Confidential Dhhs Restrictive Intervention Details Report

Confidential Dhhs Restrictive Intervention Details Report - North Carolina Page 4

North Carolina Department of Health & Human Services – Division of Mental Health/Developmental Disabilities/Substance Abuse Services

DHHS Restrictive Intervention Details Report

CONFIDENTIAL

Provider Agency Name

Consumer’s Name

Consumer’s Social Security No.

Page 4 Instructions: This page is available for the provider agency or any agencies receiving the report to use for internal tracking and follow-up

purposes. Leave this page blank when sending a report to the LME and/or other agencies..

RESTRICTIVE INTERVENTION FOLLOW-UP (for internal use only)

Report Receipt Date:

Current Consumer Status:

LME’s (or Other Oversight Agency’s) Response:

Name/title of follow-up staff person (Please print):

(

)

Phone

Signature ________________________________________________________

Date

Time

a.m.

p.m.

Notes:

Confidentiality of consumer information is protected under Federal regulations, 42 CFR Part 2 and HIPAA, 45 CFR Parts 160 & 164.

DMH/DD/SAS-Community Policy Management Section – Form QM04

Effective October, 2004 – Rev. 11/18/04

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Confidential Dhhs Restrictive Intervention Details Report - North Carolina Page 4