orange county department of social services lean six sigma

Orange County Department of Social Services Lean Six Sigma Child Welfare/Behavioral Health Process

Improvement Instructions

Pursuant to the Adoption and Safe Families Act of 1997, a petition to terminate parental rights must be

filed for all children who have been in foster care for 15 out of the last 22 months (unless a compelling

reasons exists). The Orange County Department of Social Services Lean Six Sigma Child

Welfare/Behavioral Health Process Improvement project aims to reduce the time to permanency by

creating an information flow that allows for appropriate verbal and written feedback and incorporates

stages of change language and the DLA-20 to create a common language between stakeholders. As part

of the process improvement project a referral form and monthly reporting form were created. Please

see below for instructions on completing these forms. Your participation in this process to improve time

to permanency for children in foster care is greatly appreciated.

Child Welfare Staff:

A Mental Health and/or Chemical Dependency Referral from is required for all parents whose

children are removed from custody by the Department of Social Services and have a

recommendation for behavioral health evaluation and/or services.

Child Welfare Staff will complete the Mental Health and/or Chemical Dependency Referral form

and send it to the behavioral health provider who is providing evaluation and/or services to the

parents of the children in custody.

The Mental Health and/or Chemical Dependency Referral form shall be completed for parents

who are already in treatment for mental health and/or chemical dependency, as well as for

parents who are being newly referred.

The Child Welfare Staff will provide Behavioral Health Providers with a properly completed

HIPAA complaint release at the time they provide the Mental Health and/or Chemical

Dependency Referral form

Behavioral Health Providers:

Behavioral Health Providers will receive a Mental Health and/or Chemical Dependency Referral

form from Child Welfare Staff.

If there is not a properly complete HIPAA compliant release provided from Child Welfare,

Behavioral Health Providers will make every effort to obtain one.

Behavioral Health Providers will forward initial assessment and treatment plan to Child Welfare

upon completion.

If admitted to treatment, or currently in treatment, the behavioral health provider will complete

the Foster Care Monthly Report at the time of admission and every 30 days thereafter until

permanency is achieved.

o Providers will provide a recent DLA-20 score on the Foster Care Monthly report.

o Providers will use stage of change language on the form and in communication

with Child Welfare Staff.

If not admitted, the Behavioral Health Provider will complete the Foster Care Monthly report as

completely as possible and clearly indicate the reason the individual was not admitted.

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Child Welfare Staff and Behavioral Health Providers:

Both parties agree to ongoing communication while individual is in treatment.

Both parties agree to utilize Stages of Change language and DLA-20 scores as a shared language.

Both parties agree to encourage parents to sign a HIPAA compliant release of information to

allow for both parties to initiate and maintain ongoing communication, being mindful that the

legal timeline for permanency determination (reunification, an alternative permanency plan, or

termination of parental rights) starts the day the child is removed from their parents care.

Definitions/Glossary for pages included in the packet

Stages of Change Model of Overcoming Addiction - common language to be used between

Child Welfare, Mental Health, Chemical Dependency providers, and Family Court to identify

where the client is in their change process. Although developed as a model for identifying

progress in the Chemical Dependency treatment field, the change theory is applicable across

any change progress.

Daily Assessment Tool (DLA-20) – a functional assessment tool designed to identify someone’s

current functioning state within the most recent 30 days of assessment. The DLA-20 graphic

highlights the ten domains that are assessed. A sample DLA-20 tool is included, as training is

required in order to use the tool.

*Please contact the Orange County Department of Mental Health if you require DLA-20

Training.

Core Beliefs of Child Welfare Practice - A brief outline of three concepts that are critical to Child

Welfare practice, safety (vs. risk), permanency and well-being.

Social Services Law - this page contains information regarding Social Services’ responsibility to

provide services, which would allow children to remain with their parents/caregivers as long as

they are providing what is considered to be a minimum degree of care.

Notice to Parents of Children entering Foster Care - this required legal notice is given to parents

whose children are removed from their care. This notice stipulates the federal limit (15 months)

as the amount of time children can spend in Foster Care before a petition to terminate parental

rights must be filed.

*Please see SSL384-b below for important additional information

Second Notice to Parents of Children entering Foster Care – this letter outlines the importance

of immediately taking steps to remediate the circumstances that led to the child’s removal.

