Consent: Consent for Services

I, , am the lawful parent/guardian of . I understand that Ignite Teen Treatment provides services to children and teens to assist them through the challenges of mental health, education and addiction disorders including the behavioral issues that may accompany these disorders. In providing these services, I understand that IGNITE utilizes numerous approaches. Such approaches include:

• Psychological/Educational testing;
• Psychotherapy services;
• Counseling (Individual and Group sessions);
• Therapy (Individual and Group sessions);
• Rehabilitation services, Case management;
• Medication monitoring (under the supervision and orders of appropriately licensed medical personnel);
• Drug screening (if this is a treatment goal); and
• Various activities and therapy techniques including equine therapy and fitness.

In addition to these services, IGNITE may assist in arranging for medical, dental and/or diagnostic services. Such services may include: X-rays, CT Scans, Ultrasounds, Laboratory Blood draws (and testing), medical intervention dental intervention, and anesthetic use. (Medical services/testing and procedures will only be done upon the recommendations and/or orders of properly licensed medical professional). I understand that the above-named services are not an all-inclusive list and may be amended at will by IGNITE. I further understand that the services provided may be provided and/or administered at different times and/or locations.

I hereby authorize and consent to allow to participate in the services outlined by IGNITE and the licensed professionals with whom they consult. I further understand that all the above services are voluntary and that I and other guardian(s) and custodial parent(s) of  have the right to:

• Request a change in service provider (agency or staff) or service coordinator or withdraw this consent at any time;
• Be informed of and participate in the selection of any of the above services to be provided; and
• Receive any of the above services without being required to receive other services from IGNITE.

I have read and understand the terms of this Authorization and I have had an opportunity to ask questions about the services provided by IGNITE. By my signature below, I hereby, knowingly and voluntarily, authorize IGNITE to provide the services authorized and consented to herein.

Client’s Name:  Client’s Initials:  Date: 

Parent/Legal Guardian/Agent Initials:  Date: 

for Ignite Teen Treatment Initials: ITT Date: 

Consent: Payment Agreement – Single Treatment Period

The following amends and supplements the payment obligations under the Admission Agreement between the undersigned and Ignite Teen Treatment (“IGNITE”) with respect to a single treatment period for the undersigned’s dependent minor and does not modify the Admission Agreement with respect to any other period or additional days of treatment. As used herein, a single treatment period commences with admission and ends with discharge with IGNITE reserving the right, in its sole discretion, to discharge the undersigned’s dependent minor in accordance with the terms and conditions of the Admission Agreement.

IGNITE will be billing the undersigned’s insurance company for IGNITE’ services. However, state and federal law and the applicable insurance policy require that IGNITE collect any out of pocket expenses including any deductibles and co-pays in accordance with the insurance policy’s terms and conditions. Accordingly, pending the determination of the exact amount that the insurance company will be paying and the receipt of payments from the insurance company, you agree to make an upfront deposit for the services in the amount of: *{Remaining Deductible on Insurance Policy/ out of Pocket Max} to be paid to IGNITE as follows:

Upon Admission or Via Payment Plan Signed upon Admission

__________________________________________________________________________________

The above payment(s) only applies to a single treatment period unless IGNITE, in its sole discretion, decides to apply such deposit to another period of treatment or obligation of the undersigned. This deposit is intended to account for the amounts that the policy holder is expected to pay pursuant to the terms of the insurance policy and will be treated as a deposit against, or payment for services rendered until insurance coverage has been confirmed or until IGNITE, in its sole discretion, elects to apply such payments to specific charges. (Such obligations may include but are not limited to any medication co-payments, costs of incidentals and personal items procured or paid by IGNITE for the undersigned’s dependent minor.) In the event that the undersigned’s insurance does not pay IGNITE’ full rates, all amounts deposited will be credited against IGNITE’ full rate and whatever amounts are not paid by the insurance company, are the ultimate responsibility of the primary policy holder.

