EMPOWER  |  SUPPORT  |  INSPIRE

CONSENT FORM 

ACKNOWLEDGEMENT STATEMENTS 

1. Consent to Treatment

I voluntarily consent to receive services from Pathways to Self-Reliance, Inc. ("Pathways"). Services may include screening and assessment, peer support, counseling, care coordination, recovery housing support, transportation, and related recovery services. I understand that participation is voluntary, that staff will explain the purpose, expected benefits, and any risks of services offered to me, and that I may ask questions, refuse any service, or withdraw my consent at any time. I understand no specific outcome or result has been promised or guaranteed.

2. Authorization to Bill Insurance & Assignment of Benefits

I authorize Pathways to release the information necessary to my health plan, Medicaid, managed care organization, or other payer for purposes of eligibility verification, prior authorization, claims submission, appeals, and payment. I assign all applicable benefits directly to Pathways and authorize payment to be made directly to Pathways. I understand I am financially responsible for copayments, coinsurance, deductibles, and any services not covered by my plan.

3. Acknowledgment of Notice of Privacy Practices (HIPAA)

I acknowledge that I have been provided with, or offered a copy of, Pathways' Notice of Privacy Practices, which explains how my protected health information (PHI) may be used and disclosed and describes my rights — including the right to inspect and receive a copy of my record, request an amendment, request restrictions on disclosures, request confidential communications, receive an accounting of certain disclosures, and file a complaint with Pathways or with the U.S. Department of Health and Human Services, Office for Civil Rights, without retaliation.

4. Disclosure — Limits of Confidentiality

I understand that Pathways may use and disclose my information without additional authorization for treatment, payment, and health care operations. I further understand that records relating to substance use disorder services are additionally protected under federal law (42 CFR Part 2) and generally may not be redisclosed without my specific written consent. However, my information may be disclosed without my consent in the following circumstances permitted or required by law:

• Suspected abuse, neglect, or exploitation of a child, a disabled adult, or an older adult (North Carolina law requires reporting)

• A serious and imminent threat of harm to myself or an identifiable other person

• A medical emergency where treatment is needed immediately

• A valid court order, or a subpoena accompanied by the authority required by law

• Audits, program evaluation, licensure, accreditation, or oversight activities

• A crime committed on Pathways' premises or against Pathways' staff

• Reporting required by federal or state law, including certain communicable disease and public health reporting

5. Communication Consent

I give Pathways permission to contact me at the phone number(s), email, and address I provide, including leaving voicemail, text, or email messages regarding appointments and services. I understand that text and email are not fully secure and that I may withdraw this permission in writing at any time.

6. Signature

I have read this form, or had it read to me, in a language I understand. I have had the opportunity to ask questions, and my questions have been answered. I understand this consent remains in effect while I am receiving services and that I may revoke it in writing at any time, except to the extent action has already been taken in reliance on it. 

FOR NC PROBLEM GAMBLING SERVICES

When contacting NC Problem Gambling Services, please request Crystal Graham as your provider.

Referrals are assigned by request, so be sure to state her name when you call.

• Text the phrase "morethanagamenc" to 53342

• Call 877-713-5543

• Visit morethanagame.nc.gov