Concurrent Planning - while working with birth parents towards reunification, the Department

of Social Services is required to establish an alternative permanency plan for children in foster

care. The goal is always to have parents develop an alternate permanency plan themselves in

case the child cannot be returned to their care. This is a critical step in ensuring that family

voice is included planning for the child’s future.

SSL384-b - an outline of the legal grounds under which parental rights can be terminated.

Please note that while 15 months is the federal limit on the amount of time children can spend

in Foster Care before a petition to terminate parental rights must be filed, such petitions can be

filed as early as six months (based on parental abandonment), and most commonly 12 months

(based on permanent neglect).

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MENTAL HEALTH AND/OR CHEMICAL DEPENDENCY REFERRAL CLIENT NAME ADDRESS TELEPHONE

OC DSS CASEWORKER TELEPHONE OC DSS SUPERVISOR TELEPHONE

DATE OF REFERRAL CASE INITIATION DATE (CID) LEGAL REMOVAL DATE (LDR) LEGAL CUSTODIAN (Birth parent(s) may provide consent for their child who’s in DSS Custody)

OC DSS SERVICE TYPE: FOSTER CARE SERVICES 1017 (DIRECT CUSTODY) TO RELATIVE OTHER: _____________________________________ CURRENT CRIMINAL PROCEEDING(S): PROBATION DRUG TREATMENT COURT T.A.S.C. OTHER: _____________________________________ LAST DLA-20 INFORMATION AGENCY(S) PROVIDING SERVICES

SCORE: _________________

DATE: _________________

SERVICE PLAN REVIEW INFORMATION Therapists will be asked to participate in the child’s SPRs which are held at

90 day, 6 month and every 6 months thereafter from the CID.

LEGAL MILESTONES

LAST LEGAL PROCEEDING DATE: ___________________

LAST LEGAL PROCEEDING TYPE:

ARRAIGNMENT TRIAL DISPOSITION PERMANENCY HEARING

UP-COMING SERVICE PLAN

DATE: __________________

TYPE: Initial (30 Days from CID) Comprehensive (90 Days CID) 1ST Reassessment (7 months from CID) Reassessment (6 months from last Reassessment)

NEXT LEGAL PROCEEDING DATE: ___________________

NEXT LEGAL PROCEEDING TYPE:

ARRAIGNMENT TRIAL DISPOSITION PERMANENCY HEARING EARLIEST DATES ABLE TO FILE PARENTAL RIGHTS TERMINATION

Parental Abandonment: ___________ (6 Mo from LDR) Parental Lack of Diligent Effort: ___________ (12 Mo from LDR) Federal Max. Time in Care: ___________ (15 Mo from LDR)

REFERRAL NARRATIVES- Attach additional pages as needed RELEVANT FAMILY HISTORY: See attached Social History, if applicable

REASON FOR REFERRAL:

FAMILY STRENGTHS:

DESIRED CHANGES NEEDED TO ENSURE CHILD SAFETY:

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DOB

Additional Comments (if needed):

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The Stages of Change Model of

Overcoming Addiction

The “Stages of Change” (SOC) or “Transtheoretical” Model is a way of describing the process by which people overcome Addiction. The stages of change can be

applied to a range of other behaviors that people want to change, but have difficulty doing so, but it is most well-recognized for it’s success in treating people with

addictions. SOC looks at how change occurs in “natural recovery” from addictions, and has been embraced by the move away from confrontational and pathological

approaches, toward motivational and person-centered approaches, such as motivational interviewing.

There are four main stages: Precontemplation, Contemplation, Preparation and Action. Additional stages of Maintenance and Relapse are also sometimes included.

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DLA-20 Assessment Tool

The DLA-20 is a research-backed, outcomes measurement tool that evaluates the impact of

mental illness or disabilities on areas of daily living in 20 domains. It can be quickly administered

to examine 20 areas of Daily Living Functioning and creates a reliable Global Assessment of

Functioning (GAF) Score aimed at examining the most recent 30 days of someone's functioning.

To schedule training on this tool, please contact Regina LaCatena at 845-291-2600

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http://ncbh.msgfocus.com/c/1N8uachpRs3Vr2hD0gNQwvUf

DAILY LIVING ACTIVITIES (DLA) FUNCTIONAL ASSESSMENT

Beyond Global Assessment of Functioning: Ensuring Valid Scores and Consistent Utilization for Healthcare Report Cards

Willa S. Presmanes, M.ED., MA, MTM Services and National Council Consultant and Research Coordinator and Co-Author of Daily Living Activities (DLA) Functional Assessment

The Daily Living Activities (DLA) Functional Assessment is a functional assessment, proven to be reliable and valid, designed to assess what daily living areas are impacted by mental illness or disability. The assessment tool quickly identifies where outcomes are needed so clinicians can address those functional deficits on individualized service plans.

