Healthcare Jail-Based Program

HEALTHCARE JAIL-BASED PROGRAM CONSENT AND INTAKE

Participant Identification

Participant Name:

Emergency Contact

Insurance / Billing

Medical History

Program Description and Consent

I consent to participate in the Jail-Based Healthcare Program. I understand that program services may include medical assessment, medication management, nursing care, chronic disease management, mental health evaluation, substance use screening and counseling, case management, and discharge planning within the custodial setting.

I authorize healthcare staff to provide routine and emergency medical care as indicated. I acknowledge that all care provided will be in accordance with standard clinical practice and may involve diagnostic testing, medication administration, and coordination with custody staff.

I consent to evaluation and treatment by Jail-Based Healthcare Program clinicians, including administration of prescribed medications and routine procedures.

I consent to receive prescribed medications while in custody and understand doses will be administered by authorized clinical staff. I understand clinicians will document medications and may adjust therapy for safety.

Privacy, Information Sharing, and Limits

I acknowledge that my health information will be maintained according to applicable privacy standards but may be shared with custodial staff, program clinicians, and other health entities when necessary for my care, safety, or public health reporting. Information may also be shared for discharge planning and continuity of care with community providers and authorized representatives.

I understand there are limits to confidentiality including but not limited to mandatory reporting of imminent harm to self or others, abuse or neglect, and legal obligations. Such disclosures will be limited to the minimum necessary information.

I have received and read the Notice of Privacy Practices applicable to this program and understand how my health information may be used and disclosed.

I authorize the Jail-Based Healthcare Program to share my medical information with community healthcare providers, case managers, or substance use treatment programs for purposes of continuity of care upon release.

Risks, Benefits, and Voluntary Participation

The expected benefits of participation include assessment and treatment of medical and behavioral health needs, improved symptom management, and planning for continuity of care. Risks may include side effects of medications, discomfort from procedures or testing, and potential disclosure of health information as outlined above.

Participation is voluntary. I may withdraw consent at any time by notifying the healthcare clinician; withdrawal will not affect other services provided by the facility or my legal status. Withdrawal does not negate actions taken prior to the withdrawal that were reasonably relied upon.

Grievance and Complaints

I understand I may raise concerns about my care or privacy with Jail-Based Healthcare staff or through the facility grievance process. Complaints will be documented and addressed in accordance with applicable procedures.

Acknowledgment and Certification

By signing below I certify that I have had the opportunity to ask questions about the Jail-Based Healthcare Program, have received answers to my satisfaction, and voluntarily consent to participate as described. I further certify that the information I have provided on this form is accurate to the best of my knowledge.

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