Consents and Referrals

Client Consent to Release Health Information

Consent is the process by which a client gives permission to a healthcare provider/business entity to share his/her treatment and service information with another provider/business entity or individual. This information may be shared for the purpose of treatment, continuity of care, payment for services, personal reasons, or other purposes as required by law and/or as requested by the client.

Clinical Management for Behavioral Health Services (CMBHS) provides Health and Human Services Commission (HHSC) service-contracted providers a place within a client’s record to document a client’s consent to share information. This includes who the information can be shared with, the types of information to be shared, the purpose for sharing, and how long it may be shared. The provider then prints the consent document and obtains the client’s signature.

The CMBHS system includes protections against the inappropriate disclosure of client health information. The real protection of client information, however, is in the hands of the providers who create client healthcare documents and receive documents from other providers.

Each provider must have policies and procedures in place that address the protection of client health information and a method of oversight to ensure that staff always adhere to those procedures.

In regard to the staff who have the responsibility for explaining consent to clients and obtaining client signatures on the CMBHS Client Consent for Release of Information forms, it is critical that they consistently and without bias explain all information to the client and/or the other legally authorized representative (LAR), and ensure that the client understands what he/she is signing.

 

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Create Consent

This section of CMBHS Online Help provides information about documenting consent in CMBHS for clients receiving substance use and mental health services.

Before protected healthcare information (PHI)/health care records can be released/disclosed to a third party, written consent from a client must be obtained and documented in CMBHS. There are a few exceptions to this rule, but this depends on many factors. These factors include, but are not limited to, the service type, client’s age, and legal status. 

If a provider/user has served a client and created health records for the client, the provider/user can always view those records — provided they are an active CMBHS user organization.

 

 

 

Consent for Release of Information

 Before You Start

• You must be assigned a CMBHS user role that allows you to utilize the Consent for Release of Client Information functions in CMBHS. Click here to view CMBHS Roles and their Read-Only and Read-Write Page Rights.
• The client must have a Client Profile in CMBHS.
• You must be in the client’s CMBHS record, at the Client Workspace, to create or revoke a Consent in CMBHS.
• Always verify that you have the correct person’s CMBHS record by checking the client’s name, at the top of the CMBHS page, and at least one other identifier before you begin.

 

Business Rules for Consent to Disclose Information

• An answer must be documented for each question on the Consent form. Some fields in the documentation are required, others are optional. Required fields are designated by a red * asterisk.
• For documents in Draft status or Ready for Review status, the staff/user can select the EDIT button and make changes.
• CMBHS will process the request only when all required data fields are complete, the client has signed, and the document is in Closed Complete status.
• No records are released to a third party until staff indicate in CMBHS that a paper consent form has been signed by the client and the CMBHS Consent document has been saved in Closed Complete status.
• Only documents in the client’s record that are in Closed Complete status are released.
• If the receiving organization (Disclosee) is a CMBHS-user organization, the information will be accessible as soon as the Consent is in Closed Complete status.
• If the receiving organization (Disclosee) is not a CMBHS user organization, the Consent is completed and stored in CMBHS, but any disclosure of information must take place using hard copy release or verbally.
• The releasing entity (Discloser) receives notice of the request on the Consent Request List, reviews the request, and approves or denies the release.

 

The Consent for Release of Health Information Page

The CMBHS Consent for Release of Health Information page is organized under nine sections:

• Provider Information
• Client Information
• Discloser
• Disclosee
• Expiration Date
• Health Information to be Disclosed
• Purpose of Authorization
• Signatures
• Status

The first two sections of the Client Consent for Release of Information are automatically filled in by CMBHS with provider and client information.

The remaining sections are to be completed by the staff/clinician based on information provided by the client and as appropriate to the situation.

 

How to Document Client Consent for Release of Information

To document a client’s Consent for Release of Information you must be in that individual's Client Workspace in CMBHS.

Log in to CMBHS. If needed, use Change Location under Account Management on the Administrative Toolbar to go to the CMBHS location where the client is being served.

 

From the Clinician’s Workspace

If you are at your Clinician’s Workspace, select a client from the Client List by CLICKING anywhere in the row so that the client’s name is highlighted. And then CLICK on the Client Workspace button to the bottom right of the list.

 

From the Client’s Workspace

If you are not at the client's Client Workspace, you will need to use the Find/Add Client function to locate the client in CMBHS.

If you are already in the Client Workspace, go to the Client Services Toolbar on the left side of the page and move your pointer over Consents & Referrals. A dropdown list will appear.

