Individual Service Recipient Record Requirements For All Services

AND FACILITIES. The governing body must ensure that an individual record is maintained, in electronic or hard copy format, for each client being served and which minimally includes the following information: (1) The name and social security number of the service recipient; (2) The address of the service recipient or, for residential treatment programs, a permanent or previous address; (3) The telephone number of the service recipient; (4) The sex of the service recipient; (5) The date of the service recipient’s birth; (6) The date of the service recipient’s admission to the facility; (7) The source of the service recipient’s referral to the facility; MINIMUM PROGRAM REQUIREMENTS FOR ALL SERVICES CHAPTER 0940-05-06 AND FACILITIES (8) If applicable, legal documents affirming that the service recipient has a court-appointed legal representative and the name, address and telephone number of the legal representative; (9) The name, address, and telephone number of a family representative and/or an emergency contact person; (10) If the facility charges fees for its services, a fee schedule, as described in Rule 0940-05-06- .02(1)(d), shall be dated, completed and signed by the service recipient (or the service recipient’s legal representative) prior to provision of any services other than emergency services. The licensee should complete a new fee schedule when there is a change in the amount of fees, the services provided, or additional charges for which the service recipient is responsible are incurred; (11) When appropriate, informed, signed and dated consent and authorization forms for the release or obtaining of information from the service recipient. These forms shall be in compliance with state and federal confidentiality laws and include at least the following information: (a) Name and title of the person or organization to or from whom disclosure is to be made; (b) The signature of the service recipient or the service recipient’s legal representative; (c) The purpose of the disclosure; (d) The extent and nature of information to be disclosed; (e) A statement that the content is subject to revocation at any time except to the extent that action has already been taken in reliance thereon and a specified date, event or condition upon which the consent will expire without express revocation; and, (f) The date on which the consent is signed; (12) Documentation that the service recipient or someone legally acting on behalf of the service recipient has been informed of the service recipient’s rights and responsibilities and of the facility’s general rules affecting the service recipient; (13) A written account of all monies received or disbursed on behalf of the service recipient and a copy of the annual report on the use and disbursement of service recipient funds as required by 0940-05-06-.03(6); and (14) The service recipient’s record shall include a notation of any additional behavioral health providers the service recipient may concurrently see beyond the licensee and who the assigned case manager and/or social worker of the service recipient is, if applicable.