THG Consent Packet

The Holding Group provides:

• Expert facilitation of advance care planning discussions, grounded in respect for each individual patient and family system
• Partnering with patients and their defined family members through transitions in care locations
• Collaboration with other involved care providers

Exploration and discussion of the following:

• Understanding of disease process and planning for the future
• Goals of care and completion of appropriate advance directives
• Caregiver needs, stressors and resources
• Emotional and spiritual support needs

The Holding Group remains involved in my care until:

• The Holding Group program is complete when patients, defined family members and providers have clarity regarding plan of care

PLEASE REVIEW IT CAREFULLY.

When we visit you, either in person or via phone or video conference, we create a health record about you. Your health record contains your personal information, including information that may identify you, your health information, and related health care services. This is referred to as Protected Health Information (“PHI”).

We are required by law to maintain the privacy of your PHI, to provide you with notice of our legal duties and privacy practices with respect to your PHI, and to notify you following a breach of your unsecured PHI. We will not use or give others your PHI without your written permission, except as stated in this Notice.

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU

We may use or share your PHI, without your permission, in the following ways:

• For Treatment. We can use and share your PHI with other health professionals involved in your care to provide, coordinate, or manage your health care. For example, we may share your PHI with clinical supervisors or other treatment team members for consultation purposes. We may also contact you to remind you of your appointments or to provide information to you about treatment alternatives or other health-related benefits and services that may be of interest to you.
• For Payment. We may use and share your PHI, so that we can receive payment for the treatment services we provided to you. For example, we may give enough information to your health insurance plan so that it will pay us for the services we provided to you.
• For Healthcare Operations. We may use and disclose your PHI to support our business activities including, but, not limited to, quality assessment activities, employee review activities, licensing, and conducting or arranging for other business activities. For example, we may share your PHI with third parties that perform various business activities for us such as typing services. For training or teaching purposes, we will use and disclose PHI only with your prior authorization.

OTHER USES AND DISCLOSURES ALLOWED OR REQUIRED BY LAW

We may also use and share your PHI, without your authorization, under limited circumstances. As social workers licensed in Colorado, it is our practice to adhere to more stringent privacy requirements for disclosures without an authorization. Therefore, we may use and share your PHI under the following limited circumstances, which are consistent with both the National Association of Social Work (NASW) Code of Ethics and HIPAA:

• As Required by Law. We may disclose your PHI when required by federal, state, or local law to do so. For example, we are required to make disclosures to the Secretary of the U.S. Department of Health and Human Services (“HHS”) in order to allow HHS to evaluate whether we are in compliance with the federal privacy regulations.
• Abuse or Neglect. We may disclose your PHI to a state or local agency that is authorized by law to receive reports of elder or child abuse or neglect.
• Judicial and Administrative Proceedings. We may be required to disclose your PHI in response to a court or administrative order or in response to a subpoena.
• Deceased Patients. We may disclose PHI regarding deceased patients as mandated by state law. A release of information regarding deceased patients may be limited to an executor or administrator of a deceased person’s estate. We may also disclose PHI to a coroner or medical examiner for the purpose of identifying a deceased individual or to determine the cause of death
• Health Oversight. We may disclose your PHI to a health oversight agency that is authorized by law to conduct activities such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies and organizations that provide financial assistance to the program (such as third-party payors based on your prior consent) and peer review organizations performing utilization and quality control.
• Law Enforcement. We may disclose PHI to a law enforcement official, as required by law in compliance with subpoena (with your written consent), court order, administrative order or similar document, for the purpose of identifying a suspect, material witness or missing person, in connection with the victim of a crime, in connection with a deceased person, in connection with the reporting of a crime in an emergency, or in connection with a crime on the premises.
• Specialized Government Functions. We may review requests from U.S. military command authorities if you have served as a member of the armed forces, authorized officials for national security and intelligence reasons and to the Department of State for medical suitability determinations, and disclose your PHI based on your written consent, mandatory disclosure laws and the need to prevent serious harm.
• Public Health. We may disclose your PHI to public health authorities that are authorized by law to collect or receive PHI for the purpose of activities such as preventing or controlling disease, injury, or disability; reporting child, elder, or dependent adult abuse or neglect; reporting domestic violence; and reporting reactions to medications or products.
• Public Safety. We may disclose your PHI if necessary to prevent or lessen a serious and imminent threat to the health or safety of a person (including self of other) or the public. If information is disclosed to prevent or lessen a serious threat, it will be disclosed to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat and authorities.