Point to Consent and then to Create Consent and CLICK on it.

The CMBHS Consent page will display. Some of the fields are pre-filled by CMBHS. Using the dropdown lists and check boxes, complete the required information in the following fields:

• Discloser (required dropdown list)
• Disclosure Check Box (Not required, but will help streamline the transfer of records if the provider ever merges with, takes over, or is taken over by another provider)
• Disclosee (required dropdown list)
• Expiration Date (free text date field)
• Health Information to be Disclosed (required check box options)
• Purpose of Authorization (required check box options)
• Signatures (check box functionality ‒ required)
• Status (dropdown functionality ‒ required)

Health Information to be Disclosed

This section (from the list above) has the following fields:

• All Records ‒ check box
• Records for Specific Dates ‒ check box
• Records Obtained from Other Providers ‒ check box
• Begin Date ‒ Date field ‒ manual entry
• End Date ‒ Date field ‒ manual entry

General Records

The system displays "General Records" segment, when "Records for Specific Dates" is selected by the user in the "Health Information to be Disclosed" section.

General Records section has three sub-sections.

Substance Use Records:

This subsection has an "All Records" check box and check boxes for the SUD health records.

Select “All Records” check box if all the SUD health records need to be released to the Disclosee location or go with the selection of specific SUD health records check boxes.

Mental Health Records:

This subsection has an "All Records" check box and check boxes for Mental Health records.

Select the "All Records" check box if all Mental Health records needed to be released to the Disclosee location or go with the selection of specific Mental Health records check boxes.

HCBS-AMH Health Records

This subsection has an "All Records" check box and check boxes for the Home and Community Behavioral Services-Adult Mental Health (HCBS-AMH) health reccords.

Select “All Records” check box, if all the HCBS-AMH health records need to be released to the Disclosee location or go with the selection of specific HCBS-AMH health records check boxes.

   

Business Rules for “All Records” check box:

When the user selects the “All Records” check box in any of the sub- record sections (SUD/MH/HCBS-AMH), then the system must attach all the available records created at that business entity/location type for release after the document is in closed complete status.

When the user selects the “All Records” check box in any of the sub- record sections (SUD/MH/HCBS-AMH) of “General Records,” then the system should automatically check all the check boxes of the documents in that specific section. However, the system will also provide an option to the user to unselect the document check boxes, if not needed.

When the user is not selecting the “All Records” check box in any of the sub-record sections (SUD/MH/HCBS-AMH) of “General Records,” then the user will have an option to select individual document check boxes in that specific section (SUD/MH/HCBS-AMH) (depending on the needs of the user).

When the user has selected the “All Records” check box in any of the sub-record sections (SUD/MH/HCBS-AMH), and if the user is unselecting any document check boxes on the right pane of that specific section, then the system will automatically uncheck the “All Records” check box in that particular section. When the user double clicks the selected “All Records” in any of the sub-record sections, then the system must uncheck the selected check boxes of the documents.

When the user has selected the check boxes of all the documents in any of the sections, then the system should automatically select “All Records” check box in the specific section.

Purpose of Authorization Section

This section allows the client or LAR to identify the purposes for which records may be shared.

Select one or more options from the seven check boxes. The Purpose of Authorization section has the following check boxes:

• Consent for Eligibility and Determination
• Continuity of Care
• Criminal Justice Purpose
• Health Oversight Activities
• Other
• Payment for my services from a third-party payor
• Referral to another program or provider

 

Signatures Section

1. The signature section allows the staff/clinician to record information about the signatures provided as part of the Consent process.
2. When the client signs the Consent form, the Client Signed check box at the bottom of the section should be selected. The staff/clinician should record the date the Consent was signed by the client.
3. The Signature Date on the Consent form will show today’s date but you can change the date to a past date. The date must be no more than seven days in the past. The date cannot be a future date.
4. Without the client's or LAR's signature date, the Consent cannot be Saved in Closed Complete status.
5. When the staff/clinician saves the document using the Save button, the Consent will be forwarded to the appropriate parties.
6. If Cancel is selected, the Consent will be abandoned after a message appears reminding the user that the form will not be saved and any data will be lost.
7. The check box PARTY OTHER THAN THE CLIENT IS SIGNING THE AUTHORIZATION should be checked if a person other than the client is signing the form. A person legally authorized to sign on behalf of a client is a legally authorized representative (LAR).
8. When this check box is checked, a dropdown list containing the name of persons who may be legally authorized to sign for the client, if any, will display.

