Please choose your Care Manager's name in the drop-down below and then their name will appear in the "Care Manager Name Confirmation" box. Please click the button to complete the fields below in this section. If the Care Manager's name is not listed for some reason, please choose "Not listed or unknown". If there is an error, you can skip the rest of this section.

                      General Consent for Care Management Services
I hereby authorize and give my full informed consent to Families and Community Together (FACT) to provide care management services to or on behalf of the above-named youth. Such services include the full range of treatment and support services developed through an individualized service plan to meet the needs and goals established for the youth.

               Acknowledgment of Receipt of Notice of Privacy Practices
I have received a copy of FACTs’ Notice of Privacy Practices, which contains information on the uses and disclosures of the above-named youth’s protected health information, or “PHI.” I understand that FACT has the right to change its Notice of Privacy Practices from time to time and that, whenever an important change is made to the notice, FACT will post a new notice in its offices and on its website. I may contact FACT at any time to obtain a current copy of the Notice of Privacy Practices.

         Consent to Use and Disclose Protected Health Information for                                       Treatment, Care Coordination and Payment

Families and Community (FACT) will utilize the above-named youth’s protected health information (PHI), including demographic information, received by FACT for the following purposes, and I hereby acknowledge and consent to same:

Treatment: For example, FACT will use and disclose the youth’s information to make decisions about the provision, coordination or management of care, including assessing the appropriate treatment for the youth’s conditions and health related needs. It may also be necessary to share information with another provider for the provision, coordination or management of care. These are only examples of uses and disclosures of information for treatment purposes, and there may be other situations in which FACT will disclose the youth’s PHI for treatment purposes.

Care Coordination: The youth’s records may be used and disclosed in planning and development operations, including improvements in our methods of operation and general administrative functions. We may also use and disclose PHI in our overall compliance planning, review activities, and arranging for legal, accounting, and auditing functions. These are only examples of uses and disclosures that are legally permissible, and there may be other types of legally-permissible uses and disclosures that are necessary for FACT to conduct its business operations. In addition, there may be circumstances in which FACT will be legally permitted or required to use and disclose PHI, whether pursuant to a particular law, payor requirement, a subpoena, or a court order.

Payment: For example, FACT may use or disclose information in the youth’s records to obtain reimbursement from Medicaid or other payor sources for services rendered by FACT. This may include determination of eligibility for coverage under the appropriate plan, pre-certification and pre-authorization of services or review of services for the purposes of reimbursement. This also includes using or disclosing information to file an appeal of a payment denial or otherwise to collect payment for the services provided by FACT.

I have read and understand the terms of this document. I have had an opportunity to ask questions about the contents of this document and have had any questions I may have answered. I acknowledge, consent and agree to the contents of this document.

I authorize FACT of Union County (FACT) to speak to Social Services on my and the above-named youth’s behalf. I further authorize FACT to submit the online NJ Family Care (NJFC) application on my and the youth’s behalf, via a secure internet connection. The purpose of speaking to Social Services and/or NJFC, or submitting the online application, is to assist my family to obtain NJFC health care coverage and monitor the status of the application process until completion. (Authorized Representative form may need to be obtained prior to ongoing outreach to the Medicaid Offices)

I understand that the completion of this application requires the disclosure of my family’s personal information such as birth dates, Social Security numbers, citizenship, income, places of employment, addresses, and phone numbers.
I understand that FACT will only use the information I have provided for the purposes stated in this consent and for the provision of CMO services provided by FACT

By signing below, I hereby consent to and give authorization to FACT to perform the above activities.

I hereby consent for my child/self to participate in telehealth services with Families and Community Together (FACT). 

I understand the following will apply:

1.     I understand that telehealth is the practice of delivering Care Management services via technology-assisted media or other electronic means between an FACT Staff member and a youth/family who are located in two (2) different locations. The benefits of telehealth may include removing transportation and travel barriers, and minimize face-to-face interactions to limit the exposure of COVID-19.

