Healthcare TDT Pre-ISP

Healthcare TDT Pre-ISP

This Transdisciplinary Team (TDT) Pre-Individual Service Plan (Pre-ISP) assessment documents baseline information and authorization for participation in a coordinated team planning process. Participation is voluntary. Information collected is confidential and will be shared only with members of the TDT and authorized persons as described below. The signature at the end of this form indicates informed consent for assessment, discussion within the TDT, and limited release of information in accordance with the terms below.

Patient Information

Male Female Non-binary Other (specify below)

Emergency Contact

Insurance Information

Medical & Behavioral History

Pre-ISP Clinical Summary

Suicidal ideation/attempts Homicidal ideation/violence Self-harm Substance use concerns No current known risk

Supports, Preferences & Team Participation

Phone Email Text In-person

By checking the box below and signing this form, the patient or authorized representative consents to assessment, treatment planning, and exchange of relevant health and behavioral information among the TDT members identified above for the purpose of developing an Individual Service Plan (ISP) and coordinating services.

I authorize sharing of my protected health information with the TDT members and listed supports for care coordination and ISP development.

Proposed Services & Goals (Preliminary)

Authorization, Confidentiality & Legal Notices

I authorize the release and exchange of protected health information as necessary for evaluation, care coordination, billing, and treatment planning among the members of the Transdisciplinary Team and other providers listed herein. This authorization includes summary clinical information, risk assessments, treatment plans, and service progress notes pertinent to ISP development.

Limits to confidentiality: Information may be disclosed without my consent where required or permitted by law, including but not limited to reports of suspected abuse or neglect, imminent risk of harm to self or others, or as required by court order. Information disclosed prior to revocation may not be retrievable and will remain subject to the recipient's policies.

Right to withdraw: I understand I may revoke this authorization at any time by providing a written revocation to the treating provider or organization. Revocation will not apply to information already released in reliance on this authorization prior to receipt of the revocation.

Recording consent: I consent to audio/video recording of TDT meetings when necessary for clinical documentation.

Billing & insurance: I acknowledge that services recommended in the ISP may be billed to my insurance or third-party payers. Authorization for information exchange in this document may include data necessary for billing verification and claims.

Certification: I certify that the information provided on this form is true and complete to the best of my knowledge. I understand that signing below indicates my informed consent to participate in the Pre-ISP assessment and to permit the described information sharing with the TDT and authorized individuals.

Acknowledgment of Privacy Practices

By signing this form I acknowledge that I have been offered a notice describing the organization's privacy practices. I understand my rights regarding protected health information and that I may request restrictions on disclosure; however, the organization is not required to agree to requested restrictions.

I acknowledge receipt of privacy practices notice and understand my rights.

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