The name of the legally authorized representative (LAR) is auto-filled from the Client Profile, Contact tab. If no names appear and a legally authorized representative has been designated for the client, the staff/clinician should save the authorization using the Save button with the document in Draft status, proceed to the Client Profile, Contact tab, and add the individual as the LAR.

When LAR is selected as the person signing, the name and relationship will appear at the bottom of the section with a check box labeled “signed.” When the document is signed, the check box should be selected (it will change to Signature Date and the Date the document was signed entered in mm/dd/yyyy format).

 

Audit Information

After the document has been saved, the following Audit Information will show at the bottom of the page. This information is view only and cannot be changed by the user.

• Created By – The name of the user that first started the document will display here.
• Created Date – This is the date the document was first started.
• Last Saved By – The name of the user that last opened, edited, and saved the document will display here. This field is updated each time the record is edited
  and saved.
• Last Saved Date – The date the document was last opened, edited and saved. This field is updated each time the record is edited and saved.

 

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Revoking Consent        

This section of the Clinical Management for Behavioral Health Services (CMBHS) Online Help provides information about revoking a consent for release of protected healthcare information in CMBHS for clients receiving substance use and mental health services.

Consistent with state and federal laws related to protected healthcare information (PHI), a person who gives consent for the release of his/her records may revoke that consent at any time.

 

 

How to Revoke Consent for Release of Healthcare Information

1. If you are already in the Client Workspace for the client, go to the menu on the left side of the page and move your mouse pointer over Consent & Referrals.
2. A popup menu will appear. Scroll over to Consent and then Revoke Consent, and CLICK on it. The page will refresh with a header titled Revoke Consent.
3. A list of existing Consents for the client will appear, showing the discloser, the disclosee, the date the consent was signed, a reference number, and checkboxes in a Select Consent column.
4. The staff/clinician should check each box in the Select Consent column for Consents to be revoked.
5. In the SIGNATURES section, the party authorizing the revocation should be indicated (either a party other than the client, or the client. One of the two options is required).
6. If a Party other than the client is selected, additional field choices will appear. A dropdown list containing authorized parties from the client profile contact list will be provided. When an authorized representative is selected, an additional field will appear, allowing the staff/clinician to record that the representative has signed
   the document.
7. If the client signed box is selected, the staff/clinician should record the date the client signed the Revocation. The date field is automatically populated with
   today’s date.
8. When the Revocation signed by the client is Saved, consent to disclose further information is withdrawn and no new information can be shared between the two organizations. Be sure to explain to the client that the revocation of consent does not apply to information already shared or actions taken while the consent was
   in effect.

 

 

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Making Referrals

The Texas Health and Human Services Commission (HHSC) Clinical Management for Behavioral Health Services (CMBHS) system referral function allows a provider to document a client referral and, if the receiving business entity is also a CMBHS user, to transmit the referral electronically. The referral is displayed on the receiving entity’s CMBHS Referral Administrative Action List, where it can be viewed and the appropriate action taken.

When the business entity to receive the client referral is not a CMBHS user, referrals can still be documented in CMBHS, stored in the client’s CMBHS health record, and follow-up information documented. The referral can then be printed and sent to the receiving entity using standard processes (fax, mail, or email) and provided to the client and/or family.

For some business entities contracting with HHSC, client follow-through with referrals is one of the methods used by HHSC to evaluate performance.

 

Before You Start

Referrals can only be documented in CMBHS from a CMBHS service delivery location level, not from the administrative (parent) level of your organization.

To use the Referral function, you must be assigned a CMBHS role that permits documenting and/or viewing of referrals. To view a list of CMBHS Page Rights according to Roles, click here.

 

• The client to be referred must have, at minimum, a Client Profile completed in CMBHS.
• You must be in the client’s CMBHS health record, at the Client Workspace, to document a Referral.
• Always verify that you have the correct client by checking the client’s name and at least one other identifier at the top of the page before you begin.
• Before you make a referral for a client, be sure that an Authorization to Release Client Records is in place if it is required.

