the Confidentiality Law, 42 U.S.C. 290dd-2, 42 C.F.R., Part 2. These laws allow your information to be used to determine your needs and provide you services according to those needs. Under these laws, River Region Human Services, Inc. (River Region) may not say to a person outside the agency that you attend the program, nor disclose any information identifying you as a River Region client, or disclose any other protected information except as permitted by federal law. These laws allow information to be disclosed about you if: You have given written permission to release information. A judge orders a release of information (along with a subpoena) You experience a medical emergency and then, only important medical information will be given if needed. You threaten or attempt to harm yourself or someone else. You commit a crime on River Region property or against a person at River Region. There is a suspicion of abuse or neglect of a person who is unable to take care of himself. A review of your records is necessary for research, audit, or program evaluation (By official personnel only) You are found to have a communicable disease. A report will be sent to the Health Department as required by state law. At times it may be necessary for us to provide your individual health information to certain outside persons or organizations that assist us with our operations. These are businesses that have signed an agreement with the agency that requires them to protect the privacy of any information they may use in providing the service. Your privacy and confidentiality is very important to us. We will ask you to sign a Release of Confidential Information for us to be able to disclose important information to the individuals or agencies that you choose. These may include your family member, referral source, probation officer or attorney, or private doctor for example. If you change your mind, you may revoke this consent form at any time by telling your counselor or another River Region employee. Consents will be reviewed at least annually. We will discuss with you our policies for contacting you to remind you of your appointments or to correspond with you during your treatment. You have the right to request that we communicate with you by alternative means or at an alternative location. We will accommodate any reasonable request. You have the right to inspect and obtain a copy of your own health information maintained by River Region, except in very limited circumstances: the information contains psychotherapy notes or information compiled for use in a civil, criminal or administrative proceeding. We will ask you to set an appointment to review your record with your counselor, a supervisor or a record custodian. A reasonable fee may be charged if you request copies. If you determine that your record contains errors, you may request an amendment to your record to correct these errors. Your record will be reviewed by the medical director or a program director and an amendment will be made if an error is confirmed. You have the right to request and receive an accounting of disclosures of your health related information made by River Region during the six years prior to your request. River Region is required by law to maintain the privacy of your health information and to provide you with notice of its legal duties and privacy practices with respect to your health information. River Region is required by law to abide by the terms of this notice. River Region reserves the right to change the terms of this notice and to make new notice provisions effective for all protected health information it maintains. In the event of such a change, you will be asked to sign a new Privacy Notice containing these changes. COMPLAINTS AND REPORTING VIOLATIONS: If you feel your privacy rights have been violated, you may file a written complaint with the Sr. Director of HR. You may also register a complaint with the Secretary of the United States Department of Health and Human Services. Violation of the Confidentiality Law by a program is a crime. Suspected violations of the Confidentiality Law may be reported to the United States Attorney in the district where the violation occurs. You will not be retaliated against for filing such a complaint. For further information or if you have questions about your rights to privacy and confidentiality, you may contact: Your primary counselor or case manager; The Corporate Compliance Department at (904) 899-6300 ext. 4719.     RRHS form 200- CL R/R Rev 03/07/2022 YOUR RESPONSIBILITES I agree to remain drug free and alcohol free (not to use alcohol or drugs unless prescribed by a doctor). I agree to tell the staff immediately when I am given medication and will bring in the prescription or current pill bottle. I also agree not to sell or give away any medication. I agree to protect the privacy of others. Who I see and what I hear at the program will only be discussed at the program. I agree to be non-violent; that I won't threaten any violence or carry any weapon onto the clinic property. I agree not to engage in sexual activity with other program participants or staff. I agree to attend all sessions as required. Two unexcused absences (no call or no show) may cause a review for discharge from the program. I agree to dress appropriately including wearing shoes and shirt at all times. I agree to respect others (no racial, ethnic or sexual slurs) I agree to respect the property of others (no theft or vandalism) I agree not to share needles or any drug paraphernalia I agree that I am responsible for supervising my children and/or adolescents while they are on RRHS property. If I am assessed a fee for services, I agree to pay it in a timely fashion. YOUR RIGHTS Know the rules. Receive services regardless of your race, sex, creed, color, handicap, age, marital status, sexual orientation, or national origin. Be treated with respect, to believe what you want to believe, and to say what you think and feel. Be placed in the kind and type of program that you need. Decide (with the help of your counselor or case manager) what your goals are and how to achieve them and to work with staff that can help you reach your goals. Refuse or quit receiving services (and to know what could happen to you if you do refuse or quit) I have the freedom to choose providers within River Region and Designated Collaborative Organizations as are available. Have your records kept private and confidential. 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