Wisconsin Residents Please read the notification attached it goes over your Rights to Privacy/Confidentiality/HIPAAIf you have any questions please contact us laura@magnoliacounseling.co Full Legal Name * By typing my name below I agree I have received notification of my Client Rights/Confidentiality/HIPAA Notification First Name Last Name Email * CLIENT RIGHTS When you receive any type of service for mental illness, alcoholism, drug abuse, or a developmental disability, you have the following rights under Wisconsin Statute sec. 51.61 (1) and DHS 94, Wisconsin Administrative Code: PERSONAL RIGHTS • You must be treated with dignity and respect, free from any verbal, physical, emotional, or sexual abuse. • You have the right to have staff make fair and reasonable decisions about your treatment and care. • You may not be treated unfairly because of your race, national origin, sex, age, religion, disability, or sexual orientation. • You may not be made to work except for personal housekeeping chores. If you agree to do other work, you must be paid. • You may make your own decisions about things like getting married, voting, and writing a will, if you are over the age of 18, and have not been found legally incompetent. • You may use your own money as you choose. • You may not be filmed, taped, or photographed unless you agree to it. TREATMENT AND RELATED RIGHTS • You must be provided prompt and adequate treatment, rehabilitation, and educational services appropriate for you. • You must be allowed to participate in the planning of your treatment and care. • You must be informed of your treatment and care, including alternatives to and possible side effects of treatment, including medications. • No treatment or medication may be given to you without your written, informed consent, unless it is needed in an emergency to prevent serious physical harm to you or others, or a court orders it. [If you have a guardian, however, your guardian may consent to treatment and medications on your behalf.] • You may not be given unnecessary or excessive medication. • You may not be subject to electroconvulsive therapy or any drastic treatment measures such as psychosurgery or experimental research without your written informed consent. • You must be informed in writing of any costs of your care and treatment for which you or your relatives may have to pay. • You must be treated in the least restrictive manner and setting necessary to achieve the purposes of admission to the program, within the limits of available funding. RECORD PRIVACY AND ACCESS Under Wisconsin Statute sec. 51.30 and DHS 92, Wisconsin Administrative Code: • Your treatment information must be kept private (confidential), unless the law permits disclosure. • Your records may not be released without your consent, unless the law specifically allows for it. • You may ask to see your records. You must be shown any records about your physical health or medications. Staff may limit how much you may see of the rest of your treatment records while you are receiving services. You must be informed of the reasons for any such limits. You may challenge those reasons through the grievance process. • After discharge, you may see your entire treatment record if you ask to do so. • If you believe something in your records is wrong, you may challenge its accuracy. If staff will not change the part of your record you have challenged, you may file a grievance and/or put your own version in your record. • A copy of sec. 51.30, Wis. Stats., and/or DHS 92, Wisconsin Administrative Code, is available upon request. GRIEVANCE PROCEDURE AND RIGHT OF ACCESS TO COURTS • Before treatment is begun, the service provider must inform you of your rights and how to use the grievance process. A copy of the Program’s Grievance Procedure is available upon request. • If you feel your rights have been violated, you may file a grievance. • You may not be threatened or penalized in any way for presenting your concerns informally by talking with staff, or formally by filing a grievance. • You may, instead of filing a grievance or at the end of the grievance process, or any time during it, choose to take the matter to court to sue for damages or other court relief if you believe your rights have been violated. GRIEVANCE RESOLUTION STAGES Informal Discussion (Optional) You are encouraged to first talk with staff about any concerns you have. However, you do not have to do this before filing a formal grievance with your service provider. Grievance Investigation—Formal Inquiry • If you want to file a grievance, you should do so within 45 days of the time you become aware of the problem. The program manager for good cause may grant an extension beyond the 45-day time limit. • The program’s Client Rights Specialist (CRS) will investigate your grievance and attempt to resolve it. • Unless the grievance is resolved informally, the CRS will write a report within 30 days from the date you filed the formal grievance. You will get a copy of the report. If you and the program manager agree with the CRS’s report and recommendations, the recommendations shall be put into effect within an agreed upon time frame. • You may file as many grievances as you want. However, the CRS will usually only work on one at a time. The CRS may ask you to rank them in order of importance. Program Manager’s Decision If the grievance is not resolved by the CRS’s report, the program manager or designee shall prepare a written decision within 10 days of receipt of the CRS’s report. You will be given a copy of the decision. County Level Review • If you are receiving services from a county agency, or a private agency and a county agency is paying for your services, you may appeal the program manager’s decision to the County Agency Director. You must make this appeal within 14 days of the day you receive the program manager’s decision. You may ask the program manager to forward your grievance or you may send it yourself. • The County Agency Director must issue his or her written decision within 30 days after you request this appeal. State Grievance Examiner • If your grievance went through the county level of review and you are dissatisfied with the decision, you may appeal it to the State Grievance Examiner. • If you are paying for your services from a private agency, you may appeal the program manager’s decision directly to the State Grievance Examiner. • You must appeal to the State Grievance Examiner within 14 days of receiving the decision from the previous appeal level. You may ask the program manager to forward your grievance to the State Grievance Examiner or you may send it yourself. The address is: State Grievance Examiner, Division of Care and Treatment Services (DCTS), PO Box 7851, Madison, WI 53707- 7851. Final State Review Any party has 14 days of receipt of the written decision of the State Grievance Examiner to request a final state review by the Administrator of the Division of Care and Treatment Services or designee. Send your request to the DCTS Administrator, P.O. Box 7851, Madison, WI 53707-7851. If you have any questions about anything listed here you can contact Laura Hodges at laura@magnoliacounseling.co * Thank you! Your response has been received.