 

General Business Rules for Referrals

• Referrals can only be documented in CMBHS from a CMBHS service delivery location level, not from the administrative (parent) level of your organization.
• A CMBHS Referral cannot be saved until all required fields have been completed. There is no Draft status for Referrals. Once the Referral is saved, it cannot be edited.
• CMBHS will check the client’s health record to determine whether or not a Consent to Release Client Records is required.
• If a Consent to Release Client Records is required, an appropriate Consent to Release Client Records must be completed in CMBHS. Appropriate means for the correct client, with correct dates, matching the business entity creating the referral, and the business entity to receive the referral, and not expired or revoked.
• CMBHS will not transmit the Referral until a Consent to Release Client Records is in place if it is required. You will receive a message indicating that the Consent has not been completed and the Referral will be maintained in Pending Status.
• If the required Consent to Release Client Records already exists in CMBHS, then CMBHS will transmit the Referral as soon as it is Saved in Closed Complete status.
• If the Consent does not already exist, CMBHS will transmit the Referral as soon as the matching Consent is Saved in Closed Complete status.

 

Referral from a CMBHS Provider to another CMBHS Provider – Business Rules

When a substance use services provider is referring a client to another CMBHS provider, CMBHS will check the client’s health record to determine whether or not a Consent to Release Client Records is required. If it is required, CMBHS will automatically display the message: “This Referral will be saved in pending status until there is an Consent to Release Client Records allowing release of referral information.”

• If the required Consent to Release Client Records already exists in CMBHS, then CMBHS will transmit the Referral as soon as it is saved in Closed Complete status.
• If the Consent does not already exist, CMBHS will transmit the Referral as soon as the matching Consent is saved in Closed Complete status.
• CMBHS will not transmit the Referral until a required Consent to Release Client Records is in place.

 

Referral from a CMBHS Provider to a non-CMBHS Provider -
Business Rules

When a substance use provider is referring a client to a non-CMBHS provider, CMBHS will automatically display this message to the substance use provider: “If confidential information is being released, make sure there is a Consent to release health care records.”

CMBHS cannot prevent the release of records in this instance, since the records will be released to the non-CMBHS business entity using a method other than electronic transmission by CMBHS.

 

How to Document a Referral

1. To document a Referral for a client, go to that client’s Client Workspace.
2. Go to the Client Services Toolbar on your left and select Consents & Referrals. A dropdown menu will appear. CLICK on the Referral tab.
3. The Referral page will display.
4. Fill in the required information to document a client referral to an outside provider or agency.
5. Save the document in Closed Complete.

 

Data Fields

The Client Date of Birth (DOB) is pre-filled from an earlier assessment. The Referral Date, required, will set to today’s date. This can be changed to a past or future date. When you enter the date you must enter the full date in either of the following two formats: mmddyyyy (and the system will format) or mm/dd/yyyy.

• If you select a CMBHS provider from the list as the Receiving Provider, CMBHS will display that provider’s location and contact details below the dropdown list. The information is view-only. The user cannot change it.

OR

• If you select Non-CMBHS Entity as the receiving provider, CMBHS will display multiple text boxes for you to Type in the Non-CMBHS Entity’s Name, Address, and Contact Number.

 

Referral Type (Required)

You can select more than one answer choice.

Highlight your selections and CLICK on the arrow to move them from the box on the left to the box on the right.

The answer choices are:

• Employment/Education Services
• Financial Assistance
• Household Assistance (food, clothing, utilities)
• LTSS
• Legal Assistance
• Medical/Health Services
• Mental Health Treatment (Inpatient)
• Mental Health treatment (Outpatient)
• Other
• Recovery Support Services
• Services for Family
• Substance Use Treatment
• Substance Use Treatment - MOUD

If you select Other Referral Type, you must TYPE additional information in the text box. You may enter up to 55 letters and/or numbers to explain the purpose of the referral.

 

Referred By (Required)

This field will be pre-filled with your name. This field represents the name of the person who is authorized to make Referrals by your agency and is making
this referral.

• The user’s name can be changed by selecting another name from the dropdown list. The names that display on the dropdown list are staff authorized to make referrals at that location.
• CLICK on the down arrow to display the answer choices.
• Select the name by CLICKING on it.
• Enter the Appointment Date and Appointment Time. Past and future dates may be entered.

Click Yes or No, concerning if a follow-up is required. Enter any Comments in the text box. Indicate if follow-up by the referring provider (you or someone else at your location) is required for clinical reasons, by law or contract, or by your agency’s policies and procedures.

 

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Referrals List

When a Clinical Management for Behavioral Health Services (CMBHS) substance use disorder services organization receives a client referral from another CMBHS user organization, the referral is displayed on the receiving organization’s Referrals list. From the Referrals list, the provider can see the referral, document and send a response back to the referring organization, and delete the referral from the list after it has been appropriately addressed.

