Informed Consent

Provider-client service agreement

This document contains important information about professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights about the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. When you sign this document, it denotes an agreement between Open Water Counseling and Recovery, LLC and the client/responsible party. Please present any questions during signing or at any time in the future to any member of Open Water Counseling and Recovery, LLC for further discussion.

Psychological services

Therapy is a relationship between people that works in part because of clearly defined rights and responsibilities held by each person. As a client in psychotherapy, you have certain rights and responsibilities that are important for you to understand. There are also legal limitations to those rights that you should be aware of. The Open Water treatment team will also have corresponding responsibilities to you. These rights and responsibilities are described in the following sections. Psychotherapy has both benefits and risks. Psychotherapy requires a very active effort on your part. In order to be most successful, you will have to work on things discussed outside of sessions. The first 1-3 sessions will involve a comprehensive evaluation of your needs. By the end of the evaluation, initial impressions will be offered to you of what the counseling work might include. At that point, a discussion of your treatment goals and an initial treatment plan will be created. You should evaluate this information and make your own decision about participating in the therapy process.

Medication management

Psychiatric medications can be used in conjunction with psychotherapy to treat many conditions. It is important to find the best combination of medications and therapy for each individual case. Your psychiatrist/nurse practitioner can provide an integrated approach as they are trained to administer both psychiatric medications and psychotherapy. However, in some situations, it may be appropriate to consider merely managing your psychiatric medications and sharing the psychotherapy with an alternative provider. Often called the ‘split treatment’ model, this should be discussed in order to determine if it would be a viable option for you. We can help find the best provider for you whether at the Open Water Counseling and Recovery, LLC or another provider in the community. In situations that warrant the use of medications, it is imperative for you to understand the target symptoms and likely outcomes.

Additionally, since all medications have the potential for side effects, your psychiatrist/nurse practitioner will always discuss the risks, benefits, side effects, government warnings, and alternative treatments (which always includes not using medications) with you.

Case management

Case management is a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates the options and services required to meet the client’s health and human service needs. It is characterized by advocacy, communication, and resource management and promotes quality and cost-effective interventions and outcomes. A case manager or primary therapist will be assigned to you and review your individual service plan. You may or may not need these services based on the findings of your initial assessment and treatment plan built in collaboration between you and your therapist.

Appointments

Appointments will ordinarily be 60 minutes in duration, once per week at a time we agree on, although some sessions may be more or less frequent as needed, or vary in time. The time scheduled for your appointment is assigned to you and you alone. If you need to cancel or reschedule a session, please provide 24 hours notice. You can cancel by calling the office line at (330) 539-3200. If you miss a session without canceling, or cancel with less than 24 hour notice, Open Water Counseling and Recovery, LLC policy is to collect the amount of your session payment [unless we both agree that you were unable to attend due to circumstances beyond your control or you are a Medicaid patient].

Insurance

Open Water Counseling and Recovery, LLC accepts many insurance providers both commercial and government. Please submit your insurance card prior to the first session to verify benefits. By submitting your insurance card and signing this document, you are agreeing to give Open Water Counseling and Recovery, LLC permission to bill insurance for services rendered. Any amount that insurance does not cover you are responsible for and may receive a bill. A fee schedule of all private pay amounts for each service rendered will be provided upon request.

Professional records

Open Water Counseling and Recovery, LLC keeps appropriate records of the services provided. Your records are maintained in a secure location on a HIPAA approved electronic health records software. Records contain information about your participation in treatment, your reasons for seeking treatment, the goals and progress set for treatment, your diagnosis, topics discussed, your medical, social, and treatment history, records received from other providers, copies of records sent to others, medications provided, assessments completed by other disciplines, and your billing records. Except in unusual circumstances that involve danger to yourself, you have the right to a copy of your file. Because these are professional records, they may be misinterpreted and/or upsetting to untrained readers. For this reason, it is recommend that you initially review them with your primary therapist, or have them forwarded to another mental health professional to discuss the contents. If a request for access to your records is refused, you have a right to have the decision reviewed by another mental health professional or the agency compliance office. You also have the right to request that a copy of your file be made available to any other health care provider at your written request.

Confidentiality

Open Water Counseling and Recovery policies about confidentiality, as well as other information about your privacy rights, are fully described in a separate document entitled Notice of Privacy Practices. You have been provided with a copy of that document and we have discussed those issues. Please remember that you may reopen the conversation at any time during our work together.

Parents and minors

While privacy in therapy is crucial to successful progress, parental involvement can also be essential. It is the policy of Open Water Counseling not to provide treatment to a child under age 13 unless s/he agrees that all information can be shared with a parent. For children 14 and older, Open Water requests an agreement between the client and the parents allowing the therapist to share general information about treatment progress and attendance, as well as a treatment summary upon completion of therapy. All other communication will require the child’s agreement, unless there is a safety concern (see also above section on Confidentiality for exceptions), in which case, every effort will be made to notify the child of information disclosure ahead of time and discuss the implications of that said disclosure.

