1. Consent for Treatment (COMAR & Medicaid Compliant)

I hereby voluntarily consent to receive behavioral health services from Grace & Mercy Community Services Inc. (GMCS). I understand that services are provided in accordance with COMAR and Maryland Medicaid (Carelon Behavioral Health) requirements.

I understand that I may consent to one or more of the above services, and that participation in services is voluntary. I understand services include assessment, diagnosis, treatment planning, rehabilitation, and coordination of care. Participation is voluntary, and I may withdraw consent at any time except where prohibited by law or clinical necessity.

2. Notice of Privacy Practices (HIPAA)

My protected health information (PHI) is handled in compliance with HIPAA (45 CFR Parts 160 and 164) and applicable Maryland laws. Information may be used or disclosed for treatment, payment, and healthcare operations. Disclosures without consent may occur for abuse reporting, emergencies, legal orders, or duty to warn.

I acknowledge receipt of the Notice of Privacy Practices.

3. Telehealth Consent (COMAR & Carelon Standards)

I consent to telehealth services delivered via secure HIPAA-compliant platforms. I understand risks including technology failure and confidentiality limitations. I may request in-person services at any time and may withdraw telehealth consent. I agree to provide my current location during each telehealth session. In emergencies, GMCS may contact emergency services or designated contacts. Telehealth may not be appropriate during crisis situations.

4. Carelon / Maryland Medicaid Authorization

I authorize GMCS to bill Medicaid/Carelon/my insurance and share necessary clinical and administrative information for authorization, billing, and compliance. I understand services must meet medical necessity criteria and documentation must comply with Medicaid standards.

5. Financial Responsibility & No-Show Policy

I understand services are billed to Medicaid/Carelon/my insurance; I agree to notify the agency of cancellations at least 24 hours in advance. Repeated no-shows may result in service discontinuation or discharge.

6. Grievance Policy (CARF Standard)

I have the right to file complaints without retaliation and to have grievances reviewed and resolved appropriately. I may escalate complaints internally or to regulatory bodies.

Maryland Grievance Contacts: Behavioral Health Administration (BHA): 410-402-8300 | https://health.maryland.gov/bha; Office of Health Care Quality (OHCQ): 410-402-8015

7. PRP Acknowledgment (DLA-20 & IRP)

I understand PRP services include DLA-20 assessments and Individual Rehabilitation Plans (IRP). I agree to participate in assessments and goal-setting. I understand progress will be monitored and documented regularly – weekly/monthly, or as need be.

8. Acknowledgment

I certify that I have read, understood, and agreed to all terms. I have had the opportunity to ask questions.

9. Audit Trail & Signature Verification

PARENT/LEGAL GUARDIAN CONSENT & AUTHORIZATION (FOR MINORS)

I, the undersigned, certify that I am the parent or legal guardian of the minor named below and have the legal authority to provide consent for treatment.

I hereby authorize Grace & Mercy Community Services Inc. (GMCS) to provide behavioral health services to the minor, including but not limited to assessment, diagnosis, treatment, rehabilitation services, and care coordination under the applicable programs (OMHC, PRP, OT, IOP, Community Housing, and Health Home, as appropriate).

• The minor’s participation in all recommended services and treatment planning activities
• Necessary communication and coordination of care between GMCS staff, healthcare providers, and authorized parties involved in the minor’s treatment
• The use and disclosure of the minor’s information as permitted under HIPAA, COMAR, and Maryland Medicaid (Carelon Behavioral Health) requirements

• Confidentiality protections apply, but may be limited in accordance with Maryland law, including situations involving:
  • Risk of harm to self or others
  • Suspected abuse or neglect
  • Legal or court-ordered disclosures
• Certain information may be shared with me as the parent/legal guardian, while some services may allow minors limited confidentiality rights under Maryland law

I acknowledge that I have had the opportunity to ask questions, and I voluntarily provide consent for the minor to receive services.