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    Consumer Consent

    Uploaded by

    Marina Swanson
    (1) The document outlines grievance procedures for consumers who feel their rights have been violated or are dissatisfied with services, allowing for appeals to be made to the Contra Costa County Alcohol and Other Drugs Services Administration and further appeals to the Complaint Coordinator at the Department of Alcohol and Drug Programs. (2) It states that consumer information cannot be released without prior written consent except in situations required by law such as child abuse. (3) Consumers consenting to participate in the POWER program services agree to potential follow-up contacts by staff 6 months and 12 months after discharge to assess their progress.

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    Consumer Consent

    Uploaded by

    Marina Swanson
    12 views1 page
    (1) The document outlines grievance procedures for consumers who feel their rights have been violated or are dissatisfied with services, allowing for appeals to be made to the Contra Costa County Alcohol and Other Drugs Services Administration and further appeals to the Complaint Coordinator at the Department of Alcohol and Drug Programs. (2) It states that consumer information cannot be released without prior written consent except in situations required by law such as child abuse. (3) Consumers consenting to participate in the POWER program services agree to potential follow-up contacts by staff 6 months and 12 months after discharge to assess their progress.

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    ConsumerConsent.docx

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    (1) The document outlines grievance procedures for consumers who feel their rights have been violated or are dissatisfied with services, allowing for appeals to be made to the Contra Costa County Alcohol and Other Drugs Services Administration and further appeals to the Complaint Coordinator at the Department of Alcohol and Drug Programs. (2) It states that consumer information cannot be released without prior written consent except in situations required by law such as child abuse. (3) Consumers consenting to participate in the POWER program services agree to potential follow-up contacts by staff 6 months and 12 months after discharge to assess their progress.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    12 views1 page

    Consumer Consent

    Uploaded by

    Marina Swanson
    (1) The document outlines grievance procedures for consumers who feel their rights have been violated or are dissatisfied with services, allowing for appeals to be made to the Contra Costa County Alcohol and Other Drugs Services Administration and further appeals to the Complaint Coordinator at the Department of Alcohol and Drug Programs. (2) It states that consumer information cannot be released without prior written consent except in situations required by law such as child abuse. (3) Consumers consenting to participate in the POWER program services agree to potential follow-up contacts by staff 6 months and 12 months after discharge to assess their progress.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 1

    Grievance Procedures – If you feel at any time that your rights to services have been

    violated or you are dissatisfied with the services you are getting, you may appeal in
    writing to the Contra Costa County Alcohol and Other Drugs Services Administration,
    597 Center Avenue, Suite #320, Martinez, CA, 94553. If this appeal is denied, a
    further appeal may be made in writing to the Complaint Coordinator, Department of
    Alcohol and Drug Programs, 1700 K Street, Sacramento, CA, 95814 or by calling
    (916) 327-3723.
    Statement of Consumer Confidentiality – No information about a current or
    previous consumer can be released without prior written consent of the consumer or
    former consumer except in the following situations required by law: (a) Persons under
    the influence of alcohol and other drugs; (b) Child abuse or neglect; (c) Danger to self
    and others; (d) Possession of weapons or other dangerous objects; (e) Emergency
    interventions; (f) Possession of alcohol and other drugs;
    (g) Sale of alcohol and other drugs.

    I understand that the information to be released from my records is confidential and


    cannot be disclosed without my written consent unless otherwise mandated by law
    Compliance with 42 CFR, Part 2, Article 7, Section 5325 of Subchapter 2, Part I of
    Division 5 of the Welfare and Institution Code. I understand that I may revoke this
    authorization at any time, except to the extent that action has already been taken to
    comply with it. I do not void this authorization, it will automatically expire in 6
    months from the date I signed it.

    Consent for Consumer Follow-up – After you have completed the POWER program,
    staff would like to follow-up on your progress 6 months and 12 months after
    discharge.
    I do consent________to follow up contacts after discharge or termination.
    I don’t consent_____to follow up contacts after discharge or termination.
    Acknowledgement
    I have read and understand all of the above. I have also received a copy of this
    document. I hereby consent to participate in the POWER program services and abide
    program rules. I have also read and understand my rights and responsibility as a
    consumer or participant in these services.

    Consumer Name____________________ Signature ___________Date____________

    Legal Guardian Name________________Signature____________Date____________

    Counselor Name____________________ Signature___________ Date____________

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