Client contact

Primary therapists or other providers are often not immediately available by telephone. They do not answer when in session with other clients or otherwise unavailable. At these times, you may leave a message on our confidential messaging service and your call will be returned as soon as possible, but it may take 24 hours for non-urgent matters. If, for any number of un-seen reasons, you do not hear from back or a staff member is unable to reach you, and you feel you cannot wait for a return call or if you feel unable to keep yourself safe, 1) Trumbull County Mental Health and Recovery Board 2) go to your Local Hospital Emergency Room, or 3) call 911 and ask to speak to the mental health worker on call. Every attempt will be made to inform you in advance of planned absences and a therapist/provider will be assigned to cover your case while your primary therapist is away. Open Water Counseling and Recovery staff will contact you using the contact information you provided in your initial paperwork. Efforts to contact you will be for the purposes of appointment reminders, agency notifications, and billing purposes. By signing this document and providing us your contact information, you are consenting to receiving telephonic, text, and email communication from this agency.

Other rights

If you are unhappy with what the status of your treatment, please report this to your clinician or their direct supervisor. Such comments will be taken seriously and handled with care and respect. You may also request that a referral be made to another therapist and are free to end therapy at any time. You have the right to considerate, safe and respectful care, without discrimination as to race, ethnicity, color, gender, sexual orientation, age, religion, national origin, or source of payment. You have the right to ask questions about any aspects of your treatment and about the specific training and experience of your clinician. You have the right to expect that your provider will not have social or sexual relationships with clients or with former clients.

Notice of Privacy Practices

I. THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Protected Health Information (PHI) is information that identifies you and relates to health care services, payment of health care services, or your physical or mental health or condition, in the past, present, or future. As stated above, the OPEN WATER COUNSELING AND RECOV-ERY, LLC Notice of Privacy Practices (hereinafter referred to as Notice”) describes: (1) How OPEN WATER COUNSELING AND RECOVERY, LLC may use or disclose your PHI and (2) Your rights to access, inspect, and control your PHI. This notice is posted at and is available at all OPEN WATER COUNSELING AND RECOVERY, LLC facilities where services are provided. A copy of the notice will be provided to anyone upon request.

Our responsibilities

OPEN WATER COUNSELING AND RECOVERY, LLC is required by Federal Law to: (1) maintain the privacy of your PHI, (2) provide you with notice of OPEN WATER COUNSELING AND RE-COVERY, LLC’s legal duties and privacy practices, and (3) notify you in the unlikely event of a breach of unsecured PHI. We are required to abide by the terms of this Notice so long as it is in effect. We do reserve the right to change the terms of this Notice and to make the new Notice effective for all PHI maintained by OPEN WATER COUNSELING AND RECOVERY, LLC

OPEN WATER COUNSELING AND RECOVERY, LLC will promptly revise and distribute a new Notice whenever there is a material change. Except when required by law, a material change will not be implemented before the effective date of the new Notice in which the change is reflected.

Please Note: For your convenience, all forms identified below may be obtained at any OPEN WATER COUNSELING AND RECOVERY, LLC office or by contacting the Clinical Records Man-ager at (330) 539-3200.

Use and disclosure of your protected health information

Use and Disclosure with Your Authorization: Except as outlined below, OPEN WATER COUN-SELING AND RECOVERY, LLC will not use or disclose your PHI unless you have signed a HI-PAA compliant form authorizing the use or disclosure. You also have the right to revoke an authorization in writing unless OPEN WATER COUNSELING AND RECOVERY, LLC has already taken action in reliance on that authorization. You may complete an OPEN WATER COUNSEL-ING AND RECOVERY, LLC form to revoke an authorization and may provide the completed form to the Site Manager at the office where you are seen, or you may provide it to the Clinical Records Manager at 1716 North Road SE; Warren, OH 44484. There are certain uses and dis-closures of your PHI for which OPEN WATER COUNSELING AND RECOVERY, LLC will always obtain a prior authorization. These include: (1) Most uses and disclosures of clinical notes, as applicable, unless otherwise permitted or required by law; and (2) Subject to certain limited exceptions, use or disclosure of PHI for marketing purposes and (3) Sale of your PHI.

Use and Disclosure for Treatment: OPEN WATER COUNSELING AND RECOVERY, LLC may use and disclose your PHI to coordinate or manage your care within OPEN WATER COUNSEL-ING AND RECOVERY, LLC For example, your OPEN WATER COUNSELING AND RECOVERY, LLC therapist may consult with an OPEN WATER COUNSELING AND RECOVERY, LLC doctor regarding your care. OPEN WATER COUNSELING AND RECOVERY, LLC may also use and disclose your PHI to individuals or organizations outside of OPEN WATER COUNSELING AND RECOVERY, LLC who are involved in your care, such as your primary doctor, other healthcare providers, or contracted services. For example, a doctor/healthcare facility not affiliated with OPEN WATER COUNSELING AND RECOVERY, LLC, who is involved in your care, may request parts of your PHI to make decisions about your care.

Use and Disclosure to Obtain or Provide Payment: OPEN WATER COUNSELING AND RE-COVERY, LLC may use and disclose your PHI to collect or make payment for your care. For example, OPEN WATER COUNSELING AND RECOVERY, LLC may: (1) transmit PHI regarding your treatment to entities paying for your services such as Medicaid, or Medicare/insurance companies; (2) disclose PHI to apply for pre-authorization for services; and/or (3) include PHI on invoices to collect payment from you, a person responsible for payment, or other third parties.