USES AND DISCLOSURES IN SPECIAL SITUATIONS

• Family Involvement in Care. We may disclose your PHI to close family members or friends directly involved in your treatment based on your consent or as necessary to prevent serious harm. We may also use or disclose your PHI to family members that are directly involved in your treatment with your verbal permission.
• Medical Emergencies. We may use or disclose your PHI in a medical emergency situation to medical personnel only in order to prevent serious harm. Our staff will try to provide you a copy of this Notice as soon as reasonably practicable after the resolution of the emergency.

USES AND DISCLOSURES REQUIRING YOUR WRITTEN AUTHORIZATION

Other than the uses and disclosures listed within this Notice, we will use or disclose your PHI only with your written authorization. If you authorize a particular use, you may revoke that authorization at any time by notifying us in writing that you wish to do so. Examples where we first need your written authorization include the following:

• Research. We may use and disclose your PHI to researchers only upon your written authorization or through a rigorous approval process as required by law.
• Fundraising. We may use your PHI to contact you as part of our fundraising efforts. If you do not want to receive any notices from us, notify the Privacy Officer listed within this Notice.

YOUR RIGHTS REGARDING YOUR PHI

You have certain rights regarding your PHI. To exercise any of the following rights, please submit your request in writing to dana@theholdinggroup.org.

• Right of Access to Inspect and Copy. You have the right to see and to get a copy of your health record and any other PHI that we have about you. We may restrict your right to see your health record if there is compelling evidence that access would cause serious harm to you. We may charge a reasonable, cost-based fee for copies. If your records are maintained electronically, you may also request an electronic copy.
• Right to Amend. If you feel that the PHI we have about you is incorrect or incomplete, you may ask us to amend the information, although we are not required to agree to the amendment. If we deny your request to amend the information, we must tell you in writing why we are denying your request. Please contact Dana Lahoff at dana@theholdinggroup.org if you have any questions.
• Right to an Accounting of Disclosures. You have the right to request an accounting of certain of the disclosures that we make of your PHI. We will include all the disclosures except those for treatment, payment, or health care operations purposes, and certain other disclosures. We may charge you a reasonable fee if you request more than one accounting in any 12-month period.
• Right to Request Restrictions. You have the right to ask us to not use or to share certain health information for treatment, payment, or health care operations. We are not required to agree to your request, and we can refuse to limit the information we use or share if it would affect your care. If you pay for a health care item or service in full, you can ask us to not share that information with your health insurer, and we will honor that request unless a law requires us to share that information.
• Right to Request Confidential Communication. You have the right to request that we communicate with you in a certain way (for example, by cell phone or mail) or at a certain location.
• Breach Notification. If there is a breach of unsecured PHI concerning you, we may be required to notify you of this breach, including what happened and what you can do to protect yourself.
• Right to a Copy of this Notice. You have the right to a paper copy of this Notice.

QUESTION, CONCERNS, COMPLAINTS

If you have any questions about this Notice of Privacy Practices, please contact our Privacy Officer, Dana Lahoff, dana@theholdinggroup.org . If you believe your privacy rights have been violated, you have the right to file a complaint in writing with us or with the Secretary of the U.S. Department of Health and Human Services. To file a complaint with us, contact our Privacy Officer, Dana Lahoff, at dana@theholdinggroup.org . To file a complaint with the Secretary of the U.S. Department of Health and Human Services, submit your complaint to:

The Office for Civil Rights
U.S. Department of Health and Human Services Office
200 Independence Avenue, S.W.
Washington, D.C. 20201
(202) 619-0257

All complaints must be submitted in writing unless you are unable to write, in which case someone will assist you with putting your complaint into a written form. We will not retaliate against you for filing a complaint.

We reserve the right to revise our HIPAA Notice of Privacy Practices and to make the revisions apply to your health information that we created or received before the effective date of the revision. We will notify you of any revisions to our HIPAA Notice of Privacy Practices by posting the revised notice in the common area and on our web site.

The effective date of this Notice is January 2013.

The Holding Group believes that people know what’s best for them and that they deserve to be informed, empowered and supported.

DISCLOSURE STATEMENT

The Holding Group
2590 Welton St. Suit 200
Denver, CO 80205
(720) 295-1844

PROFESSIONALS INCLUDE:

• Dana Lahoff, LCSW, MSW The Ohio State University 2008 (Clinical Social Work Practice, 2012 – Present)
• Bree Owens, LCSW, MSW University of Denver 2007 (Clinical Social Work Practice, 2010 – Present)
• Bonnie Herrmann, LCSW, MSW The University of Texas at Austin 2013 (Clinical Social Work Practice, 2017 – Present)
• Cathy Dorsey, LCSW, MSW California State University-Long Beach, Long Beach CA 2007 (Clinical Social Work Practice, 2012 – Present)
• Denise Dollar, LCSW, MSW University of Denver, 2020 (Clinical Social Work Practice, 2023 – Present)
• Jennifer LeBlanc, LCSW, MSW Louisiana State University, 1998 (Clinical Social Work Practice, 2012- Present)
• Erica Kennedy, LCSW, MSW Florida State University, 2008 (Clinical Social Work Practice, 2016- Present)
• Meghan Fera, LCSW, MSW New York University, 2013 (Clinical Social Work Practice, 2017- Present)
• Kay Adams, LCSW, MSW Augsburg University, 1994 (Clinical Social Work Practice, 1998- Present)