2.     I understand that I have the right to withdraw this consent for myself/child to participate in telehealth at any time without affecting my child’s/my right to future care or treatment or risking the loss or withdrawal of any program benefits at FACT to which  would otherwise be provided.

3.     I understand that there are risks and consequences associated with telehealth.  These include but are not limited to technology limitations and failures; interruptions and/or confidentiality issues because other persons may be present during the telehealth session; limited ability to see or hear things that are crucial to the session; and/or the limited ability for FACT to respond to an emergency that they are made aware of during a telehealth session.  I also understand that telehealth may not be as effective as in-person health services.

4.     I understand that recording, taking screenshots, etc., of any kind during any telehealth session is strictly prohibited.

5.     I understand that all laws relating to confidentiality of records; all provisions of the FACT Notice of Privacy Practices that I received; and all provisions of the Informed Consent will apply to the telehealth process. All information disclosed during sessions and all information that FACT places in its records will be kept confidential in accordance with applicable law, except where I have authorized the disclosure pursuant to a separate authorization or as otherwise required by law. 

6.     I understand that to conduct the telehealth session, FACT will use a third party platform (Microsoft Teams) and that platform has represented that it is compliant with the Health Insurance Portability and Accountability Act of 1996 and its implementing regulations, as amended (“HIPAA”).  FACT assumes no liability or responsibility for the failure of the platform to be HIPAA-compliant or to safeguard and/or protect my confidentiality.  I will advise my Care Manager immediately if I wish to use a different third party platform to conduct the telehealth session and in extenuating circumstances FACT may grant such request.  I understand and acknowledge that there may be risks associated with the use of any other third party platform and I agree to hold FACT harmless for all losses resulting from the use of any other third party platform.  FACT reserves the right to deny requests to use any other third party platform.  In the event that FACT denies my request to use any other third party platform, FACT will let me know why it is denying the request and offer other alternatives to conduct the session (i.e., telephone conference). 

7.     I understand that I and/or my child is/are expected to be available, focused and engaged in telehealth session(s).

8.     I understand that in order to protect confidentiality, we cannot share the links to any telehealth sessions and that the session needs to occur in a private location where we can speak openly without being overheard or interrupted by others. If someone comes into the room during a session or if confidentiality is somehow affected, we agree to advise FACT immediately so that we can discuss the best way to handle.  FACT assumes no responsibility for breaches of confidentiality that may occur due to the failure to participate in a telehealth session in a private location or to failure to safeguard any telehealth links.

9.     I understand that if FACT believes that another form of communication would better serve my child or me, telehealth will no longer be used.

10.  I agree to call 911 or to go to my local emergency room immediately if my child is in crisis during a telehealth session.

I understand that the time for any meeting is specifically reserved for me/my child and we are responsible for joining the meeting on time.  If I/my child is late, the appointment will still end at the scheduled end time.  If we need to cancel or reschedule a session, I will contact the Care Manager prior to the scheduled meeting time.

I understand that FACT assumes no responsibility for my/my child’s failure to participate in a session, in whole or in part, due to issues caused by us, including but not limited to dead or uncharged equipment batteries; malfunctioning equipment; poor reception due to location; or failure to obtain a confidential place to participate in the session. 

I understand that during a telehealth session, technical difficulties beyond both FACT’s and our control could result in service interruptions.  If this occurs, we will end and restart the session.  If we are unable to reconnect within fifteen (15) minutes following any service interruption, the meeting organizer will reach out to us to discuss or to reschedule, if need be.

I understand that telehealth may or may not be authorized by the Department of Children and Families and the Center for Medicaid Services in the future. If these entities do not approve the use of telehealth for the provision of Care Management services, FACT may be unable to continue to utilize telehealth. 

I will not hold FACT responsible for any technical failures during the telehealth encounter beyond the control of FACT, including any resulting delays in evaluation or for information lost due to such technical failures.

I understand that I need to inform FACT of my child’s location at the start of any session in case of an emergency and to provide the name of a contact person who FACT can communicate with on my/my child’s behalf in case of a life-threatening emergency that arises during a session.