In CMBHS, the Referrals list is found on the Administrative Toolbar at the top of each page of CMBHS, in Provider Tools > Administrative Action Lists > Referrals. The Referrals page will display. 

Before You Start

All CMBHS substance use service locations can make and receive client referrals and view the Referral List.

If a Consent for Release of Client Information is required by law, contract, or policy as part of the referral process, the Consent must be in Closed Complete status in the client’s CMBHS record before the referring entity can send the Referral to the receiving entity.

To view or use the Referral List, a user must be assigned a role that permits access to the list.

Click here to view tables of all CMBHS pages and what roles have Read-Only or Read-Write access to the pages.

 

How to Use the Referrals List

After opening the Referrals List page, if there have been no referrals to your business entity, “No Records Found” will display in the table.

If there have been Referrals, they will be listed in the table. You can search the Referrals list for a specific Referral, view a Referral, and delete a Referral.

 

How to Search the Referrals List for a Referral

Three of the column headers are data fields completed by the referring provider: Date, Client Name, and Referring Business Entity. These headers are in blue text, bold, and underlined, indicating that they can be used to sort the information in
the table.

You may sort the Referrals in the table by CLICKING on any of the column headers. The column headers are:

• Date (View only) – This is the date the referral was made by the referring provider.
• Client Name (View only) – The full Name of the client for whom the referral is made.
• Referring Business Entity (Provider) (View only) – This is the name of the business entity (provider) that is referring the client (sending the referral on the client’s behalf).

 

How to View a Referral

Pick the Referral you want to view by CLICKING on the View link at the end of that row.

This will open the client’s Referral page.

 

How to Delete a Referral

• To use the Delete function, CLICK in the checkbox before the word Select for the client whose referral is to be deleted from the list.
• Then CLICK on the Delete Selected button at the top of the page.
• Remember, this deletes a Referral so that it no longer displays on the list, but it remains in the client record and can be seen from the Client Workspace, Client Document List.
• If you want to delete all the Referrals that display on a page, CLICK in the
  Select All box at the top of the list.
• Check marks will display in all the selection boxes on that page.
• Then CLICK on Delete Selected.
• All Referrals that have been selected will be deleted from the list.

 

What’s Next?

After you have documented the Referral Action, you can use the Buttons at the top of the page to do the following:

• Close the list – This function closes the Referrals list page and returns you to your Clinician Workspace or other designated home page. To close, CLICK on the Close button.
• Print the list – This function turns the page into a PDF file and prints the page. To Print, CLICK on the Print button at the top or bottom of the page.

SHSDP Referral form

State Hospital Step Down Referral Form

• Create a referral form that state hospitals can use to express interest in a State Hospital-Step Down Program (SHSDP) program.
• The provider for the Local Behavioral Health Authority and Local Mental Health Authority can update it when the patient is admitted to the step-down project.
• This report will be used by the program to keep track of participants and report on necessary statistics.

How to Use the State Stepdown referral form

Once reaching the appropriate client profile location, there will be an option on the left side navigation menu for SHSDP Referral Form.

The form has five sections.

• Step Down Referral Form – This includes demographics information, commitment status dropdown with options to choose, LAR dropdown with options to choose and Home Preference options.
• Current medical status – This includes the basic clinical details like diagnosis, treatment, medications, list of allergies and activities of daily living informations.
• Current Psychiatric Status – This includes details pertaining to Psychiatric evaluations and diagnosis within the last three months.
• Substance Abuse Treatment History – This includes a wide range of substance of choices check-box to select.
• Admission Decision Section – This tracks the decision related details and communications between a Requestor, Reviewer and Approver with appropriate comments for audit trail purposes. The Requestor/Reviewer/Approver is a role driven functionality. Once the form is approved by the Approver, the status of the form will be displayed to the Requestor at their respective location.

1. 1. Requestor : This role should also have the ability to enter a diagnosis (Diagnosis page access required). Please ensure that the diagnosis (ICD 10) selection is possible for this role to enter a diagnosis and mark it to a close complete status.  the diagnosis document.
   2. Reviewer : This role should also have the ability to review the form, edit, mark it in draft, review & close complete status.
   3. Approver : This role will be the final person to approve and hence will need the ability to Approve and mark the document status to either Draft, Ready for Review or Closed Complete.  

• Document Status – Appropriate document status eg: “Close Complete” etc.. is captured with date.