Center for Child & Family Health*
411 W. Chapel Hill St. Suite 908, Durham, NC 27701
(919) 419-3474
YOUR RIGHTS AND RESPONSIBILITIES
When you receive services at the Center for Child & Family Health (CCFH), you have certain rights and responsibilities. This handout will tell you about your rights and responsibilities and will tell you what to do if you have questions or problems regarding those rights and responsibilities. We are committed to respecting your rights and facilitating your understanding of your responsibilities as a partner in the treatment process.
Your Rights:
o You have the right to dignity, privacy, humane care, and freedom from discrimination, physical punishment, abuse, neglect and exploitation.
o You have a right to live as normally as possible while receiving care and treatment at CCFH.
o You have a right to receive high quality care, services, and treatment based on a plan written especially for you. Your plan must be implemented at the first therapy appointment and it should help you to regain or increase your level of functioning.
o Before you agree to your treatment plan, you will be informed of the benefits or risk involved in the services you will receive. You may receive a copy of your treatment plan upon request.
o While you are receiving services at CCFH, you have a right to be free from unnecessary or excessive medication of any kind. You have a right to not have medication used as a punishment, for discipline, or for the convenience of staff.
o You cannot be treated with electric shock therapy, experimental drugs or procedures without your written permission.
o If you have asked to receive services, you always have the right to agree to or refuse any specific treatment. The ONLY time you can be treated without your consent is: in an emergency; if your treatment has been ordered by the court; when more than one professional agrees that you need that specific treatment in order to improve your condition; to prevent harm to yourself or others; or if you are under 18 years old, your parent(s)/legal guardian(s) can give permission even if you object.
o Physical restraints or seclusion may not be used by CCFH staff.
o The fact that you are receiving services, or any other information about your care, is
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confidential. You have a right to see the information in your own record, unless more than one professional determines that it would be harmful for you to have it.
o In general, under state and federal laws, no one can share information with another about the services you receive. These same laws, however, require us to share information with others under the following conditions:
1. Your next of kin may be informed that you are a client if it is in your best interest; and if you are under 18, your parents may be informed about your care when it is in your best interest and not considered to be harmful;
2. With your permission, your next of kin, or a family member with a legitimate role in your service, or another person who you name may be given information about your care;
3. If you have a Guardian Ad Litem (GAL) working on your behalf, that advocate may review your record without your consent.
Appeals to any change in services/Customer complaints:
Before anyone can change your service or deny your request for a service, you will receive a notice explaining your rights. You have a right to appeal any changes to the services you already receive or any services you and your service provider have requested to receive. The way you appeal the changes depends on how your services are funded:
o If Medicaid pays for your services, you may appeal the changes through the Division of Medical Assistance. Follow the directions in the written letter for your federal rights. If you appeal the decision by the deadline in the letter, your services will continue during the appeal.
o If your services are paid for by state funds (sometimes called IPRS funds), you may appeal the decision to the local management entity (LME). If you still are unsatisfied with what the LME decides, you may appeal to the North Carolina Division of Mental Health, Developmental Disabilities and Substance Abuse Services (NCDMH/DD/SAS) to review the decision. Your services may or may not continue while you are appealing this decision.
o If your private insurance company pays for your services you can appeal the decision directly through your particular insurance company.
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If you are unsure how to appeal changes to your services or if you have questions about appeals, contact your LME customer service office. You can also contact the Advocacy and Customer Service Section at the NCDMH/DD/SAS at (919) 715-3197. For all appeals, call the number on your appeal notice.
CCFH staff strive to resolve complaints as quickly as possible. If, however, you are unable to resolve your matter with CCFH staff, below are additional resources that are available to you:
If you live within Durham County:
Alliance Behavioral Healthcare Customer Services:
1-800-510-9132
If you live outside of Durham County:
Department of Health and Human Services (DHHS) Toll-free CARE-LINE:
(24 hours a day, every day)
1-800-662-7030 (English & Spanish) or
TTY 1-877-452-2514 (for the hearing impaired)
Additionally, the North Carolina Division of Mental Health, Developmental Disabilities and Substance Abuse Services (NCDMH/DD/SAS) Advocacy and Customer Services Section is available to assist you:
Call them at:
(919) 715-3197
Mon-Fri. (8am-5pm)
(919) 715-1968 (TTY)
Write to them at:
NC Division of MH/DD/SAS, Advocacy and Customer Services Section
3009 Mail Service Center
Raleigh, North Carolina 27699-3009
Email them at:
Visit their website:
http://www.ncdhhs.gov/mhddsas/services/advocacyandcustomerservice
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Your Responsibilities:
o You have the responsibility to provide as much information as possible about your health, medical history, and insurance benefits.
o It is your responsibility to pay your bill in full at each appointment. If you are having financial difficulty, it is your responsibility to notify the business office so that arrangements can be considered.
o It is your responsibility to tell us about any other care you are receiving and about medicines you are taking. Typically, clients receiving enhanced mental health services (such as Intensive In Home or Day Treatment Services) are not eligible for outpatient therapy at the same time. Please bring all bottles of medicine you are taking now to your first visit with our clinician(s), and update us about any medication changes your doctor makes while you are receiving services here.
o You have the responsibility to keep appointments and follow through with service plan responsibilities that are a part of the plan for your care. Please call us as soon as you know you cannot keep an appointment, and we will reschedule. CCFH reserves the right to charge an administrative fee, when lawful to do so, for appointments that are not canceled with at least 24 hours notice.
o It is your responsibility to tell us if your name, address, or telephone number changes. We also need to know who to contact in case there is an emergency.
o Each time you come to see us you should bring your Medicaid or insurance card – please let us know if there have been any recent changes. Due to possible insurance benefit changes, we will be better able to serve you if you always have your card with you. You are responsible for making arrangements to pay your bills, and we are happy to answer any billing questions you may have.
o It is your responsibility to treat staff and others here with respect and consideration. You are also responsible for respecting other clients’ rights and their confidentiality.
o You must not bring weapons, illegal drugs, or alcohol here. You are responsible for making sure that people who come here with you do not bring these items either.
o You are responsible for providing supervision for your child while at CCFH. If you are here for your child’s initial assessment, and your child is under the age of 6 or if you bring any other children under the age of 6, another adult needs to accompany you to supervise your child(ren) in the waiting area while you are interviewed.
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I have received written information about my rights and responsibilities (pages 1-4 of this form) and understand my rights and responsibilities as a client/parent/legal guardian at the Center for Child & Family Health.
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Client Name Client Medicaid # CCFH #
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Client/Parent/Legal Guardian Signature Date
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Witness Signature Date
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Rev. 7/13/12
*A consortium of Duke University, North Carolina Central University, the
University of North Carolina Chapel Hill, Child & Parent Support Services,
& the community.