I have read and understood the foregoing.  The risks of telehealth have been explained to me and I have had the opportunity to ask questions.  I hereby consent to participate in telehealth with FACT.

This form reviews the various methods of electronic communication that FACT of Union County (FACT) may use while providing care management services to the families we serve. The purpose of providing various options for communication is to be able to communicate with families in an efficient and timely manner while safeguarding sensitive information and while honoring the preferences of the families we serve.

Email, text, telephone calls, voicemails & videoconferencing are used for the following purposes:

• Child Family Team Meetings as well as any other meetings or appointments, including date, time, location, agenda, and related information
• All matters related to the below-named youth’s Individual Service Plan, including progress, strategies for addressing the youth’s needs, clarification of services, and any other information related to the plan of care for the youth
• Medicaid information
• Announcements of upcoming events such as community trainings and support groups
• Organizational newsletters or information about special events, and/or
• Communication from the Contracted Systems Administrator (PerformCare).

I understand that on occasion there will be a need for Families and Community of Union County (FACT) to transport the youth named above. In consideration of this, I do hereby give designated staff of FACT permission to transport the above-named youth in order for him/her to receive or participate in authorized services and activities.  In the event that FACT or its employees needs to contact me regarding any transportation issue, my contact information and emergency contact information is below.

By signing below, I acknowledge and expressly agree:

• The youth will not use the transportation for any purpose other than the official activities of FACT.
• The youth will take full responsibility for any personal possessions during transportation. I hereby accept financial responsibility for personal items lost or damaged during transportation.
• The youth will have no illicit substances or contraband items on his/her person or in his/her belongings.  If any of the above are found, the youth and/or parent/guardian may be legally responsible for any consequences resulting thereof.  If any illicit substances or contraband items are found in the youth’s possession, the youth will forfeit any further transportation services provided by FACT.
• I understand that there is an inherent danger in connection with using the transportation provided by FACT.
• I authorize FACT, in its discretion, to arrange for any emergency medical care for the youth that may be needed during the course of travel, and agree to accept all costs associated with the same.
• The youth and I agree to assume the full risk of, and complete responsibility for, any and all personal injury, health issues, or medical problems that the youth may experience in connection with, or as a result of, using the transportation, regardless of whether such personal injury, health issues or medical problems resulting from the negligent or grossly negligent actions of FACTs’ and/or its trustees, officers, directors, employees, contractors, or agents.
• Neither I, the youth, nor anyone else on my or their behalf, will make any claim against, sue, or prosecute FACTs’ or its officers, directors, employees, contractors, agents, successors, or assigns, arising out of or in connection with any property damage, personal injury (including death), health issues, or medical problems that the youth may experience in connection with using the transportation.  In addition, I, the youth, and anyone else on my or their behalf, including heirs and legal representatives, hereby release and forever discharge FACT or its officers, directors, employees, contractors, agents, successors and assigns, from any and all actions, claims, causes of actions or demands that I, the youth or any of us, may now or in the future have in connection with any property damage, personal injury (including death), health issues and/or medical problems in connection with the youth’s use of the transportation.
• This authorization and waiver will be interpreted under the laws of the State of New Jersey, and all disputes relating to this authorization and waiver shall be brought in the state and federal courts located in New Jersey.
• A photocopy of this authorization and waiver will be considered valid as the original.  I have been given a copy of this authorization and waiver.

I have carefully read this Authorization to Transport and Waiver of Liability and fully understand its contents.  I am aware that this Authorization to Transport and Waiver of Liability is a contract between myself, the youth (if over 18), and Families and Community of  Union County (FACT) and sign this document knowingly and of my own free will.

Please note: Please complete for any providers that are currently working with the family. This may include Therapist, Psychiatrist, Primary Care Doctor, DCP&P, Probation Officer, School District/Teacher, etc. This authorization can be used for family members or close friends that could be of benefit to the team. 

If you need more than 4 copies of this form, please inform your Care Manager. 

I authorize FACT to disclose or obtain the following protected health information, including information about mental health treatment to/from: