Client Information Form

FOR MEDICAID RECIPIENTS ONLY

PLEASE PROVIDE THE FOLLOWING INFORMATION ONLY IF YOU HAVE COMMERCIAL INSURANCE:

Targeted Case Management

Clients Rights

Right to request how we contact you.

Right to release your medical records.

Right to inspect and copy your medical and billing records.

Right to add information or amend your medical records.

Right to an accounting of disclosures.

Right to request restrictions on uses and disclosures of your health information.

Right to complain.

Consent to Release Information

I consent for Kentucky Mental Health Care, LLC and those representing this group to share my (or my child’s) private health care information with the following individuals and/or entities. KMHC is permitted to send and receive information to and from the entities below if needed:

HIPAA NOTICE OF PRIVACY PRACTICES

METHOD OF CONTACT BY OFFICE

INFORMED CONSENT

TREATMENT PROCESS AND DOCUMENTATION

INSURANCE BILLING

CONFIDENTIALITY AND EMERGENCY SITUATIONS:

CONFIDENTIALITY AND EMERGENCY SITUATIONS:

Patient Attestation Form/Participation in the Development of the Plan of Care