To the extent that the treatment period results in more than one out of pocket maximum or series of deductibles being applicable (i.e., the treatment period covering two calendar years), then IGNITE may only require the undersigned to pay for a single treatment period. This provision will only apply in circumstances wherein IGNITE’ doing so does not in any way reduce or otherwise adversely affect the amount that the undersigned’s insurance is required to pay or otherwise violate applicable law or affect IGNITE’ usual and customary rate. The foregoing limitation shall not apply to the cost of medications, co-payments in connection therewith, incidentals and personal items that IGNITE may procure for the undersigned’s dependent minor. By signing below, I hereby accept, and agree to make, the foregoing payments with respect to the single treatment period for my minor dependent under the terms and conditions above and the terms and conditions of the Admission Agreement.

By initialing here, I hereby accept, agree and authorize that the charges enumerated herein will be charged against any credit card(s) that I have provided to IGNITE.   Except as modified hereby, the Admission Agreement remains unmodified and in full force and effect. Dated as of .

Client’s Name:  

Parent/Legal Guardian/Agent Initials:  Date:

for Ignite Teen Treatment Centers Initials: ITTC Date: ­­­­­ 

Consent: Credit Card Authorization

Client Name:

Parent/Legal Guardian Name:

Credit Card Payment Authorization

Name as it appears on card:

Type of Card:

Card Number:  

CVV Code:  

Billing Zip Code:  

Expiration Date:

I understand by signing this form, I give authorization to Ignite Teen Treatment, to charge my credit/debit card account for the above agreed upon payment plan for the aforementioned patient’s treatment at this facility. All payments are non-refundable and will be charged to my credit/debit card on the installment days specified or the next business day. I realize that if any account number(s) listed on this form change(s), this authorization will remain in effect for the new account numbers and I MUST contact IGNITE to update my payment information.

Cardholder Initials: Date:

Client’s Name:  

Parent/Legal Guardian/Agent Initials:  Date:  

for Ignite Teen Treatment Initials:  Date: 

Consent: 3^rd Party Liability Waiver

In an effort to provide you with positive engaging activities, IGNITE Treatment contracts with third party vendors to provide services to IGNITE clients. These third-party vendors are not the employees or agents of IGNITE but rather, provide services to assist clients in achieving their recovery goals. Participation in any of these programs is voluntary and dependent upon the client’s needs and services plan as well as the client’s authorization and consent to participate in these programs

Waiver: In consideration of being permitted to participate in “The Activity”, I, for myself, my heirs, personal representatives or assigns, do hereby release, waive, discharge, and covenant not to sue IGNITE TEEN TREATMENT, its officers, employees, and agents from liability from any and all claims including the negligence IGNITE TEEN TREATMENT , its officers, employees and agents, resulting in personal injury, accidents or illnesses (including death), and property loss arising from, but not limited to, participation in The Activity.

Assumption of Risks: Participation in The Activity carries with it certain inherent risks that cannot be eliminated regardless of the care taken to avoid injuries. The specific risks vary from one activity to another, but the risks range from 1) minor injuries such as scratches, bruises, and sprains 2) major injuries such as eye injury or loss of sight, joint or back injuries, heart attacks, and concussions to 3) catastrophic injuries including paralysis and death.

 I have read the previous paragraphs and I know, understand, and appreciate these and other risks that are inherent in The Activity. I hereby assert that my participation is voluntary and that I knowingly assume all such risks.

Indemnification and Hold Harmless: I also agree to INDEMNIFY AND HOLD IGNITE TEEN TREATMENT HARMLESS from any and all claims, actions, suits, procedures, costs, expenses, damages and liabilities, including attorney’s fees brought as a result of my involvement in The Activity and to reimburse them for any such expenses incurred.

Severability: The undersigned further expressly agrees that the foregoing waiver and assumption of risks agreement is intended to be as broad and inclusive as is permitted by the law of the State of California and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.