The DLA is intended to be used by all disabilities and ages. Developmental Disabilities and Alcohol/Drug Abuse forms are personalized for daily functional strengths and problems associated with those diagnoses. An Adult form exists for SMI and SPMI consumers over the age of 18 and a Youth form for consumers between the ages of 6 and 18.

A sample of five domains (of the Twenty DLA Indicators) and the scoring criteria are listed in Appendix A below.

RELIABILITY AND VALIDITY: The DLA is a reliable and valid measure for the purposes oflevel of care consideration, treatment planning around outcomes, and to correlate and predict DSMIV, Axis V. Two studies with 971 consumers over repeated measures will be reviewed with the results reflecting a satisfactory treatment plan time-saver for case coordinators. The tool is published in the Research on Social Work Practice (Abstract and other reference articles are in Appendix B). Please note, however, that since 2005, the DLA has been copyrighted to protect reliability and validity, not for additional monetary remuneration beyond training fees.

WHO COMPLETES THE DLA FUNCTIONAL ASSESSMENT: The consumer’s primary clinician or case manager typically has the most information about daily functioning at home or in the community and are best prepared to complete the form. The tool has been shown to take approximately 6 to 10 minutes to complete at the conclusion of an assessment. The information has proven value for treatment planning and estimating Axis V (Global Assessment of Functioning or GAF) of DSMIV and contributes valuable information in psychiatric approval for Medicaid reimbursement and healthcare reporting standards.

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TRAINING ON THE DLA

The DLA is a copyrighted measure available for free after appropriate training from MTM Services. Programs who register for training are awarded the rights to manually or electronically use the tool as long as the DLA is not altered, shortened and it is used for validated purposes. The tool is not to be implemented without training through MTM Services.

A DESCRIPTION OF TRAINING SEMINAR: Participants will initially learn why functional assessments are in the forefront of audits and accountability. They will participate in established pretests in order to experience the definition of reliability and validity. They will be introduced to criteria for scoring the functional assessment tool (copyrighted DLA) via the presentation of a current consumer’s functional assessment. Subsequently, small groups congregate under the supervision of the author to assess various members’ consumers using the DLA. Small groups confront intricate questions, misconceptions and learn to focus on functioning for designing measurable goals and treatment plans. In concluding the session, participants reconvene to examine DLAs and their correlation with level of care assignments, DSMIV, Axis V (GAF), scoring GAF with and without objective criteria and using functional assessments in treatment plans, progress notes, and tracking outcomes. Materials for training trainers and clinicians are included.

WHO SHOULD ATTEND THE TRAINING: Psychiatrists, Clinicians, Case Managers, Quality Assurance Officers, human resource trainers working with the aforementioned employees.

Educational Objectives: 1. To Inform programs serving severely mentally ill, substance abuse and developmental disabilities about the

APA, Medicaid, OIG Healthcare Report Card basis for requiring functional assessments (separate fromsymptoms) and research-based criteria necessary for shifting from a subjective to a quantitative GlobalAssessment of Functioning (GAF).

2. To Validate the GAF: Score, Use, Interpret GAF for customers - Customers who pay and audit us;Customers (staff) who have varying needs when serving consumers; Customers (managers) who manageservice and pay employees; and most important with the most emphasis: consumers’ reportedsatisfaction with treatment, outcomes.

3. To Ensure GAF utilization is consistently scored, reliable with national norms for public healthcare reportcards.

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Appendix A: Five Sample Domains (of the Twenty DLA Indicators) and the Anchors Supporting the Scoring

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Appendix B: References

Abstract from Research on Social Work Practice (v11:3), 373-389 (2001)

Reliability and Validity of the Daily Living Activities Scale: A Functional Assessment Measure for Severe Mental Disorders

Roger L. Scott (Georgia Mountains Community Services, Gainesville, Georgia)

Willa S. Presmanes (DeKalb Community Service Board, Decatur, Georgia)

Objective: Two studies evaluated the validity and reliability of the Daily Living Activities Scale (DLA), a 20-item functional assessment measure for adults with severe mental disorders. Method: The first study evaluated the internal consistency and interrater reliability of the DLA scoring for 85 clients with severe mental disorders currently receiving services from one of five different treatment programs. In the second study, symptomatology and functional assessment data were collected for 886 clients at time of admission to three different levels of care in community treatment and support services and at the time of 6-month progress reviews. Results: Internal consistency and interrater reliability were adequate. Criterion-related validity was evidenced by the ability of DLA scores to differentiate consumers in different levels of care and by diagnostic categories. Conclusions: Study findings provide evidence of the usefulness of the DLA to support the functional assessment data needs of service providers.

