This document is meant to explain Prevention is Key program policies, State and Federal laws, and your rights. It also serves as an agreement to participate voluntarily in Prevention Is Key programs. If you have other questions or concerns, please ask and we will address any concerns.
42 CFR Part 2 Prevention is Key staff is required to keep your personal information, including your involvement with our programs, private. Any information you share with us is protected and only shared with necessary program staff. The only time we will share information about you is if you sign a form that states exactly what information we can share with who and in what format (fax, verbal, email, etc.). This is so that we can work effectively with other community organizations that are providing you and your family services, such as a treatment program, a care management organization (CMO), probation, school, etc. We could also be required to share certain information in a limited number of emergency situations (please see below).
The Privacy Rule permits disclosures for “treatment, payment and health care operations” as well as certain other disclosures without the individual’s prior written authorization. Disclosures not otherwise specifically permitted or required by the Privacy Rule must have an authorization that meets certain requirements. With certain exceptions, the Privacy Rule generally requires that use and disclosures of Protected Health Information (PHI) be the minimum necessary for the intended purpose of the use or disclosure.
CONFIDENTIALITY AND EMERGENCY SITUATIONS
We will keep all information private, except in the following situations:
• If a participant reports physical or sexual abuse of a minor; then, by New Jersey State Law, program staff must report this to the Department of Child Protection and Permanency;
• If you sign a release of information to have specific information shared;
• If you provide information that informs program staff that you are imminently in danger of harming yourself or others;
• Information necessary for case supervision or consultation;
• Or when required by law.
If an emergency happens, and you or your parent/guardian need immediate attention, please contact the emergency services in the community (call 911) for those services. We will follow up those emergency services with standard support to you and your family. You may have a copy of this form upon request.
This document certifies that I agree to allow a Prevention is Key staff member to contact me and perform other duties as essential to Prevention is Key programs. I agree that any exchange of contact information (phone numbers, email addresses, physical addresses, etc) with a member of Prevention is Key will be done only with mutual agreement between myself and the Prevention is Key representative.
I understand and agree to the following:
• I understand that I am agreeing to receive services from a Prevention is Key representative(s), which could include recovery coaching, telephone recovery support, CRAFT, recovery meetings, recovery trainings, community events, or others.
• I understand that if at any time I desire a referral to services not provided by Prevention is Key (e.g., mental health treatment, transportation, substance detox, etc.) I will be assisted in finding such services.
• I understand that if I decide to discontinue receiving services from Prevention is Key, I will notify my recovery coach, or call CARES at 973.625.1143
• I understand that my substance use disorder treatment records are protected under federal regulations (42 CFR Part 2 – Confidentiality of Alcohol and Drug Abuse Patient Records) and cannot be disclosed without my written consent. I may revoke this consent orally or in writing at any time. I understand that the revocation will not be effective retroactively for information disclosures that have already occurred.
