Consent Form for Case Management and Collaboration of Care Services

Confidentiality: Beacon Community Connections will not share your Personal Health Information (or PHI) with any outside agencies without your verbal permissions, except as required by law or in a situation deemed potentially life threatening.

Privacy Practices: We comply with Louisiana State and Federal Laws concerning personal health information.

Resource Allocation and Support Services: By signing this form, you allow us to collect, use, and disclose necessary PHI to assist you in locating support services to improve your health. Without this consent, we cannot refer you to certain helpful programs.

Contact: With your consent, we may contact you via phone, text, email, or in person for appointment reminders, resources, and follow-ups.

Request to Restrict Disclosure: You can request a limitation on the use or disclosure of your health information. We will comply unless the information is needed for your treatment, emergency care, or as required by law. You may revoke this request in writing, understanding that we cannot take back any uses or disclosures already made with your permission and that we are required to retain our records of care provided.

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By signing below, you acknowledge that you have read, understood, and agree to this consent form. Your consent allows us to create referrals and contact other agencies on your behalf.

I hereby authorize any representative of Beacon Community Connections to release or obtain concerning my treatment participation, including attendance records for medical, mental health, or substance abuse treatment, protected health information, or other subjects as deemed necessary for program participation. This release does not include diagnoses, treatment plans, or session notes.

Request to Restrict Disclosure

If you are concerned about some of your information being used or disclosed, as outlined in this consent form, you have a right to request, in writing, a restriction or limitation on the health information we use or disclose about you for treatment, resource allocation, referrals, or health care operations. We will comply with your request unless the information is necessary to treat you, is needed to provide you with emergency treatment, or if complying with the request is against the law.

After signing this request, you have the right to revoke it by submitting the request in writing and we will comply with the request, with the understanding that we cannot take back any uses or disclosures that may have already been made with your permission, and that we are required to retain our records of the care that we have provided you.

Prohibition on Redisclosure

Information disclosed whose confidentiality is protected under Title 42, Part 2 of the Code of Federal Regulations (C.F.R. Part 2) is prohibited from any further disclosure unless further disclosure is expressly permitted by written consent of the person to whom it pertains or otherwise permitted by CFR Part 2.