Additional References:

• PERMES Training Materials (Performance Evaluation), State of Ga., DHR, 2002 - 2005• Reliability, Validity of the Daily Living Activities Scale (to correlate and improve Axis V reliability), 2001• JCAHO Valid Outcome Indicator, 1998 (Chicago)• CARF suggested outcome indicator, 2005• Role Functioning Scale (GA-RFS, 1985 – 2004 multiple publications)

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CORE BELIEFS OF

CHILD WELFARE PRACTICE

Safety – a child is “safe” when there is no immediate or

impending danger of serious harm to a child’s life or

health, as a result of acts of commission or omission by the

parent(s) or caretaker(s). **Risk – the likelihood that a

child will be abused or maltreated in the future.

Permanency – a birthright; a commitment to a child and

continuity in the child’s relationship with others.

Permanency is achieved through family preservation or

reunification, adoption, guardianship and through

placements with relatives or with alternate permanency

resources.

Well-being – a unity of physical, cognitive, emotional and

spiritual health, encompassing factors such as safety,

security, education and socialization as well as a sense of

being loved, valued and included in their family.

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Minimal Care Needs:

“Failed to exercise a minimum degree of care” is a legal phrase which means

that a person has not been as careful or watchful as we expect people in any

position of responsibility for the welfare of children to be.

Types of Reasonable / Diligent Efforts:

Efforts to prevent the removal of a child from his/her home

Efforts to prevent a child from coming into foster care (alternative child care)

Efforts to reunite the child and the parent when child is in foster care

Efforts to achieve other permanency for the child if return is not feasible

“Reasonable Efforts” and “Diligent Efforts” - Gene D. Skarin 2007

Social Service Law 384-B(1)(a)(iii)

Statement of legislative findings and intent.

(a) The legislature recognizes that the health and safety of children is of paramount importance. To

the extent it is consistent with the health and safety of the child, the legislature further hereby finds

that:

(i) it is desirable for children to grow up with a normal family life in a permanent home and that such

circumstance offers the best opportunity for children to develop and thrive;

(ii) it is generally desirable for the child to remain with or be returned to the birth parent because the

child’s need for a normal family life will usually best be met in the home of its birth parent, and that

parents are entitled to bring up their own children unless the best interests of the child would be

thereby endangered;

(iii) the state’s first obligation is to help the family with services to prevent its break-up or to reunite

it if the child has already left home and;

(iv) when it is clear that the birth parent cannot or will not provide a normal family home for the child

and when continued foster care is not an appropriate plan for the child, then a permanent alternative

home should be sought for the child.

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NOTICE TO PARENTS OF CHILDREN ENTERING FOSTER CARE

State and Federal Law now require that the Department of Social Services file a petition to terminate parental rights for any child who is in foster care 15 of the most recent 22 months. There are very few exceptions.

For this reason, it is important that you make every effort to enable your child to return home safely as soon as possible. Your child’s return to home will depend largely upon your cooperation with services offered to you by the Department of Social Services of the Family Court.

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Date ____________________ Dear ______________________________:

As you know, your child(ren) was (were) recently placed in foster care. At the time of their placement, you should have received a Notice to Parents of Children Entering Foster Care. That notice informed you that the Department of Social Services must seek the termination of parental rights for any child who is in foster care for 15 of the most recent 22 months. The law allows very few exceptions.

A termination of parental rights can be avoided by safely returning the child to the parents’ care or by discharging the child to some other permanent living arrangement. The Department of Social Services will assist you by every means available to regain custody of your child(ren) or to make some other permanent plan for your child(ren)’s care.

It is very important for you to begin working towards your child(ren) return home as soon as possible. Visiting with your child(ren) in foster care is one of the most important things you can do to maintain your bond with them and will show the Court your commitment to regaining custody of your child(ren). You must inform your caseworker of anything which prevents you from visiting regularly so that you may work together to overcome the problem.