Use and Disclosure for Healthcare Operations: OPEN WATER COUNSELING AND RECOVERY, LLC may use and disclose your PHI for OPEN WATER COUNSELING AND RECOVERY, LLC operations as necessary, and as permitted by law, to provide and improve services. Examples include but are not limited to: (1) quality assurance and improvement activities; (2) case man- agement and care coordination; (3) professional review and performance evaluation; (4) au- diting, including compliance reviews; (S) medical reviews; (6) legal services; and (7) business management and general administrative activities. For example, OPEN WATER COUNSELING AND RECOVERY, LLC may: (1) use PHI to evaluate staff performance; (2) combine your PHI with other clients’ PHI to evaluate how to better serve clients; (3) disclose PHI to contract- ed personnel for limited training purposes; or (4) disclose PHI to another healthcare facility, healthcare professional, or health plan for purposes such as quality assurance and case man- agement, but only if that individual or entity also has or had a patient/client relationship with you.

Family and Friends Involved in your care: With your approval, OPEN WATER COUNSELING AND RECOVERY, LLC may disclose your PHI to designated family, friends, and others who are involved in your care or in payment for your care. However, we may share limited PHI with such individuals without your approval if you are unavailable, incapacitated, or facing an emergency medical situation, and we determine that a limited disclosure may be in your best interest. We may also share limited PHI with such individuals if otherwise permitted or required by law.

Business Associates: Certain aspects and components of our services are performed through contracts/agreements with outside persons/organizations/businesses, such as auditing, ac-creditation, actuarial services, claims payment, data compilation, legal services, and others.

At times, it may be necessary to provide certain parts of your PHI to one or more of these persons/organizations/businesses. In all cases, OPEN WATER COUNSELING AND RECOV-ERY, LLC requires that these Business Associates appropriately safeguard the privacy and security of your PHI.

Appointment Reminders: OPEN WATER COUNSELING AND RECOVERY, LLC may use and disclose your PHI to contact you to leave appointment reminders. If you wish to not have appointment reminders left on voicemail or do not want mail sent to a particular address, we will accommodate reasonable requests and will not require an explanation. You may make the request by completing an OPEN WATER COUNSELING AND RECOVERY, LLC’s request for confidential communication form and providing it to the Clinical Records Manager 1716 North Road SE Warren, OH 44484.

Treatment Alternatives: OPEN WATER COUNSELING AND RECOVERY, LLC may use and dis- close your PHI to advise you of, or recommend services or treatment options that may be of interest to you. We will not use your PHI to communicate with you about products or services which are not health related without your written permission.

Other uses or disclosures

OPEN WATER COUNSELING AND RECOVERY, LLC is permitted or required by law to make certain other additional uses and disclosures without your authorization. OPEN WATER COUNSELING AND RECOVERY, LLC will follow applicable law when making such disclosures.

Legally Required Disclosures: OPEN WATER COUNSELING AND RECOVERY, LLC will disclose your PHI for any purpose required by Federal, State, or local law.

Serious Threat to Life, Health, or Safety: OPEN WATER COUNSELING AND RECOVERY, LLC may disclose your PHI if it is believed, in good faith and consistent with applicable law and ethical standards, that it is necessary to prevent or decrease serious and imminent threat to your life, health, or safety or the life, health, or safety of another individual(s) or the public.

Risks to Public Health: OPEN WATER COUNSELING AND RECOVERY, LLC may disclose your PHI to a public health authority, as allowed or required by law to: (1) prevent or control a dis- ease, injury, or disability;(2) report disease, injury, and vital events such as birth or death; (3) conduct public surveillance, investigations, and interventions;(4) notify a person(s) who has been exposed to a communicable disease or who may be at risk of contracting or spreading a disease.

Reports to the Food and Drug Administration: In accordance with applicable law, OPEN WA- TER COUNSELING AND RECOVERY, LLC may release your PHI to report adverse events and/ or product defects to the Food and Drug Administration or to participate in product recalls initiated by the Food and Drug Administration.

Report of Abuse, Neglect, or Domestic Violence: In accordance with applicable law, OPEN WATER COUNSELING AND RECOVERY, LLC will disclose your PHI to fulfill legal obligations to report to legal authorities suspected child abuse or neglect. We may also release your PHI, as required by law, if we have reasonable belief that you are a victim of abuse, neglect, or domestic violence.

Health Oversight: OPEN WATER COUNSELING AND RECOVERY, LLC may disclose your PHI if required by law to a health oversight agency conducting: audits, civil administrative or crimi- nal investigations, inspections, or licensure or action. However, we may not disclose your PHI if you are the subject of an investigation that does not fall under health oversight activities. For example, if your PHI is not directly related to your receipt of health care or public benefits.

Judicial and Administrative Proceedings: OPEN WATER COUNSELING AND RECOVERY, LLC may disclose your PHI if required by law to do so by a court or administrative ordered subpoe- na or discovery request (in most cases you will have notice of such a request).

Law Enforcement: OPEN WATER COUNSELING AND RECOVERY, LLC may disclose specific and limited PHI about you for certain law enforcement reasons as required by law, including but not limited to reporting wounds, injuries, and crimes.

Research: OPEN WATER COUNSELING AND RECOVERY, LLC may, under limited circum- stances, use and disclose your PHI for research. For example, a researcher might want to re- view the outcomes of clients who received a particular medication or other treatment. Before PHI which could identify you would be released for such research purposes, the project will be subject to an extensive OPEN WATER COUNSELING AND RECOVERY, LLC review and approval process including strict confidentiality requirements. In all cases where your specific prior authorization is not requested, your privacy will be protected by strict confidentiality requirements applied by an Institutional Review Board or privacy board which oversees the research or by representations of the researchers that limit their use and disclosure of PHI information.

Specialized Government Functions: OPEN WATER COUNSELING AND RECOVERY, LLC may be required or authorized by Federal regulations to use or disclose your PHI to facilitate spec-ified government functions. For example, OPEN WATER COUNSELING AND RECOVERY, LLC may be required by law to release your PHI if you are a member of the military as required by armed forces services; we may also release your PHI for national security and intelligence activities and protective services for the President and others.

Correctional Institution: We may release your PHI to a correctional institution or to law en- forcement officials under certain circumstances, if you are an inmate or under the custody of a law enforcement official.

Worker’s Compensation: OPEN WATER COUNSELING AND RECOVERY, LLC may use or dis- close your PHI to comply with worker’s compensation law or similar programs established by law that provide benefits for work related injuries or illness.

Transfer of Information at Death: In accordance with applicable law, OPEN WATER COUN- SELING AND RECOVERY, LLC may disclose PHI to funeral directors, medical examiners, and coroners.

Organ Procurement: In accordance with applicable law, OPEN WATER COUNSELING AND RECOVERY, LLC may disclose your PHI to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs if necessary to arrange an organ, eye, or tissue donation by you or a transplant for you.

Your rights with regard to PHI

Right to a Personal Representative: You may identify a person(s) to serve as your authorized personal representative, such as a court-appointed guardian, a properly executed and spe- cific power-of-attorney granting such authority, or a Durable Power of Attorney for Health Care, if it allows such person to act when you are able to communicate on your own, or other method recognized by applicable law. OPEN WATER COUNSELING AND RECOVERY, LLC may, however, reject a representative if, in our professional judgment, we determine that it is not in your best interest.

Right to Request Restrictions: You may request restrictions on certain uses and disclosures of your PHI for treatment, payment, or healthcare operations by notifying OPEN WATER COUN-SELING AND RECOVERY, LLC in writing of the request. OPEN WATER COUNSELING AND RECOVERY, LLC will consider the request, but is under no obligation to accept it or abide by it unless the request concerns disclosure of PHI to a health plan for purposes of carrying out payment or health care operations and the PHI pertains solely to a health care service for which the provider has been paid out of pocket in full by you or someone else You may request a restriction by completing a OPEN WATER COUNSELING AND RECOVERY, LLC disclosure restriction form and providing it to the Clinical Records Manager at 1716 North Road SE; Warren, OH 44484. OPEN WATER COUNSELING AND RECOVERY, LLC has the right

to terminate a restriction (except as described above) if we believe it is not appropriate, and OPEN WATER COUNSELING AND RECOVERY, LLC will notify you of such termination. You also have the right to terminate orally or in writing a previous restriction. Oral terminations will be documented by OPEN WATER COUNSELING AND RECOVERY, LLC personnel. For your convenience, written termination may be communicated by completing an OPEN WA-TER COUNSELING AND RECOVERY, LLC termination of restrictions form and providing it to the Clinical Records Manager at 1716 North Road SE; Warren, OH 44484.

Right to Receive Confidential Communications: You have the right to request that we com-municate with you in a confidential manner. For example, you may wish to not have messages left on your voicemail or sent to a particular address. You may request that we communicate regarding your PHI using alternative means or a different location.

We may not require that you provide an explanation for your request. The request must be made in writing and signed by you/your authorized representative. You may make a request by completing an OPEN WATER COUNSELING AND RECOVERY, LLC request for confidential communication form and providing it to the Clinical Records Manager at 1716 North Road SE; Warren, OH 44484. We will attempt to honor any reasonable request.

Right to Access, Inspect, and Copy Your PHI: You have the right to copy and/or inspect much of the PHI that we retain on your behalf. The request must be made in writing and signed by you/your authorized representative. Certain restrictions may apply as permitted or required by law. You may make a written request by completing an OPEN WATER COUNSELING AND RECOVERY, LLC form to request access/inspection/copying of your PHI and providing it to the Clinical Records Manager at 1716 North Road SE; Warren, OH 44484. If you request a copy of health information, we may charge reasonable copying, processing and personnel

fees. You may request an electronic copy of your health information that exists in an elec- tronic format, and you may direct that the copy be transmitted directly to an entity or person designated by you, providing the designation are clear and specific with complete name and mailing address or other identifying information. Under special circumstances as required or permitted by law, we may decide not to share information. You may request a review of the denial by completing an OPEN WATER COUNSELING AND RECOVERY, LLC request for re-view of denial form and providing it to the Clinical Records Manager at 1716 North Road SE; Warren, OH 44484.

