MY RIGHTS. I understand this authorization is voluntary. Treatment, payment, enrollment, or eligibility for benefits may not be conditioned on signing this authorization except if the authorization is for: (1) conducting research-related treatment; (2) obtaining information in connection with eligibility or enrollment in a health; (3) for determining an entity’s obligation to pay a claim; or (4) creating health information to provide to a third party. Under no circumstances, however, am I required to authorize the release of mental health records.
MY RIGHTS. I understand this authorization is voluntary. Treatment, payment, enrollment, or eligibility for benefits may not be conditioned on signing this authorization except if the authorization is for: (1) conducting research-related treatment; (2) obtaining information in connection with eligibility or enrollment in a health; (3) for determining an entity’s obligation to pay a claim; or (4) creating health information to provide to a third party. Under no circumstances, however, am I required to authorize the release of mental health records. I may revoke this authorization at any time, provided that I do so in writing and submit it to: XX. XXXXXX X EGGLESTON, D.C. The revocation will take effect when received by XX. XXXXXX X EGGLESTON, D.C., except to the extent that XX. XXXXXX X EGGLESTON, D.C. or other have already relied on it. I am entitled to received a copy of this Authorization EXPIRATION OF AUTHORIZATION Unless otherwise revoked, this authorization expires (insert applicable date or event). If not date is indicated, this authorization will expire 12 months after the date of signing this form.
MY RIGHTS. I understand this authorization is voluntary. Treatment, payment, enrollment, or eligibility for benefits may not be conditioned on signing this authorization except if the authorization is for: (1) conducting research-related treatment; (2) obtaining information in connection with eligibility or enrollment in a health; (3) for determining an entity’s obligation to pay a claim; or (4) creating health information to provide to a third party. Under no circumstances, however, am I required to authorize the release of mental health records. I may revoke this authorization at any time, provided that I do so in writing and submit it to: XXXXXX X XXXXXXXXX, D.C. The revocation will take effect when received by XXXXXX X XXXXXXXXX, D.C., except to the extent that XXXXXX X XXXXXXXXX, D.C. or other have already relied on it. I am entitled to received a copy of this Authorization EXPIRATION OF AUTHORIZATION Unless otherwise revoked, this authorization expires (insert applicable date or event). If not date is indicated, this authorization will expire 12 months after the date of signing this form. SIGNATURE X (Signature of Patient or Patient’s Legal Representative) Date AM PM Printed Name Time (Legal Relationship of Signatory if not Patient) Signature of Witness or Translator CLIENT INTAKE SHEET REF. BY: Driver Premises Liability: Slip/Fall NAME: DATE OF ACCIDENT: TIME: Address: Telephone: Home: ( ) Cell: ( ) Work: ( ) Email Address: S.S.#: Marital Status:
MY RIGHTS. To be fully informed of the program and its methods. • To refuse treatment and leave the program at any time. • To be accommodated in a safe, drug-free, healthy and supportive environment • To have access to appropriate medical and legal assistance, if necessary. • To be able to voice grievances and suggestions freely and openly. • To be free from violence and exploitation. • To have adequate nutrition. • To have assistance with other government agencies such as Courts, Centerlink • To expect details of my personal history and written records to be kept in strict confidence, except where the service is legally bound to surrender information. • To expect not to be personally identified in any publication, research or other public communication by the service without my express consent. • In the case of a dispute with a staff member which cannot be resolved with that staff member I have the right to take the issue to Xxxxx Xxx GYM, FITNESS CLASSES AND OUTING I have been explained and understand the GYM Guidelines below * Fitness classes are part of the program I must have Doctors certificate to be exempted. * Weight training program can only be 4 days per week. I must have at least 3 days off in the one week. * There is to be two people in the gym or weights area at all times when exercising. No exceptions. MY OBLIGATIONS • Declare all money to Centerlink. • All Centerlink mail must come through our PO Box 608 Macksville NSW 2447 • To give AAGANA the Authority to Liaise with Centerlink on all matters regarding my Centerlink Benefit and have all monies direct payment from Centerlink, deposited into AAGANA account while in the Program. • Deposit income into AAGANA account – income means: wages, social security payments, money loaned, and any one-off payments from any source. You will be allocated money and will live within a budget as set out by your case manager. • To abide by the rules and guidelines of which are not negotiable? • On the decision to leave AAGANA Inc all personal belongings are to be taken at the time of departure. • No responsibility will be taken by AAGANA for any belongings left behind. • Any property left will be tagged and placed in storage. After one month all items will be donated to a charity • If I wish for any person to pick up my belongings, they must produce signed authorisation, or my belongings will be held. • To abide by the financial commitments to board, lodging and other expenses incurred on my behalf. If I cannot pay Board,...
MY RIGHTS. Being in the program is voluntary, and you may leave the program at any time.