Your caseworker will discuss a service plan with you. This plan will outline those services you will be expected to go to in order to solve the problems that led to your child(ren) entering foster. Following through with these recommended or Court-ordered services will also help to get your child(ren) back home. It is absolutely necessary that you use the services provided and improve your ability to care for your child(ren). Again, anything which prevents you from solving the problems which resulted in your child(ren)’s placement must be reported immediately to the caseworker or service provider. It is the Department’s responsibility to make a reasonable effort to help you solve your problems. We will work with you toward the safe return of your child(ren).

Sincerely,

_________________________ _________________________ Caseworker Telephone Number

_________________________ _________________________ Supervisor Date

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CONCURRENT PLANNING

Concurrent Planning is a term heard frequently in child welfare since

ASFA’s enactment. ASFA amended section 471 (a)(15)(F) of the Social

Security Act to explicitly permit that reasonable efforts to place a child for

adoption or with a legal guardian may be made concurrently with

reasonable efforts to make is possible for a child to safely return to the

child’s home. In other words. It is permissible to work toward reunification,

while at the same time establishing an alternative permanency plan.

Concurrent Planning is now widely regarded as a basic tool for the

achievement of permanent homes for children in foster care. The intent of

concurrent planning is to effect permanent placement in less time than it

would likely take a series of plans, each based on a single permanency

goal.

CORE COMPONENTS OF CONCURRENT PLANNING

Early engagement of parents, family members, resource families, and others in team

planning and decision making

Early and thorough assessment of children’s needs, family functioning, safety,

support, important connections, and reunification potential

Full disclosure of information: rights, responsibilities, expectations, children’s needs,

and parenting capacities

Frequent and meaningful visitation

Early diligent search for absent parents and clarification of paternity

Developing Plan A and Plan B: recruiting and supporting resource families (relatives

and non-relatives)

Options Counseling: alternative permanency options, including voluntary

relinquishment and open adoption

Behaviorally-specific case plans with clear case documentation and parental

agreement

Intensive casework with families

Court and community collaborations

Supervising Concurrent Planning - 2005 Research Foundation of SUNY/CDHS

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SSL §384‐b LEGAL BASIS TO INVOLUNTARILY TERMINATE PARENTAL RIGHTS IN N.Y. STATE (Parent(s) will not sign "surrender" for child or you believe such "surrender" is not appropriate and you believe it would be in the. best interests of the child to be freed for adoption. (With 2006 changes)

Mother Father (he may not have full "consent" rights; he may only have rights to "notice" or no rights)

ABANDONMENT

Child in care of county or agency for six months immediately prior to date of filing petition and

Parent failed to visit child or failed to communicate with child or failed to contact agency or any such

visits/communications/contacts were inconsequential(as per legal precedents) and

Parent physically and financially able to visit/communicate/contact and

Parent not prevented or discouraged from doing so by agency or court and

Parent evinced an intent to abandon.

PERMANENT NEGLECT

Child in care with county/agency for either at least one year or 15 out of the most recent 22 months and

Diligent/reasonable efforts addressing problems were made to reuni9 the family and failed or

Proof of diligent]reasonable efforts excused either (1) as detrimental to best interests of child or

(2)Parent failed to keep agency apprised of their whereabouts for at least 6 months during the one year period

or (3)court previously granted a "no reasonable efforts" to reunify order and

Parent substantially and continuously or repeatedly failed to maintain contact with the child and not

prevented from doing so by agency or court order or

Parent failed to plan for future of the child and

Parent had the physical and financial ability.

BUT For incarcerated parent proof of diligent/reasonable efforts may be excused if (s)he failed on more than

one occasion to cooperate with the agency on visitation or planning.

MENTAL ILLNESS or MENTAL RETARDATION

Child has been in care of county /agency for the last year prior to filing petition and

Parent is mentally ill (expert evidence needed) or

Parent is mentally retarded (expert evidence needed) and

As the result of Mental Illness or Mental Retardation the parent cannot now provide proper and adequate

care for the child and such impairment is likely to remain in the foreseeable future.

SEVERE ABUSE

Child in care of county or agency and

Child found to be severely abused. (see definition in Social Services Law §384‐b 8.(a) which now include one

parent convicted of murder/manslaughter (or attempt) of other parent) and

Diligent/reasonable efforts were made to encourage and strengthen the parental relationship when such

efforts will not be detrimental to the best interests of the child or family court previously granted a FCA 1039‐

b "no reasonable efforts" required to reunify order and

Such diligent/reasonable efforts have been unsuccessful and are likely to be unsuccessful in the foreseeable

future.