Right to Amend Your PHI: You have the right to request an amendment of your records if you believe that your PHI is incorrect or incomplete. That request may be made as long as we maintain the information. The request must be made in writing and signed by you/your au-thorized representative. You may make a request for an amendment by completing an OPEN WATER COUNSELING AND RECOVERY, LLC request for amendment form and providing it to the Clinical Records Manager at 1716 North Road SE; Warren, OH 44484. OPEN WATER COUNSELING AND RECOVERY, LLC may deny the request if it is not in writing or if it does not include a reason for the request. The request may also be denied if: (1) your health information records were not created by us; (2) the records you are requesting to amend: a) are not part of our records, or b) are not part of the health information you are permitted to inspect and copy; or (3) if, in our opinion, the records containing your health information are accurate and complete. Amendments may take the form of including a written statement from you and may not include changing, defacing, or destroying any necessary information related to your health care.

Right to Accounting of Disclosure: You have the right to request an accounting of disclosures of your PHI made by OPEN WATER COUNSELING AND RECOVERY, LLC for certain reasons, including reasons related to public purposes authorized by law, and certain research. The request must be made in writing and must be signed by you/your authorized representative.

You may make a request by completing an OPEN WATER COUNSELING AND RECOVERY, LLC accounting of disclosures form and providing it to the Clinical Records Manager at 1716 North Road SE; Warren, OH 44484. Accounting requests may not be made for periods of time beyond six (6) years prior to the date on which the accounting is requested.

Right to a Paper Copy of this Notice: You have a right to receive a paper copy of this Notice at any time, even if you have received this Notice previously or have previously agreed to receive it electronically. To obtain a paper copy, please contact the Site Manager at any of our offices or contact the Clinical Records Manager at (330)539-3200.

Complaints

lf you believe that your privacy rights have been violated, you may file a written complaint with the OPEN WATER COUNSELING AND RECOVERY, LLC Chief Compliance Officer at 1716 North Road SE; Warren, OH 44484. You may receive a form for your convenience by contact-ing the Clinical Records Manager at (330) 539-3200. You will not be retaliated against in any way for filing a complaint.

You may also file a written complaint within 180 days of a violation of your rights with the Secretary of the U.S. Department of Health and Human Services, 200 Independence Avenue SW, Washington, D.C., 20201 or call toll- free (877) 696-6775, or email to OCRComplaint@hhs. gov, or to Region V, Office for Civil Rights, U.S. Department of Health and Human Services, 233 N. Michigan Ave ., Suite 240, Chicago, Ill. 60601, Voice Phone (312) 886-2359, Fax (312) 886-1807, or TDD (312) 353-5693.

For further information

If you have any questions regarding this Notice of Privacy Practices, please contact the OPEN WATER COUNSELING AND RECOVERY, LLC’s Chief Compliance Officer at (330) 539-3200.

EFFECTIVE DATE: May 25, 2020

Confidentiality of Alcohol and Drug Abuse patient records

The confidentiality of alcohol and drug abuse patient records maintained by this program is protected by Federal law and regulations. Generally, the program may not say to a person outside the program that a patient attends the program, or disclose any information identify-ing a patient as an alcohol or drug abuser unless:

1. The patient consents in writing,
2. The disclosure is allowed by a court order; or
3. The disclosure is made to medical personnel in a medical emergency or to qualified per-sonnel for research, audit, or program evaluation. Violation of the Federal law and reg-ulations by a program is a crime. Suspected violations may be reported to appropriate authorities in accordance with Federal regulations. Federal law and regulations do not protect any information about a crime committed by a patient either at the program or against any person who works for the program or about any threat to commit such a crime. Federal laws and regulations do not protect any information about suspected child abuse or neglect from being reported under State law to appropriate State or local au-thorities. See 42 U.S.C 290dd-3 and 42 U.S.C. 29033-3 for Federal laws and 42 CFR part 2 for Federal regulations.)

(Approved by the Office of Management and Budget under control number 0930-0099).

Statement of Access of Records by Non-Custodial Parent

Subject to division (H)(1) of Ohio Revised Code (ORC) 3109.051,section 3125.16, and Division (F) of ORC Section 3319.321, a parent of a child who is not the residential parent of the child is entitled to access, under the same terms and conditions under which access is provided to the residential parent, to any record that is related to the child and to which the resident parent of the child legally is provided access, unless the court determines that it would not be in the best interest of the child for the parent who is not the residential parent to have access to the records under those terms and conditions. If the court determines that the parent of a child who is not the residential parent should not have access to records related to the child under the same terms and conditions as provided for the residential parent, the court shall specify the terms and conditions under which the parent who is not the residential parent is to have access to those records; shall enter its written findings of facts and opinion in the jour-nal and shall issue an order containing the terms and conditions to both the residential parent and the parent of the child who is not the residential parent. The court shall include in every order issued pursuant to this division notice that any keeper of a records who knowingly fails to comply with the order or Division (H) of this section is in contempt of court.