Regulatory requirements applicable to the above mental health professionals:

• A Licensed Clinical Social Worker (LCSW), a Licensed Marriage and Family Therapist (LMFT), and a Licensed Professional Counselor (LPC) must hold a master’s degree in their profession and have two years of post-masters supervision.
• A Licensed Social Worker (LSW) must hold a master’s degree in social work.

The practice of licensed social workers or licensed clinical social workers is regulated by the Mental Health Licensing Section of the Division of Registrations of the Colorado Department of Regulatory Agencies. The Board of Social Work Examiners can be reached at: 1560 Broadway, Suite 1340, Denver, CO 80202, (303) 894-7760.

Under the Colorado Mental Health Practice Statute, C.R.S. § 12-43-214, you are entitled to receive information about the methods of clinical work, the techniques used, the duration of clinical work (if known), and the fee structure. You may seek a second opinion from another licensed or registered mental health professional or you may terminate our work at any time. In a professional relationship, sexual intimacy is inappropriate and should be reported to the Board of Social Work Examiners.

Generally, the information provided by you and to you during sessions is legally confidential and cannot be released without your consent. There are exceptions to this confidentiality, some of which are listed in section C.R.S. § 12-43-218 and the HIPAA Notice of Privacy Rights you were provided, as well as other exceptions in Colorado and Federal law. For example, one exception is that mental health professionals are required to report elder and/ child abuse to authorities. Confidentiality is further discussed in the Practice Policies and Procedures.

The Holding Group LLC has an on staff advanced practice nurses (Nurse Practitioners) to assist in the delivery of Palliative Care and GUIDE medical care. Our Nurse Practitioner is Jennifer Davis, who is a Adult Gerontology Nurse Practitioner.

An advanced practice nurse is not a doctor. An advanced practice nurse is a registered nurse who has received advanced education and training in the provision of health care. An advanced practice nurse can diagnose, treat, and monitor common acute and chronic diseases as well as provide health maintenance care. They do this by obtaining histories, performing exams, developing and implementing care plans. In addition, the advanced practice nurse may treat prescribe medications when needed. I have read the above, and hereby consent to the services of an advanced practice nurse for my healthcare needs. I understand that at any time I can refuse to see the advanced practice nurse and request to see the doctor, subject to availability.

I choose to receive consultative services from The Holding Group, LLC.  I acknowledge and understand the following:

• Services focus on symptom management, disease education, advocacy, and resource counseling.
• Services will be provided by a licensed clinical social worker, nurse practitioner, and/or patient navigator as applicable and may occur in a variety of different settings such as my home, in a facility, or via phone or video conference, during scheduled appointments.
• Decisions regarding services will be made by me or by others authorized to make medical decisions on my behalf.

The goals of The Holding Group:

• Assist with the completion of advance directives.
• Provide information and education regarding illness and treatment options.
• Symptom Managment.
• Help me and my defined family articulate health care goals.
• Address caregiver concerns if appropriate.
• Provide information and referrals for emotional/spiritual resources if appropriate.

The responsibilities and scope of services include the following:

1. To provide a compassionate quality service regardless of race, religion, gender, sexual orientation, age, physical or mental disabilities.
2. To provide trained, professional staff.
3. To provide consultation and counseling which is ethical with respect to the life values, beliefs, religious preferences, dignity, individuality, personal property, privacy in treatment, and personal needs of myself and my family.
4. To respond to, investigate and resolve any complaint. The process and resolution will be documented for quality improvement purposes.

RELATIONSHIP:

You will maintain a professional relationship with The Holding Group, LLC, existing exclusively for consultative support and counseling related to advanced illness. This relationship functions most effectively when it remains strictly professional. The Holding Group can best serve your needs by focusing solely on consultative support and counseling and avoiding any type of social or business relationship.  Gifts are not appropriate.

CANCELLATION POLICY:

If you must cancel or reschedule your appointment, we ask that you call our office at 720-295- 1844 at least 24 hours in advance. This will free your appointment time for another client. If you fail to notify The Holding Group 24 hours prior to your scheduled time of a cancellation, you will be charged the full rate for your missed session. This requirement will be waived in the case of an unforeseen emergency.

