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Outpatient Consent

Combined Consents
Effective Date: 12/07/2020

Clients Rights: Centerstone of Illinois Statement of Client Rights
Centerstone is committed to assisting you with getting the services you need. To be sure that this happens, a list of your rights as a client has been developed. When the law requires it, and/or if you give your permission in writing, your parent, guardian, or someone else acting on your behalf may exercise these rights.

Ethical Treatment:

  1. You keep all rights, benefits, and privileges that the law says you have.
  2. You have the right to be treated with respect and receive service that is free of neglect, humiliation, retaliation, harassment, physical, sexual, fiduciary (financial) and psychological abuse, and physical punishment. Seclusion, restraint, or any form of exploitation, including financial, is prohibited. IF YOU BELIEVE THAT YOU ARE BEING ABUSED, NEGLECTED,

GENERAL (OIG) HOTLINE AT: 1-800-368-1463.

  1. Services will be provided to you and/or your family without discrimination. Ethnic background,

handicapped status (per the Americans with Disabilities Act of 1990), HIV status, personal and social beliefs, being of a certain race, sex, religion, sexual orientation, or age will not make a difference in the quality of services you get.

  1. Clients who cannot pay Centerstone fees may apply for a Client Assistance discount. Clients seen at a National Health Service Corps (NHSC) approved Centerstone site shall not be denied requested services, and shall not be discriminated against in the provision of services because the client is unable to pay for the services.
  2. You have the right to know the names and professional credentials of all staff members who are working with you. You have the right to express your preference regarding your choice of case manager, therapist, or other service provider.
  3. Services will be provided with as short a waiting time as possible. We will try to provide services at times that are convenient to as many clients as possible.
  4. If we don’t think that we have the services you need, we will provide you with information about where you can go to get the help you need.

All information about you is confidential and will only be released with your written consent, except in cases when state and/or federal laws require that information be given without your consent. For example, we are required by law to report evidence of suspected child or elder abuse or neglect, or if you threaten serious bodily harm to yourself or someone else. Our records can also be subpoenaed by the court. In programs licensed by the Illinois Offices of Mental Health and Developmental Disabilities, clients rights to confidentiality are governed by the Mental Health and Developmental Disabilities Confidentiality Act (740 ILCS 110). Substance Use Service records are governed by 42 CFR, Part 2. Confidentiality of persons involved with services due to involvement with the Department of Children and Family Services is governed by Rule 431. All federal and state laws and regulations regarding confidentiality will be followed, including HIPAA and laws of confidentiality that apply to HIV status.
Justification for restriction of your rights as cited in Chapter 2 of the Mental Health and Developmental Disabilities Confidentiality Code [405 ILCS 5], the Confidentiality Act, the Human Rights Act {775 ILCS5} and HIPAA shall be documented in your clinical record. You have the right to be notified of that restriction(s) of your rights. Your parent or guardian and any agency you designate (Guardianship and Advocacy Commission, Equip for Equality, Inc.) shall also be notified of the restriction.
If you ask to do so in writing, you have the right to look at your current file, including any information that has been or will be given to someone else giving you services. These records must be looked at by appointment with staff. You have the right to purchase copies of filed Documents.


  1. You will be involved in the development of your individual service plan, will sign to show that you accept it, and will receive a copy of it. You will be given information that you need to help you make decisions about your treatment in a timely manner and it will be explained to you in a manner that you understand. You may at any time seek a second opinion or go somewhere else for services.
  2. You have the right to attend formal staffing meetings about you. You may be asked to make your request to attend in writing.
  3. You have the right to ask for information about any medication prescribed for you by any physician who is providing part of your treatment.
  4. You have the right to refuse to be involved in or be questioned for research.
  5. You have the right to informed consent or refusal regarding the composition of your service delivery team. You have a right to be informed of any potential consequences resulting from such a refusal.
  6. You have the right to end services at any time. Please let us know in advance if you are ending services. You may be asked to provide feedback about the services that you received and the people who worked with you.
  7. You have the right to contact the public payer.
  8. Services will be provided in the least restrictive environment available.
  9. You have the right to refuse services or any specific treatment procedure, including participating in more than one program at the same time, and a right to be informed of any potential consequences resulting from such refusal.
  10. You have the right to contact HFS or its designee and to be informed by HFS or its designee of the client’s healthcare benefit and the process for reviewing grievances.
  11. The right to not have any services reduced, denied, suspended, or terminated for exercising any rights.
  12. You have the right to have disabilities accommodated as required by the Americans With Disabilities Act, section 504 of the Rehabilitation Act [775 ILCS 5].

Service Consent:
Centerstone Telehealth Service
Informed Consent
Telehealth is a service that may be provided by some Centerstone service providers. These services are to make sure that Centerstone clients get the services they need. These services use telephones and computers so that Centerstone providers can deliver a service to a client from a place other than the place where the provider usually works. These services will let you, your mental health providers and persons with your okay, talk over the telephone or computer about your treatment and care.

Your use of telehealth services is done freely. If you decide that you do not want to use these services you may stop them at any time and face-to face-services will be set up for you.

Your privacy and confidentiality is our utmost concern. Your provider will make sure that only the staff involved in your treatment, or those persons who have your okay, will see or hear you on the provider’s telephone or computer equipment. You must make sure that only you and people who have your okay, will see and hear you and your providers talking on your telephone or computer equipment.