Per (H)(2) of ORC 3109.051: subject to section 3125.16 and division (F) of section 3319.321 of the ORC subsequent to the insurance of an order under Division (H)(I) of this Section, the keeper of any record that is related to a particular child and to which the residential parent legally is provided access, shall permit the parent of the child who is not the residential parent to have access to the record under (same terms and conditions under which access is pro-vided to the residential parent) unless residential parent has presented keeper of the record with a copy of any order issued under Division (H)(I) of this Section that limits the terms and conditions under which the parent who is not the residential parent is to have access to re-cords pertaining to the child and the order pertains to the record in question. If the residential parent presents the keeper of the record with a copy of that type of order, the keeper of the record shall permit the parent who is not the residential parent to have access to the record only in accordance with the most recent order that has been issued pursuant to Division (H)(I) of this Section and presented to the keeper by the residential parent or the parent who is not the residential parent. Any keeper of any record who knowingly fails to comply with Division (H)(I) of this Section is in contempt of court.

Client Rights and Grievance Procedures

Client rights:

1. The right to be treated with kindness, consideration, and respect for personal dignity, au-tonomy, and privacy.
2. The right to reasonable protection from physical, sexual or emotional abuse, neglect and inhumane treatment.
3. The right to receive services in the least restrictive, feasible environment.
4. The right to participate in any appropriate and available service that is consistent with an individual services plan (ISP), regardless of the refusal of any other services, unless that services is a necessity for clear treatment reasons and requires the person’s participation.
5. The right to give informed consent to or to refuse any service, treatment or therapy, in-cluding medication absent an emergency.
6. The right to participate in the development, review and revision of one’s own individual-ized treatment plan and receive a copy of it.
7. The right to freedom from unnecessary or excessive medication, and to be free from re-straint or seclusion unless there is immediate risk of physical harm to self or others.
8. The right to be informed and the right to refuse any unusual or hazardous treatment pro-cedures.
9. The right to be advised and the right to refuse observation by others and by techniques such as one- way vision mirrors, tape recorders, video recorders, television, movies, photo-graphs or other audio and visual technology. This right does not prohibit any agency from using closed circuit monitoring to observe seclusion rooms or common areas, which does not include bathrooms or sleeping areas.
10. The right to confidentiality or communications and personal identifying information within the limitations and requirements for disclosure of client information under state and fed-deral laws and regulations.
11. The right to have access to one’s own client record unless access to certain informationis restricted for clear treatment reasons. If access is restricted, the treatment plan shall include the reason for the restriction, and the treatment being offered to remove the restriction.
12. The right to be informed a reasonable amount of time in advance of the reason for ter-minating participation in a service, and to be provided a referral, unless the services is unavailable or not necessary.
13. The right to be informed of the reason for denial of a service.
14. The right not to be discriminated against for receiving services on the basis or race, eth-nicity, age, color, religion, gender, national origin, sexual orientation, physical or mental handicap, developmental disability, genetic information, human immunodeficiency virus status, or in any manner prohibited by local state or federal laws.
15. The right to know the cost of services.
16. The right to be verbally informed of all client rights, and to receive a written copy upon request.
17. The right to exercise one’s own rights without reprisal, except that no right extends so far as the supersede health and safety considerations.
18. The right to file a grievance.
19. The right to have oral and written instructions concerning the procedure for filing a griev-ance and to assistance in filing a grievance if requested.
20. The right to be informed one’s own condition.
21. The right to consult with an independent treatment specialist or legal counsel at one’s own expense.

Client rights procedure:

Open Water Counseling and Recovery, LLC will distribute to each applicant or client at the scheduled diagnostic evaluation, or following subsequent appointment, a copy of the Client Rights Policy & Procedure. If the client continues to receive services beyond one year, the cli-ent rights policy will be reviewed with the client by a staff person on an annual basis.

The Client Advocate/Client Rights Officer is available upon request. It is the Client Advocate/Client Rights Officer’s responsibility to accept and oversee the processing of any and all grievances filed by a client or other person or agency on behalf of a client. The Client Advo-cate/Client Rights Officer will also be available to explain any and all aspects of client rights and grievance procedures.

In a crisis or emergency situation, the Client Advocate/Client Rights Officer shall advise the client of at least the immediate pertinent rights to consent to, or to refuse, the offered treat-ment and the consequences of that agreement or refusal. Under these circumstances, the written copy and full verbal explanation of the client’s rights policy may be delayed to a sub-sequent meeting.

All clients or recipients of the type of mental health services specified as “Community Ser-vices” (Information and referral, consultation services, mental health education service, training) may have a copy and explanation of the client rights policy upon request.

A copy of the client rights policy will be distributed to each applicant or client and will be posted in a conspicuous location at each building operated by Open Water Counseling and Recovery, LLC

All staff persons at the Board, including both administrative and support staff, will be familiar-ized with all specific client rights and grievance policies and procedures.