REPEATEDLY ABUSED

Child in care of county or agency and

This child has been found to be abused (case #2) [under FCA § 1012 (e)(i) or (iii)] and

This child and/or another child of this parent was previously adjudicated as abused(case #1) [under FCA § 1012

(e)(l) or(iii) ] within 5 years of filing abuse case #2 and

Diligent/reasonable efforts were made to encourage and strengthen the parental relationship when such

efforts will not be detrimental to the best interests of the child or family court previously granted a FCA 1039‐

b "no reasonable efforts" required to reunify order and

Such Diligent/reasonable efforts have been unsuccessful and are likely to be unsuccessful in the foreseeable

future.

PARENT(S) DECEASED AND NO GUARDIAN APPOINTED

But see Domestic Relations Law § 1 13 (adoption from an authorized agency) whereby separate TPR is not

needed when parent(s) deceased and child in care and custody of an authorized agency under a child

protective proceeding placement order or a voluntary placement instrument

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AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA AND 42 C.F.R. PART 2

We are committed to providing comprehensive care for your individual needs; this depends on cross-system collaboration. By signing this form you

agree to the sharing of information by and between the entities listed in items 7 and 8, which are not able to share information without your

authorization. You may limit the amount of time this authorization is effective or cancel this authorization at any time. You are entitled to receive a

completed copy of this authorization.

Having read the above paragraph, I, or my authorized representative, by signing, request that health information regarding my care and treatment be

released between and among the applicable entities as set forth on this form. I understand that my alcohol and/or drug treatment records are protected

under the federal regulations governing Confidentiality and Drug Abuse Patient Records, 42 C.F.R. Part 2, and the Health Insurance Portability and

Accountability Act of 1996 (“HIPAA”). Federal law prohibits disclosure or redisclosure of my information unless such disclosure or redisclosure is

expressly permitted by my written consent or otherwise provided for by applicable regulations.

I understand that:

1. This authorization may include disclosure of information relating to ALCOHOL and DRUG TREATMENT (as permitted by 42 CFR Part 2),

MENTAL HEALTH TREATMENT (except psychotherapy notes), and CONFIDENTIAL HIV1 RELATED INFORMATION. If applicable,

this information will only be disclosed among the entities listed if I place my initials on the appropriate line in Item 9. In the event the health

information described below includes any of these types of information, and I initial the line on the box in Item 9, I specifically authorize

release of such information from any of the entities set forth in Item 7 to any of the entities set forth in Item 8.

2. If I am authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatment information, the recipient is prohibited

from re-disclosing such information without my authorization unless permitted to do so under federal or state law. I understand that I have

the right to request a list of people who may receive or use my HIV-related information without authorization. If I experience discrimination

because of the release or disclosure of HIV-related information, I may contact the New York State Division of Human Rights at (212) 480-2493

or the New York City Commission of Human Rights at (212) 306-7450. These agencies are responsible for protecting my rights.

3. I have the right to revoke this authorization at any time by writing to any of the entities listed below. I understand that I may revoke this

authorization except to the extent that action has already been taken based on this authorization.

4. I understand that signing this authorization is voluntary. My treatment, payment, enrollment i n a health p l a n , o r eligibility fo r benefits will

not be conditioned upon my authorization of this disclosure, however, I acknowledge that cross system collaboration is the best practice for my care.

5. Information disclosed under this authorization may be shared among all entities listed below to the degree necessary to fulfill the reason for release of

information (item 10).

6. This authorization authorizes the entities listed in Item 7to discuss my health information or medical care only with the entities listed in item 8.