Acknowledgment of Understanding: I have read this waiver of liability, assumption of risk, and indemnity agreement, fully understand its terms, and understand that I am giving up substantial rights, including my right to sue. I acknowledge that I am signing the agreement freely and voluntarily, and intend by my signature to be a complete and unconditional release of all liability to the greatest extent allowed by law.

Client’s Name:   

Parent/Legal Guardian/Agent Initials:  Date: 

for Ignite Teen Treatment Centers Initials: ITTC Date: 

Consent: Authorization for Release of Confidential Protected Health/Education Information

I hereby authorize,   , to release the following information of:

Client Name:  

Home Address: 

Home Telephone:  

Date of Birth:  

To:  

Address:  

Phone Number:  

By signing my initials next to a category of confidential information listed below, I specifically authorize the person/entity listed above, to use and/or disclosure of the type of confidential information indicated next to my initials.

Health care information

Mental health information

Educational Information (School records)

Drug and Alcohol Information

Therapy information (Occupational, Speech/Language and Physical)

No psychotherapy records will be released.

This Authorization shall remain in effect for:
One year from the date of execution; or Until discharge from the program;
or Date:

I understand that during the process of using or releasing my health information or educational information, Ignite Teen Treatment will abide by applicable federal and state laws governing the use and disclosure of my confidential health and educational information.

I understand that I may at any time make a written request to Ignite Teen Treatment to inspect and/or obtain a copy of my health information and that Ignite Teen Treatment will comply with state and federal regulations in providing me a copy of same.

I understand that I have a right to receive a copy of this Authorization.

I understand that I may refuse to sign or may revoke this Authorization at any time and for any reason.

I understand that this Authorization will remain in effect until the term of this Authorization expires or I provide a written notice of revocation to Ignite Teen Treatment Privacy Information Officer at the address listed below. The revocation will be effective immediately upon Ignite Teen Treatment’s receipt of my written notice, except that the revocation will not have any effect on any action taken by Ignite Teen Treatment in reliance on this Authorization and before receiving my written notice of revocation.

Ignite Teen Treatment’s Privacy Information Officer is: Privacy Information Officer at 866.604.7273; or by electronic mail at [email protected].

I have read and understand the terms of this Authorization and I have had an opportunity to ask questions about the use and disclosure of the health information requested.

By my signature below, I hereby, knowingly and voluntarily, authorize Ignite Teen Treatment to use and/or disclose the health information in the manner described herein.

Client’s Name:  

Parent/Legal Guardian/Agent Initials: Date:

for Ignite Teen Treatment Centers Initials: ITTC Date:   

Consent: Compliance/Grievance Policy

Policy

Promptly addressing any concerns, complaints or grievances voiced by a client, their legal guardian or representative or employees is important to the ongoing success of each client. As such, individuals who would like to voice such a concern or grievance, are encouraged to do so.

Procedures

• Complaint concerns or grievances may be brought to the attention of any employee at the facility. The facility employee is encouraged to direct the complainant to the client’s individualized therapist.
• If the complainant does not want to speak with the therapist, the complaint or concern shall be forwarded directly to the facility’s Program Manager.
• The complainant may directly contact IGNITE at _____________________; or by electronic mail at _____________________.
• To the extent feasible, a meeting will be arranged wherein any issues may be directly addressed and resolved. Further, any complaints may also be made to Department of Health and Human Services, Division of Public and Behavioral Health.

Ignite Teen Treatment maintains a no retaliation policy. This means that no client or family member will be retaliated against by any IGNITE staff relative to any concern, complaint or grievance voiced.

Client’s Name:  

Parent/Legal Guardian/Agent Initials: Date:

for Ignite Teen Treatment Centers Initials: ITTC Date:

Consent: Informed Consent Verification for Use of Over the Counter (OTC) Medication

(Parent/legal guardian verification)

I, , am the legal representative of . I have read the manufacturer’s instructions regarding the risks and benefits for the over the counter medications listed below. I hereby give Ignite Teen Treatment permission to administer any of the following over the counter medication to my child when needed.

