Chapter Participation Form | YPR - Young People In Recovery

Program*

Program Site*

GPRA Eligibility

I am seeking services for Opioid Use Disorder (OUD)

Opioids can include substances like heroin, methadone or other prescription drugs.

Name*

First Last

Date of Birth*

Phone

Email*

Enter Email Confirm Email

Contact Preference

Best Time of Day to Contact*

HIPAA Release

Date*

I hereby authorize Young People in Recovery and its affiliates, its employees and agents to collect my personal health information maintained by the referral site selected below (e.g., information relating to the diagnosis, treatment, claims payment, and health care services provided or to be provided to me and which identifies my name, address) except the following information about me:

I understand that any personal health information or other information released to the person or organization identified above may be subject to re-disclosure by such person/organization and may no longer be protected by applicable federal and state privacy laws. This authorization is valid from the date of my/my representative’s signature below. I understand that I have a right to revoke this authorization by providing written notice to Young People in Recovery. However, this authorization may not be revoked if Young People in Recovery, it’s employees or agents have taken action on this authorization prior to receiving my written notice. I also understand that I have a right to have a copy of this authorization. I further understand that this authorization is voluntary and that I may refuse to sign this authorization. My refusal to sign will not affect my eligibility for benefits or enrollment or payment for or coverage of services.

Consent*

I have read, understand and consent to the release of information.

Additional information on my rights can be found here.

Evalution Consent

Consent*

I understand all of the following information and consent to evaluation.

Young People in Recovery has explained the evaluation to you and answered all of your questions. You have been told the possible benefits and the potential risks and/or discomforts of the evaluation. You understand that you do not have to take part in this evaluation, and your refusal to participate or your decision to withdraw will involve no penalty or loss of rights or benefits. The evaluation personnel may choose to stop your participation at any time. You understand why the evaluation is being conducted and how it will be performed. You understand your rights as a evaluation participant and you voluntarily consent to participate in this evaluation. You have been told you will receive a copy of this form.

Submission

GPRA Completion*

I have completed the GPRA intake process

The GPRA can be completed at this site.

REDCAP ID*

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