Client grievances procedure

We appreciate communication from our clients if our policies, procedures or personnel make it necessary for them to make a complaint. Open Water Counseling and Recovery, LLC., and its representatives in the client grievance process (the Ombudsman, or the Owner/President) are committed to approaching all client complaints in a spirit of consultation, problem solv-ing and as an opportunity to improve our procedures. Any person using the client grievance process of Open Water Counseling, LLC is guaranteed ongoing, positive, supportive services from the organization if services are desired. There will be no interference, coercion, discrim-ination or reprisal for any client using this process.

The published Client Grievance Procedure describes the means by which client rights are pro-tected and exercised. The grievance procedure shall be posted in the Open Water Counseling office and be given to each client upon admission and contain the phone number and address of the OMHAS’s Community Supports and Client’s Rights Office. The Owner/President shall serve as the client’s rights officer for the organization, maintain all grievances in a separate file and make reports of all client grievances and their resolution to the appropriate agency personnel.

Any client complaint shall be considered satisfactorily resolved at any point where the client withdraws the complaint or indicates that he/she accepts the determination provided. Such withdrawal or acceptance must be in writing by the client or documented in writing by the President/Owner upon verbal contact with the client. Any employee of Open Water Counseling who is adversely affected by the final determination of a client complaint shall have the opportunity to seek redress by using Open Water Coun- seling and Recovery LLC’s employee grievance procedure.

The Client Grievance Procedure shall have no more than three appeal steps, provided for the client to have an advocate present at hearings and shall include contact information for the OMHAS’s Community Supports and Client’s Rights Office as well as the Trumbull County Men-tal Health Board and Disability Right Ohio.

Open Water Counseling and Recovery will designate a Client Advocate to ensure that the process is adhered to and client rights are protected. Open Water Counseling and Recovery will maintain detailed records of all grievances for a minimum of two years after the grievance is resolved/withdrawn. The record of client grievances will include:

1. Copy of client grievance form.
2. Documentation reflecting process used and resolution/remedy of the grievance.
3. Documentation, if applicable, of extenuating circumstance for extending the time period for resolving the grievance beyond twenty business days.

Grievance Procedure

A notice shall be posted in the service delivery locations advising clients whom they may contact if they have a complaint/grievance concerning services. The following procedure is available to clients for resolving complaints/grievances concerning services rendered by staff of Open Water Counseling and Recovery, LLC.

STAGE I

An individual who, in applying for or receiving services from Open Water Counseling and Recovery LLC believes that he/she has been treated unfairly may seek resolution by contact-ing the Owner/President at (330) 539-3200. The Owner/President shall outline Open Water Counseling and Recovery client complaint/grievance procedure to the complaining client and advise that individual, if he/she desires to submit a formal notice of grievance. Such notice shall be in writing and shall describe briefly the situation about which the complaint is being made and shall indicate the client’s willingness to discuss the situation described in more specific detail with the Owner/President. The formal grievance must be in writing and dated and signed by the client, the individual filing the grievance on behalf of the client, or have an attestation by the client advocate the the written grievance is a true and accurate represen-tation of the client’s grievance. (See attached Client Grievance Form) The grievance may be made verbally and the client advocate (listed below) will be responsible for preparing the written text of the grievance.

A written acknowledgement of the receipt of the grievance will provided to the grievance within three business days from the receipt of the grievance. The written acknowledgment will include the following:

1. Date grievance was received
2. Summary of grievance
3. Overview of grievance investigation process
4. Timetable for completion of investigation and notification of resolution
5. Treatment provider contact name, address and telephone number.

STAGE II

Within ten (10) working days of receipt of the signed, formal notice of complaint, the Owner/President shall contact the aggrieved client for the purpose of gaining more information and resolving the complaint. The Owner/President shall have ten (10) working days after such contact in which to investigate and resolve the complaint. The Owner/President may question any employee named in the complaint.

By the end of this period, and in consultation with the Owner/President, one of the following actions shall be documented in written form:

1. The client ‘s withdrawal of the complaint
2. The client’s acceptance of a resolution together (with the details of that resolution reached)
3. The client takes no further action; OR If the final determination of the Board is not seen by the complaining client as reasonable and/or satisfactory, the client will then be referred to the county mental health and recovery board and/or the OMHAS’s Community Supports and Client Rights Office, etc.

Contacts:

Open Water Counseling and Recovery Client Advocate

Hannah Day
1716 North Road SE
Warren, OH 44484
Tel: (330) 539-3200
hannahday@openwatercounseling.com

OhioMHAS’s Community Supports and Clients Rights Office

30 East Broad St., Suite 742
Columbus, OH 43215
Tel: (877) 275-6364 / (614) 466-7228
TTY: 1-888-636-4889

Trumbull County Mental Health and Recovery Board

The Office of the Ombudsman
4076 Youngstown Rd. SE
Warren, OH 44484
Tel: (330) 675-2765

Disability Rights of Ohio

200 Civic Center Drive, Suite 300
Columbus, Ohio 43215-5923
Tel: (614) 466-7264 / (800) 282-9181
TTY: (614) 728-2553 / (800) 858-3542
Fax: (614) 644-1888
Web: disabilityrightsohio.org

US Dept. of Health and Human Services

Civil Rights Regional Office Chicago
233 North Michigan Avenue, Suite 1300
Chicago, IL 60601
Tel: (312) 353-5160
Fax: (312) 353-4144

Office of Quality and Patient Safety

The Joint Commission
One Renaissance Boulevard
Oakbrook Terrace, Illinois 60181
Tel: (630) 792-5800

Client Grievance Form

INSTRUCTIONS: Please read over the entire form before completing. Fill out the form as completely as possible: the more specific you are on dates, times, and names of persons in-volved in your grievance, the easier it will be to help you with your grievance. If you need as-sistance please ask a member of the staff or the Open Water Counseling Owner/President.

