2. EMERGENCY INFORMATION AND CONSENT FORM

In the case of a medical emergency while the client is participating in a program, the staff will provide first aid. In the event that the emergency room, hospitalization, or other appropriate medical or dental care is needed, appropriate transportation to the appropriate facility will be arranged. The parent/guardian/custodian (or designated contact person) will be contacted to meet the client at the facility. If the parent/guardian/custodian (or designated contact person) cannot be reached, the staff member may authorize the physician/dentist/facility to provide emergency treatment.

I, (Client/Legally Responsible Person), authorize Positive Growth Counseling Center to contact the individual and/or physician I have indicated below in the event I become incapacitated due to emergency illness or accident while in treatment. This emergency contact consent will be in lieu of any other authorizations, if any, I have granted, or not granted to the below individual.

I also will hold harmless Positive Growth Community Based Core Service Program against any liability caused by their taking of any emergency procedures and/or contacts. I agree to the Emergency Care Process as outlined above. I will assume the full responsibility of all incurred emergency treatment expenses.

I authorize Positive Growth, Inc. Counseling Center the holder of medical or other information about me to release any information necessary to process insurance claims, and request payment of medical insurance benefits either to myself or to the party who accepts assignment. Regulations pertaining to insurance assignment of benefits apply. I authorize Positive Growth, Inc. to provide, as necessary, to its contracted Qualified Service Organizations (e.g., laboratories, pharmacies, management information systems, billing and collection agencies) the following identifying information: my name, address, telephone number, date of birth, social security number, dates of service, and diagnostic code. This consent is valid until the above transactions related to my services are completed, not to exceed one year from the date below, unless and until I specifically revoke my consent to the release of any or all information at an earlier date.

I have read and understand the information regarding emergency contacts, emergency care and consent and the accounting of disclosure/release of information. All of the aforementioned forms have been explained to me.

I, (Client/Legally Responsible Person) have received a copy of the Clients' Bill of Rights and confidentiality handout and each has been explained to me.

Client / Lagally Responsible Person
Date
Employee Signature
Date