In an effort to make sure telehealth services can be provided to as many people as possible, some telehealth services may be provided with the personal telephones or computers of Centerstone service providers.

I agree that I have been told about and know about telehealth services and I freely agree to use these services. I know that all information about me will be kept safe and will be used only for treatment purposes and for Centerstone to get paid for these services.

If the way that you are being served or have been served by this agency concerns you, you may ask at any time to share your feelings with your service provider, or his/her supervisor.

If you wish to file a formal grievance, you may obtain a copy of the Clients Grievance Procedure, which will tell you how to do this. These forms are located in the lobbies of all agency facilities.

You or your guardian or personal representative, on your behalf, have the right to present grievances and appeal decisions about your services that you don’t agree with through your service program’s supervisory chain up to and including the Executive Director or equivalent. If you are not satisfied with the action taken by the Department Director, you may appeal the grievance to the Incident Review Subcommittee, which serves as the final stage of review for the agency. If you are still not satisfied with the outcome of the appeal process, you may seek review from the entities listed below.

At each level of the grievance process, the employee responding to the grievance will provide you with a written response regarding the actions that he/she is willing to take to address the

Your decision to file a grievance or to appeal decisions made at any level of the process will not result in retaliation or barriers to service.

In programs licensed by the Illinois Offices of Mental Health and Developmental Disabilities, clients’ rights are protected in accordance with Chapter 2 of the Mental Health and Developmental Disabilities Code. Any restrictions on individual rights will also be conducted in accordance with Chapter 2 of the Code.

If you have concerns about the services that are being provided to you that you are unable to resolve through the agency’s grievance process, you have the right to contact:

Guardianship and Advocacy Commission – Egyptian Regional Office
#7 Cottage Dr.
Anna, IL 62906
618-833-4897 or 312-793-5937(TTY)

Guardianship and Advocacy Commission – Metro East Regional Office
4500 College Avenue, Ste. 100
Alton, IL 62002-5051
Phone: 618-474-5503
Fax: 618-474-5517

Equip for Equality (formerly Protection and Advocacy) – Southern Illinois Region
300 E. Main Street, Ste. 18
Carbondale, IL 62901

Equip for Equality – Central Illinois Region
West Old State Capitol Plaza Ste. 816
Springfield, IL 62701
217-544-0464 (Voice)
800-758-0464 (Voice)
800-610-2779 (TTY)
217-523-0720 (Fax)

Department of Human Services Division of Mental Health
100 N. 9th St.,Springfield, IL 62765-1300
(800) 843-6154 or (800) 447-6404 (TTY)

Division of Substance Use Prevention and Recovery
100 West Randolph St., Suite 5-600
Chicago, IL 60601-3297
(866) 213-0548 or (312) 419-8432 (TTY)

Illinois Department of Children and Family Services
406 East Monroe Street, Springfield, IL 62701
(217) 785-2509 or (217) 524-3715 (TTY)

If you have concerns or complaints regarding your mental health care, you also have the right to contact the public payer and to be informed of the public payer’s process for reviewing  grievances. You may do this by contacting the Consumer and Family Care toll free line at: (866) 359-7953. Those staff will ask you some basic questions and will explain the steps in the process. They will also explain your rights when filing a complaint. If you decide that you want to file a complaint, they will explain your rights and answer any questions that you might have.

You also have the right to contact HFS or its designee and to be informed by HFS or its designee of your healthcare benefit and the process for reviewing grievances.
Services will not be denied, suspended, terminated or reduced if you exercise any of your rights.
Illinois Consent for Services:
I recognize that the practice of behavioral healthcare is not an exact science, and, therefore, acknowledge that no guarantees have been or can be made regarding the likelihood of success or outcome of any treatment or test performed at Centerstone.

I understand that I may have a picture taken of my image to keep on record in Centerstone’s Electronic Health record. Any images taken of me outside of the Electronic Health Record,
Centerstone staff will obtain a specific consent.

I hereby give my consent to Centerstone to provide counseling/treatment/Intervention to me and/or my family member(s).

Carequality Consent Statement:
Carequality is a unidirectional HIE. Centerstone will NOT be engaging in sending any of your treatment or service history to any one, at any time. We however are in a care network that allows us to get information about a recent hospital or clinical visit for your care- should you have seen any provider that is in our Network. These providers include area hospitals, primary care physicians, and specialists within Illinois and surrounding states. Noting, any and all access to medical records, and particularly sensitive data, is limited in strict accordance with the Health Insurance Portability and Accountability Act (HIPAA), which clearly states who can access and view protected health information (PHI). If the client is not comfortable with their HIE consent, then they must change their consent status with the participating organization that is releasing the information.

The HIE participation has been reviewed with the client.: Yes

I authorize Centerstone to contact my responsible party/emergency contact.: Yes

I authorize Centerstone to exchange psychiatric and/or substance abuse information with community hospitals as needed for continuity of care.: Yes

I authorize Centerstone to leave messages on my phone regarding my appointment reminder, prescription refills, medication information or when returning your your call.: Yes

I authorize Centerstone to send educational information, special appeals and/or news of special events.: Yes

I authorize Centerstone to email me at the email address provided within the MDLive platform: Yes

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