7a. Treating entities authorized to release this information:

Mental Health Clinical Provider:

Substance Use Disorder Outpatient Provider:

Inpatient/Residential Provider:

Primary Care:

Care Management Agency:

Hospitals:

CFTSS: Abbot House, ASFL, CHDFS, Children’s Home of Poughkeepsie, The Children’s Village, St. Dominic’s Family Services

Other:

8a. Treating entities authorized to obtain this information:

Mental Health Clinical Provider:

Substance Use Disorder Outpatient Provider:

Inpatient/Residential Provider:

Primary Care:

Care Management Agency:

Hospitals:

CFTSS: Abbot House, ASFL, CHDFS, Children’s Home of Poughkeepsie, The Children’s Village, St. Dominic’s Family Services

Other:

7b. Non-treating entities authorized to release this information: 8b. Non-treating entities authorized to obtain this information:

Agency/Provider Specific Individual Agency/Provider Specific Individual

Orange County Dept. of Mental Health Orange County Dept. of Mental Health

Orange County Dept. of Social Services Orange County Dept. of Social Services

Family/ Significant Other/Other Supports Family/ Significant Other/Other Supports:

Developmental Disability Provider: Developmental Disability Provider:

Peer Services: Peer Services:

Legal: Legal:

Other: Other:

9. Specific information to be released:

☐ Medical Record from (insert date)_________ to (insert date) ______________

☐ Medical Record, include:☐ patient histories, ☐ office notes (except psychotherapy notes), ☐ test results, ☐ radiology studies,

☐ films, ☐ referrals, ☐ consults, ☐ billing records, ☐ insurance records.

☐ Other___________________________________ Include: (Indicate by Initialing )

___________________________________ ______ Alcohol/Drug Treatment

(Indicate approval by Initialing ) ______ ______ Mental Health Information

______ HIV-Related Information

______ Primary Care Provider

10. Reason for release of information:

Coordination to meet complex co-occurring needs

11. Date or event on which this authorization will expire:

12. If not the client, name of person signing form: 13. Authority to sign on behalf of client (see instructions):

All items on this form have been completed and my questions about this form have been answered. In addition, I have been provided a copy of the form.

_____________________________________ _____________ _____________________________________ _____________

Signature of client or representative Date Signature of Witness Date

authorized by law

Client Name: Date of Birth: Social Security Number:

Client Address:

AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA AND 42 C.F.R. PART 2

State of New York

OFFICE OF ALCOHOLISM AND SUBSTANCE ABUSE SERVICES

NOTE: This form must be attached to all disclosures/releases of information concerning substance abuse patients.

PROHIBITION ON REDISCLOSURE OF INFORMATION CONCERNING

SUBSTANCE ABUSE PATIENT

(To accompany disclosure of information made with consent of substance abuse patient)

This information has been disclosed to you from records protected by Federal confidentiality rules (42

CFR part 2 and HIPAA). The federal rules prohibit you from making further disclosure of this information

unless further disclosure is expressly permitted by the written consent of the person to whom it pertains

or as otherwise permitted by 42 CFR Part 2 and/or HIPAA. A general authorization for the release of

medical or other information is NOT sufficient for this purpose. The federal rules restrict any use of the

information to criminally investigate or prosecute any alcohol or drug abuse patient. TRS-1 (5/03)

Footnotes: 1 Human Immunodeficiency Virus that causes AIDS. The New York State Public Health Law protects

information which reasonably could identify someone as having HIV symptoms or infection and information regarding a

person's contacts.

2 Item 5 does not compel an entity to release all information. Program must review applicable laws and regulations

and determine the appropriate information to release based on the content of the release and the applicable laws and

regulations as they apply to each specific entity. Release of information should be limited to what is necessary to

fulfill the intent of the consent. Entities listed in item 7 may choose to release different information to each entity

listed in item 8 in order to comply with the laws and regulations while still meeting the individual’s needs.

Redisclosure is not permitted without specific written consent.

Instructions:

Must include name and date of birth or Social Security number.

7a. Other

May include entities not listed in another field. May also use this field if you have more than one entity from a

single category.

7b. Legal

May include probation, courts, lawyers, law enforcement agencies, etc. Must specify what entity and specific

person. If either is left blank information will not be shared without an additional written consent.

7b. Other

May include entities not listed in another field. May also use this field if you have more than one entity from a

single category.

9. Specific Information to be released

Individual must initial next to each line to indicate the type of information that may be released.

12. If not the client, name of person signing the form. 13 Authority to sign on behalf of client.

The individual named in item12 must have the legal authority to sign the authorization for release of health

information. That legal authority must be indicated in number 13. Proof of this legal authority must accompany

this release when requesting documentation (i.e. power of attorney, parent, legal guardian, etc.). Each entity must

follow the laws and regulations as they pertain to them and therefore legal authority that is sufficient for one entity

may not be for another which may limit the ability to share information. If the client is a minor both the parent or

legal guardian and client must sign the form for OASAS licensed programs.

orange county department of social services lean six sigma

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