TGI Consent for Release (TGI_CR)

Jump to Section: 

Form Details

• Form Properties
  1. Form Title: TGI Consent for Release
  2. Start from an Existing Form – No
  3. Copyrighted Form – No
  4. Billable Progress Note – No
  5. Have multiple versions open at same time – Yes
  6. Open Blank on new version – Yes
• B. Required Fields – Yes
• C. Lookup Tables – Yes
  1. 2nd Details Tab → “Extent of Information” Table pulls from “Release Extent of Information” look-up table in Setup → Lookup Manager.
  2. 2nd Details Tab → “Purpose of the disclosure” Table pulls from “Release Purpose of Disclosure” look-up table in Setup → Lookup Manager.
• D. Pre-Fill Logic
  1. Release templates can be created in Administration à Form Manager à Setup Release button. These releases can be selected in the “Release Name” field in the form. This will fill both Details tabs and the non-signature fields on the Signature tab based on your template.
  2. If you choose to enter Agency Name on the 1st Details Tab that information can be pulled in from Other Organizations.
• Fill to Logic – None
• Signatures
  1. Signature of Client (2)
     • Sig type: Patient
     • Signature required to lock form.
  2. Signature of Parent, Guardian (if applicable)
     • Sig type: None
     • N/A checkbox is available.
     • Signature required to lock form.
  3. Counselor Signature (2)
     • Sig type: Any
     • Signature required to lock form.

[Back to Top]

1st Details Tab

1. Release Name – Can be populated from the lookup table generated from Other Organizations. If a selection is chosen from the list, the demographic information and contact name will populate. If the release is to a new person or organization, it can be manually typed into this box.
2. Select box to enter in Agency Name.
3. Enter demographics of organization or person in which you are releasing information to. You can enter up to five different organizations or persons.
4. Enter contact of person within the organization you are releasing information to.

[Back to Top]

2nd Details Tab

1. Choose the extent of information to be disclosed. Information comes from Lookup table: Release Extent of Information.
2. Text fields can be used to add any additional information that may be necessary.
3. Choose the purpose of need for such disclosures. Information comes from the Lookup table: Release Purpose of Disclosures.
4. Text fields can be used to add any additional information that may be necessary.

[Back to Top]

Signatures Tab

1. Optional to choose if the consent is set to expire.
2. Optional to select if additional information is required.
3. Signature of Client
   • Sig type: Patient
   • Signature required to lock form.
4. Signature of Parent, Guardian (if applicable)
   • Sig type: None
   • N/A checkbox is available.
   • Signature required to lock form.
5. Counselor Signature
   • Sig type: Any
   • Signature required to lock form.

[Back to Top]

Withdrawal of Consent Tab

1. Enter person(s) of organization(s) in which consent is being withdrawn.
2. Date of Original Authorization.
3. Signature of Client
   • Sig Type: Patient
4. Counselor Signature
   • Sig Type: Any

[Back to Top]