PAYMENT:

You are responsible for copayments or charges incurred from services received. Your contract with your insurance entity may or may not cover some services. All insurance policies are not the same. The Holding Group is not responsible or able to know every policy available. It is your responsibility to verify applicable coverage prior to receiving the services. The Holding Group will bill your insurance provider for services provided to the patient and family.

HOURS OF SERVICE:

The Holding Group is a non-emergency program. The Holding Group’s general operating hours are Monday- Friday 8am to 4pm.

EMERGENCIES:

If you are experiencing a life-threatening emergency, call 911 or have someone take you to the nearest emergency room for help.

CONFIDENTIALITY:

The Holding Group follows all legal and ethical standards prescribed by state and federal law. We are required by practice guidelines and standards of care to keep records of your counseling. These records are confidential with the exceptions noted in the Notice of Privacy Practices provided to you.

CONSENT TO TREATMENT:

By signing the Receipt of Paperwork/Consent to Treatment form as the Client or personal representative of said Client, I acknowledge that I have read, understand, and agree to the terms and conditions contained in this form. I have been given appropriate opportunity to address any questions or request clarification for anything that is unclear to me. I am voluntarily agreeing to consultative services, and I understand that I may stop such services at any time.

With my signature I authorize The Holding Group’s Nurse Practitioner, when applicable, to provide medical care for me, or to this patient for which I am the Medical Power of Attorney. This medical care may include services and supplies related to my health (or the identified person) and may include (but not limited to) preventative, diagnostic, therapeutic, rehabilitative, maintenance, palliative care, counseling, assessment of review of physical or mental status/function of the body and sale and dispensing of drugs, devices, equipment or other items required and in accordance with a prescription. This consent includes contact and discussion with other health care professionals for care and treatment.

If available to me, I will be told by my provider I am eligible for Principal Illness Navigation, Chronic Care Management or Complex Chronic Care Management services (herein referred to as Care Management) provided by The Holding Group. These services are available to individuals who have one major medical condition or two or more chronic conditions. Services includes non-face to face services that help support me and my overall care including referrals and connection to community resources, collaboration and communication with other involved medical providers, support during transitional times (such as hospital to sub-acute rehab or sub-acute rehab to home), and the drafting and updating of a care plan that addresses my medical and medically related needs and a plan to address meeting those needs. If I verbally agree to management services, I acknowledge I may be subject to a monthly copay even though I may not have a visit with the person who is providing the complex chronic care management services. Copay’s for Complex Chronic Care Management services on average $10 per month, but this may be different depending on insurance plan. Please call your insurance provider for the most up to date copay information. Only one medical provider can be billing Care Management services at a time, so please inform your providers if another provider is already providing you Care Management services.

The Holding Group believes that people know what’s best for them and that they deserve to be informed, empowered and supported.

RECEIPT OF PAPERWORK/CONSENT TO TREATMENT

By signing below, I acknowledge that I have received the documents titled HIPAA Notice of Privacy Practices, Disclosure Statement, and Practice Policies and Procedures. I have had the opportunity to read the information contained within those documents. I further acknowledge that I understand my rights as set forth within these documents, and that I have the right to request additional information, if needed.

Consent for Telehealth Consultation and Treatment

To serve the needs of people when face-to-face visits are not an option, The Holding Group consultative services are available by two-way interactive video communications. This is referred to as “telehealth.

Telehealth sessions are provided through a HIPAA-compliant Zoom platform. You do not need your own Zoom account; however, you will need a computer, tablet, I-Pad, or smart phone with a video-camera. Before the scheduled meeting, you will receive a link. At the time of the meeting, click on the link. A video screen will pop up. You may have to click on icons to turn on your microphone and camera. In case connection is lost, please call our remote office at 720- 295-1844 to troubleshoot. If we cannot successfully reconnect on the internet, we can reschedule or continue the telephone.

In participation, I understand

1. A variety of technological problems can cause delays in starting meetings or can interrupt a meeting.
2. I will be told of any more personnel that are present, seen or unseen, during the telehealth meeting other than the THG Provider.
3. Transmitted data may be kept, viewed and used for the purposes of guiding healthcare providers (such as advance directives). Transmitted data may become part of my medical record.
4. THG providers will keep a written record of the telehealth consultation in my medical record.

I understand that:

1. I can refuse care through telehealth at any time. Refusing care through telehealth will not affect my right to care or treatment in the future.
2. I will disclose all participants that are present, seen or unseen, during the telehealth meeting to The Holding Group provider.
3. Telehealth visits are subject to the same privacy protections as in-person healthcare services.
4. I will tell THG provider if I sense that there has been a misunderstanding in communication or unhelpful response, as soon as possible so that we can work to repair the mis-communication or mis-step.

I additionally consent to receiving consultative services from The Holding Group, LLC