Over the counter PRN (AS NEEDED) Medications:

Said medication must be given in accordance with manufacturer’s instructions.

Client’s Name: 

Parent/Legal Guardian/Agent Initials:  Date:

for Ignite Teen Treatment Centers Initials: ITTC Date: 

Consent: Contraband

This list is not exhaustive and may be amended.

The following items may not be provided to your child while your child is receiving services through Ignite Teen Treatment:

• Alcohol
• Cigarettes
• Prescription medications without a physician’s order
• Any illegal drugs
• Marijuana/Cannabis
• Other drugs, medications or remedies (with or without a prescription)
• Guns
• Knives
• Explosives and incendiary devices
• Any other item that could be used as a weapon

The following items should be left at home:

• Movies rated R or greater and any games bearing a similar rating
• Piercing jewelry
• Pornography
• Inappropriate Clothing/Accessories (as determined by parents and staff)
• Inappropriate Music (as determined by parents and staff)
• Money, credit and debit cards and other means of monetary exchange
• Cell phones and pagers
• Personal Electronics

I have read and understand these rules.

Client’s Name:  Client’s Initials:  Date: 

Parent/Legal Guardian/Agent Initials:  Date:

for Ignite Teen Treatment Centers Initials: ITTC Date:

Consent: Discharge Policy

Policy

Ignite Teen Treatment is committed to providing a safe and healthy environment for all its clients and employees. There are circumstances that may arise when achieving this policy is not feasible and discharge is appropriate. Discharge of a client may only be made after careful consideration and analysis of the client’s situation. Possible reasons for discharge include:

• Nonpayment of services within ten days of the due date.
• The client’s failure to comply with state or local law.
• Client’s failure to comply with general facility policies documented in the facility Admission Agreement or which impact the health, safety and well-being of other clients and/or staff.
• Client’s failure to participate in the services and activities specified in his/her Needs and Services Plan.
• Inability of the facility to meet the client’s needs.
• The client refuses to comply with his/her Restricted Health Condition Care Plan, if any
• Change of use of the facility.

Procedure

• When a client is being considered for discharge, the therapeutic team shall meet and prepare an updated Needs and Service Plan.
• The client and his/her authorized representative(s) will be offered the opportunity to participate in the development of a discharge plan for the child. If it is determined that IGNITE cannot meet the needs of the client, IGNITE staff shall notify the authorized representative(s) and request that the client be placed elsewhere.
• Prior written approval shall be obtained from the child’s authorized representative(s) before the discharge.

If emergency circumstances arise wherein the client’s health safety or well-being is in immediate jeopardy, the client may be emergently transferred to an appropriate health care facility. The client’s authorized representative shall be notified immediately or as soon as practicable.

Client’s Name:  Client’s Intials: Date:

Parent/Legal Guardian/Agent Initials: Date:  

for Ignite Teen Treatment Centers Initials: ITTC Date:

Consent: Living Accommodations

1. Living accommodations: This facility offers furnished double rooms.
2. Linens: The facility will provide bed linens (sheets, blanket and a bedspread), washcloths and towels for use by the client throughout the term of this contract.
3. Utilities: Standard utilities such as heating, cooling, water, electricity are included. Telephone service is included at the approved call times (as noted in the program handbook).
4. Meal Service: The facility will provide three (3) meals and three (3) snacks periods, per day. In between mealtimes, certain food items will always be available (e.g. string cheese, fruit, and yogurt). Whenever possible, dietary restrictions and preferences will be accommodated.
5. Hygiene: Standard toiletries such as toilet paper, towels, soap, toothpaste, toothbrushes, sanitary napkins, shampoo/conditioner and moisturizing lotion are included in the basic living rate. In cases of brand preference, clients are invited to bring unopened/sealed products into the facility, if no alcohol is present in the item, nor is it in the form of an aerosol can. The facility reserves the right to determine what products are appropriate/inappropriate to have onsite. See Additional Living Services below.
6. Laundry: Clients are provided the opportunity to launder their linens and personal belongings once a week. Detergent is included in the basic living rate. In cases, a client does not know how to do their own laundry, a staff member will walk them through the process until they are able to do it independently.
7. Housekeeping: Light housekeeping services are conducted in the facility 3 times per week. Clients are expected to tidy their rooms daily, and made their bed each day, along with their daily chore responsibilities.
8. Care and Supervision: Facility staff will provide supervision and observation for changes in the client’s physical, mental, emotional and social functioning. When such changes in condition are identified, facility staff will notify the primary therapist, facility manager and/or program director who will notify the client’s authorized representative (parent) and/or physician or other appropriate agency consistent with the client’s condition. Staff will assist clients with Activities of Daily Living as needed, and as appropriate. Additional care will be provided based upon the Pre-Admissions Assessment, client plan of care, Physicians Report and/or change of client condition. See Additional Living Services below.
9. Planned activities: The facility offers activities that are included in the basic living rate. These activities are typically planned on a weekly basis and are dependent on client behavior. The facility may also schedule special activities which are also included in the basic living rate.
10. Emergency Response and Fire Protection: Each client room is equipped with a smoke detector and a round-the-clock emergency call response system.
11. Transportation: Facility staff will work with the responsible party assisting in arranging transportation to medical and dental appointments. If the use of an external transportation provider (non-emergency transportation services) is required, the services will be billed directly to the client or authorized representative.
12. Access to supportive services: Whenever possible, facility staff will aid in arranging external supportive services and/or appointments. Examples are appointments for medical, dental, other health care services, or IEP meetings.

Clients Name:  

Parent/Legal Guardian/Agent Initials: Date: 

for Ignite Teen Treatment Centers Initials: ITTC Date:

Consent: Privacy Policy

Policy

This organization’s policy is to maintain the privacy of its clients and not disclose an individual’s personally identifiable health information (also referred to as Protected Health Information (PHI)) or their confidential educational information in accordance with current State and Federal regulations. It is also this organization’s policy to allow clients and/or their legally authorized representative(s) to control how their health information is used.

Procedures

• Upon admission, the client and/or legal representative will receive for review and sign, as necessary, the following:
• Admission Agreement
• Promise of Privacy Notice
• Authorization for Release of Confidential Protected Health Information and Educational Information
• HIPAA Client Consent Form
• Staff will be trained in maintaining PHI for each client.
• Requests for PHI from any person outside of the client’s treatment team, shall be analyzed and reviewed to ensure compliance with State and Federal regulations. Any such requests shall be forwarded to the Privacy Information Officer to ensure same. No documents or information shall be disclosed prior to review by the Privacy Information Officer.
• Unauthorized disclosures of PHI will be immediately reported to the Privacy Information Officer and reports made to authorities in accordance with State and Federal regulations.

Clients Name: Client’s Signature:  Date: 

Parent/Legal Guardian/Agent Initials: Date:

 for Ignite Teen Treatment Centers Initials: ITTC Date:

Consent: Promise of HIPPA Privacy Notes

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

Ignite Teen Treatment understands the importance of privacy and are committed to maintaining the confidentiality of your protected health information. We make a record of the services we provide and some of those services may include information from professional healthcare providers. Further, we may receive protected health information about you from others. We use these records to provide quality services to you and to transmit to other providers to assist with continuity of care. These records are also used to obtain payment for services provided to you which enables us to meet our professional and legal obligations to operate this organization.

We are required by law to maintain the privacy of protected health information, to provide individuals with notice of our legal duties and privacy practices, and to notify affected individuals following a breach of unsecured protected health information.

This Notice also describes your rights regarding your medical information and our legal obligations and how we may use and disclose medical information.

How we may use and disclose your Protected Healthcare Information (PHI)

Federal privacy law allows us to use and disclose your PHI for:

• Planning your care and any necessary treatment(s);
• Law enforcement;
• Communications among many healthcare providers that will contribute to your care while you are receiving services from us and to improve the quality of care we provide to our clients;
• Payment for services provided to you by us or others (like your physician) by third party payers. For example: we might give your insurance company PHI about your present conditions so that there can be proper reimbursement;
• A tool in educating health professionals and staff;
• A source of data for facility planning and marketing;
• Assisting business associates, such as physician services, emergency, radiology, laboratory, etc.;
• Disaster relief, so authorities know about your condition at the time of a disaster;
• Crime, abuse and neglect reporting;
• State and Federal healthcare officials and evaluators. We may disclose your PHI/ePHI to State and Federal healthcare oversight agencies as necessary so that these agencies may carry out their job further; and
• Other individuals as mandated by law.

We may disclose PHI to the following:

• Public health/legal authorities charged with preventing or controlling disease, injury, or disability;
• Correctional institutions (if you are on probation or a diversion program);
• Workers’ Compensation agents;
• Organ and tissue donation organizations; Military command authorities;
• Health oversight agencies;
• Funeral directors, coroners, and medical examiners;
• National security and intelligence agencies; and
• Quality Assurance findings within the organization.

Your Health Information Rights:

• Inspect and copy – With some exceptions, you have the right to inspect and obtain a digital or hard copy of your health information maintained in your designated record set. We may charge a fee for the associated cost of labor, mailing, or other supplies. We may deny your request to inspect and copy in certain limited circumstances. If you are denied access, you may request a review of the denial.

• Amend – This means you may request an amendment of health information about you for as long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Please contact the Privacy Information Officer if you have questions about amending your medical record.

• Accounting of Disclosures – You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment, or healthcare operations. You also have the right to request a limit on the medical information we disclose about you to someone involved in your care or the payment for your care, such as a family member or friend. For example, you could ask that we not use or disclose information about a procedure or lab test that you had. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.

• Receive confidential communications – You have the right to request to receive communications of health information by alternate means or at alternative locations. We will strive to accommodate all reasonable requests.

• Paper copy of this Notice – You may request a paper copy of this Notice at any time, even if you have agreed to receive this Notice electronically.

Our Responsibility

• We are required by law to maintain the privacy of protected health information;
• Provide you with this Notice of our legal duties and privacy practices with respect to protected PHI/ePHI; and
• To notify you if you are affected by a breach of unsecured protected health information.

We are required to abide by the terms of this Notice while it is in effect. We reserve the right to change the terms of our Notice and to make the new Notice provisions effective for all protected health information that we maintain. We reserve the right to change our practices and to make the new provisions effective for all protected health information we maintain. Should our information practices change, we will mail a revised Notice to the address you have supplied us with. We will not disclose your health information without your authorization, except as described in this Notice.

If you ever have any questions or concerns about the information contained in this Notice or the services or charges, we encourage you to contact our Privacy Information Officer at 866.604.7273 electronic mail at [email protected].

By my signature below, I acknowledge how my confidential information may be used and knowingly and voluntarily accept and consent to same, including, without limitation, all manners of disclosure and use described in this notice. I further understand my rights regarding my confidential information.

Clients Name:  

Parent/Legal Guardian/Agent Initials: Date: 

for Ignite Teen Treatment Centers Initials: ITTC Date: 

Consent: RTC Emergency Consent Form

As the parent or authorized representative, I hereby give consent Ignite Teen Treatment to provide all emergency medical or dental care prescribed by a duly licensed physician (M.D.), Osteopath (D.O.), or Dentist (D.D.S.) for . This care may be given under any conditions that are necessary to preserve the life, limb, or well-being of the child named above.

Client has the following allergies (please include any allergies to medications):

Clients Name:  

 Parent/Legal Guardian/Agent Initials: Date:

 for Ignite Teen Treatment Centers Initials: ITTC Date:

Consents: Assignment of Benefits

I , the lawful parent/guardian of , hereby authorize benefits, including, without limitation, insurance benefits and Nevada Check Up / Medicaid  benefits (if I am a Nevada Check Up / Medicaid  beneficiary) to be assigned (and to the extent permitted by my insurance and other reimbursement plans specifically do assign) to Ignite Teen Treatment  (“IGNITE”), for healthcare services provided to me by IGNITE. I hereby certify that the insurance information that I have provided IGNITE is true and accurate as of the date of service and that I am responsible for keeping it updated.

I am fully aware that having health insurance does not absolve me of my responsibility to ensure that my bill from IGNITE is paid in full. I also understand that in some cases exact insurance benefits cannot be determined until an insurance company receives a claim, that my insurance company may not pay 100% of the amount of the medical/healthcare claim and that I may be responsible for all amounts not payable by my insurance company including any portion paid and not applied to in network benefits for any out of network services.

I hereby authorize IGNITE to submit claims, on my behalf, to the insurance company listed on the copy of the current insurance card I have provided IGNITE, in good faith. I fully agree and understand that the submission of a claim does not absolve me of my responsibility to ensure the claim is paid in full. A copy of this authorization will be sent to the Health Care Financing Administration, my insurance company or other entity if requested.

I hereby irrevocably, designate, authorize and appoint IGNITE as my true and lawful attorney-in-fact. This power of attorney is hereby provided for the limited purpose of receiving all payments due under my policy/medical/healthcare care plan because medical/healthcare services and care rendered or to be rendered. This power of attorney shall automatically terminate, without formal action being taken, as soon as IGNITE has received payment in full and remedies under applicable regulatory guidelines for all medical/healthcare care services provided to patient. I hereby confirm and ratify all actions taken by my attorney-in-fact pursuant to the authority granted herein. I hereby authorize my insurer to assign and transfer any applicable ERISA plan benefits and rights to IGNITE including the right to receive any applicable plan documents/remedies, pursue appeals and litigation on my behalf. This authorization includes any other rights due me permissible under state and federal laws.

I hereby instruct and direct my Insurance Company to pay IGNITE. I understand under ERISA that I have the right and authority to direct where payment for services rendered is sent. If my current policy prohibits direct payment to the provider of service, I under my rights per state and federal ERSIA regulations hereby instruct and direct my Insurance Company to provide SPD documentation stating such non-assign ability clause to myself and IGNITE. Upon proof of non-assign ability documentation, I hereby instruct that the insurer make out the check to me and mail it directly to:

1976 S. La Cienega Blvd #668
Los Angeles, CA 90034

for the professional or medical/healthcare expense benefits, and otherwise payable to me under my current insurance policy as payment towards the total charges for the professional services rendered.

I agree and understand that any funds I receive by my insurance company due for services rendered by IGNITE will be immediately signed over and sent directly to IGNITE.

This is a direct assignment of my rights and benefits under this policy. This payment will not exceed my indebtedness to the above-mentioned assignee, and I have agreed to pay, in a current manner, any balance of said professional service charges over and above this insurance payment. Upon receipt of said check, I authorize IGNITE to receive any such checks, endorse them for deposit only, and to deposit and apply all the proceeds toward payment on my account.

I authorize the release of any information pertinent to my case to any insurance company, adjuster, or attorney involved in this case, including, without limitation, protected healthcare information (“PHI”). I authorize IGNITE to obtain PHI and to be my personal representative, which allows IGNITE to: (1) submit any and all appeals (including, without limitation, internal and external appeals) if and when my insurance company denies me benefits to which I am entitled, (2) submit any and all requests for benefit information from my insurance company, and (3) initiate formal complaints to any State or Federal agency that has jurisdiction over my benefits. I fully understand and agree that I am responsible for full payment of the medical/healthcare debt if my insurance company has refused to pay 100% of my benefits based on billed charges, within ninety (90) days of all appeals or request for information. Should the account be referred to an attorney or outside agency for collection, the undersigned shall pay reasonable attorney’s fees and collection expenses. All delinquent accounts bear interest at the legal rate. I also agree that any fines levied against my insurance company will be paid to IGNITE Growth Initiatives, LLC for acting as my personal representative.

I authorize Ignite Treatment and its associates to provide medical/healthcare reasonable by today’s standards. A photocopy of this Assignment shall be considered as effective and valid as the original. By signing this document, I also acknowledge that I have received a copy of the organization’s Promise of Privacy Notice (HIPAA Consent Form). This acknowledgement is required by the Health Insurance Portability and Accountability Act (HIPAA) to ensure that I have been made aware of my privacy rights.

Clients Name:  

Parent/Legal Guardian/Agent Initials: Date:

for Ignite Teen Treatment Centers Initials: ITTC Date: ­­­ 

Consents: Authorization to Obtain and Release Information

This will authorize Ignite Teen Treatment to disclose to and/or obtain from:

Name/Organization:  

Relationship:  

Address:   

Phone Number:   

The following information:

Description of Information to be Disclosed (Parent should initial each item to be disclosed)

Purpose

The purpose of this disclosure of information is to improve assessment and treatment planning, share information relevant to treatment and, when appropriate, coordinate treatment services. If other purpose, please specify:

Expiration

Unless sooner revoked, this consent is valid for 12 months due to the need for ongoing communication for the coordination of treatment, or at termination of treatment.

Conditions

I understand that Ignite Teen Treatment will not condition my treatment on whether I give authorization for the requested disclosure. The consequences of refusing to sign this authorization have been explained to me.

Forms of Disclosure: Unless you have requested in writing that disclosure be made in a certain format, we reserve the right to disclose information as permitted by this authorization in any manner we deem to be appropriate and consistent with applicable law, including but not limited to verbally, in paper format, or electronically.

RE-DISCLOSURE

“This information has been disclosed to you from records protected by Federal Confidentiality rules (42 CFR part 2). The Federal rules prohibit you from making any 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. A general authorization for the release of medical or other information in NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse Client.”

I may request a copy of this authorization for my records.

I understand that my records are protected under Federal Confidentiality regulations (42 CFR Part 2). Published August 10. 1987, and the Heath Insurance Portability and Accountability Act of 1996 (P.L. 104-191), 42 U.S.C. Section 1320d, et. Seq, and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I understand that my medical record may contain information concerning my psychiatric, psychological, drug and alcohol abuse, HIV/Acquired Immune Deficiency Syndrome (AIDS) and/or related conditions. (Under the Mental Health Code, release of mental health records must be germane to the purpose and need for disclosure).

RIGHT TO REVOCATION

I understand that I have a right to revoke this authorization, in writing, at any time by sending written notification to Ignite Teen Treatment. I further understand that a revocation of the authorization is not effective to the extent that action has been taken in reliance on the authorization.

Clients Name:  

Parent/Legal Guardian/Agent Initials:  Date:

for Ignite Teen Treatment Centers Initials: ITTC Date:  

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Signed by Ignite Teen Treatment Centers
Signed On: November 3, 2018

Ignite Teen Treatment https://igniteteentreatment.com

Signature Certificate

Document name: Consent Waiver / Admission Form

Unique Document ID: 89c0b09c94302f6cc5fce0163723f87961f79fc8

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Timestamp	Audit
July 24, 2018 1:01 pm PDT	Consent Waiver / Admission Form Uploaded by Ignite Teen Treatment Centers - [email protected] IP 88.177.171.144

This audit trail report provides a detailed record of the online activity and events recorded for this document.

https://igniteteentreatment.com/

Audit Trail Serial# 06e37decdbc3f05d34502575ba07b0f6