Describe your grievance. State all facts, including names, time(s), places of incident, wit-nesses (if any) and all persons involved.

_______________________________________________________________________________________________

What do you want to occur in response to your grievance?

_______________________________________________________________________________________________

___________________________________ _________________
Client signature Date

___________________________________ _________________
Open Water Owner/President Date

Response to grievance:

___________________________________ _________________
Client grievance number Initial date

_______________________________________________________________________________________________

Grievance resolution

___________________________________ _________________
Client Name Client Number

___________________________________ _________________
Date grievance filed Date

Grievance description:

_______________________________________________________________________________________________

All involved:

_______________________________________________________________________________________________

Action taken in response to grievance:

_______________________________________________________________________________________________

Final resolution of grievance:

_______________________________________________________________________________________________

___________________________________ _________________
Written copy provided to Date

_______________________________________________________________________________________________
Copy of all forms of grievance submitted to Open Water Owner/President

Telehealth Informed Consent

Below is the informed consent for telehealth. Whereas the form referneces “OWCR”, it rep-resents Open Water Counseling and Recovery, LLC of 1716 North Road SE Warren, OH 44484.

By signing the signature page, I understand and agree with the following Telehealth/Telemedicine involves the use of electronic communications to enable health care providers at different locations to share individual patient medical information for the purpose of improving patient care. Providers may include primary care practitioners, specialists and/or subspecialists, nurse practitioners, registered nurses, medical assistants and other health-care providers who are part of my clinical care team. In addition to myself and the members of my clinical care team, my family members, caregivers, or other legal representatives or guardians may join and participate on the telehealth/telemedicine service, and I agree to share my personal information with such family members, caregivers, legal representatives or guardians. The information may be used for diagnosis, therapy, follow-up and/or education.

Telehealth/Telemedicine requires transmission, via Internet or tele-communication device, of health information, which may include:

• Progress reports, assessments, or other intervention-related documents

• Bio-physiological data transmitted electronically

• Videos, pictures, text messages, audio and any digital form of data

The laws that protect the privacy and confidentiality of health and care information also apply to telehealth/telemedicine. Information obtained during telehealth/telemedicine that identi-fies me will not be given to anyone without my consent except for the purposes of treatment, education, billing and healthcare operations. By agreeing to use the telehealth/telemedicine services, I am consenting to sharing of my protected health information with certain third parties as more fully described in Privacy Policy. I understand, agree, and expressly consent to OWCR obtaining, using, storing, and disseminating to necessary third parties, information about me, including my image, as necessary to provide the telehealth/telemedicine services.

As with any Internet-based communication, I understand that there is a risk of security breach. Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

Individuals other than my clinical care team or consulting providers may also be present and have access to my information for the telehealth/telemedicine session. This is so they can operate or repair the video or audio equipment used. These persons will adhere to applicable privacy and security policies.

Telehealth/telemedicine sessions may not always be possible. Disruptions of signals or problems with the Internet’s infrastructure may cause broadcast and reception problems (e.g., poor picture or sound quality, dropped connections, audio interference) that prevent effec-tive interaction between consulting clinician(s), participant, patient or care team.

I hereby release and hold harmless OWCR and all members of my care team from any loss of data or information due to technical failures associated with the telehealth/telemedicine service.

I understand and agree that the health information I provide at the time of my telehealth/telemedicine service may be the only source of health information used by the medical professionals during the course of my evaluation and treatment at the time of my telehealth/telemedicine visit, and that such professionals may not have access to my full medical record or information held at OWCR.

I understand that I will be given information about test(s), treatments(s) and procedures(s), as applicable, including the benefits, risks, possible problems or complications, and alternate choices for my medical care through the telehealth/telemedicine visit.

I have the right to withhold or withdraw consent to the use of telehealth/telemedicine services at any time and revert back to traditional in-person clinic services. I understand that if I withdraw my consent for telehealth/telemedicine, it will not affect any future services or care benefits to which I am entitled.

Your signature below indicates that you have been given the standard admission information regarding each policy listed below. It also indicates that each policy has been reviewed and adequately explained to you in a manner that leaves no remaining questions. Your signature indicates that you agree to each policies terms and consent Open Water to perform services as discussed.

______ Informed Consent

______ Client Rights and Grievance Procedures

______ Notice of Privacy Practices

______ Telehealth Informed Consent

___________________________________ ___________________________________
Signature of Patient or Personal Representative Signature of Agency Representative

___________________________________ ___________________________________
Printed Name of Patient or Personal Representative Date

___________________________________ ___________________________________
Date Nursing Home Name if Applicable

___________________________________ ___________________________________
Relationship to Patient Patient Name