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Consent for Services - Signing a Contract
ABOUT

CONSENT FOR SERVICES, EMERGENCY TREATMENT, CONFIDENTIALITY, CONSENT FOR PHOTOGRAPH AND PARTICIPANT CHOICE

Please note that children under 18 must be accompanied by a legal guardian. Adults with guardians must obtain written consent from the legal guardian prior to being served. (Please provide a copy of guardianship papers for Adults).

Is this your legal name?
Legal Guardian?
Legal Guardian Relationship

I authorize AWS to provide care and coordination of services to me. This may include medication management, psychiatric treatment, medical appointments, outpatient, habilitative treatment and assistance with money management. I understand that all information is confidential, and no information will be released without my consent. I consent to the provider having access to my records via Population Health. I understand the consent may be withdrawn at any time. 


During my course of treatment at AWS, it may be necessary for my psychiatrist or clinician to communicate with other healthcare professionals on my behalf. I further understand that there are specific and limited exceptions to this confidentiality clause, which includes the following: 

 

  1. When there is risk of imminent danger to myself or to another person, the provider and clinician are ethically bound to take necessary steps to prevent such danger.

  2. When there is suspicion that a child or elder is being sexually or physically abused or is at risk of such abuse, the provider and clinician are legally required to take steps to protect the child or elder, and inform the proper authorities.

  3. When a valid court order is issued for medical records, the provider, clinician, and agency are bound by law to comply with such requests

Consent for Services and Population Health:

In the case of a medical emergency, I hereby authorize AWS to obtain emergency medical care on
my behalf. A medical emergency is defined as: 

 

  • Immediate services are required for the alleviation of pain, or

  • Immediate diagnosis and treatment of unforeseeable medical conditions are required, if such condition would lead to serious disability or death if not immediately diagnosed and treated.

Consent for Emergency Medical Care:

I authorize AWS, Inc. to take my photograph for the purposes of documenting activities and
programs, and/or informing the public of our services. These photographs will in no way be used for 
individual or financial gain.

Consent to Photograph:

I understand that AWS, Inc. has a Med Clinic to offer Medication Management services for their Medicaid and non-Medicaid participants. This information has been discussed with me and I have made the following choice. I have chosen AWS, Inc. to provide the services to me that have been marked with a check. These services are listed below.

Participant Choice:

I understand and consent to these treatment services and that I may stop treatment services at any time. I also understand that I may refuse to take medication and/or revoke consent at any time. This authorization is to remain in effect for one year or until revoked in writing. My signature below indicates that I have read and understand this consent/choice form.

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