1. (a) Providers must maintain copies of disclosure forms signed by the client, or by the client’s parent or guardian, before outpatient behavioral health services are delivered, except in emergencies.

2. (b) Such forms must, at a minimum:

   1. (1) Disclose that the services to be provided are outpatient behavioral health services;
   2. (2) Explain outpatient behavioral health services eligibility, SED, and SMI criteria;
   3. (3) Contain a brief description of the behavioral health agency services;
   4. (4) Explain that all outpatient behavioral health services care must be medically necessary;
   5. (5) Disclose that third-party (e.g., Medicaid or insurance) outpatient behavioral health service payments may be denied based on the third-party payer’s policies or rules;
   6. (6) Identify and define any services to be offered or provided in addition to those offered by the behavioral health agency, state whether there will be a charge for such services, and, if so, document payment arrangements;
   7. (7) Notify that services may be discontinued by the client at any time;
   8. (8) Offer to provide copies of behavioral health agency and outpatient behavioral health services rules;
   9. (9) Provide and explain contact information for making complaints to the provider regarding care delivery, discrimination, or any other dissatisfaction with care provided by the behavioral health agency; and
   10. (10) Provide and explain contact information for making complaints to state and federal agencies that enforce compliance under 20 CAR § 706-103(6).

Codification Notes: “SED” means serious emotional disturbance. "SMI" means serious mental illness.