Renaissance Ranch Ogden Consent to Follow Up After Services

  • We are wanting to measure the quality of service that we have provided here at Renaissance Ranch to our patients. This particular information is important to help improve the services we offer to you and the recovery community.
    This information will be collected within 30 days of you having been discharged or graduating from Renaissance Ranch. We would appreciate your cooperation in improving our services. Your opinion matters to us. You are not required to participate in this survey and can withdraw from this survey at anytime. You will not be denied from receiving further services from Renaissance Ranch R such as After care or returning to the program if you feel the need.
    Please be assured we care about your confidentiality, and by participating in this survey it will not be compromised in any way. If you have any questions concerning this survey, please fell free to speak with a staff member.
    I give consent to be contacted after graduating or discharging from Renaissance Ranch within 30-days to participate in this followup survey. I know that I do not have to participate if I so choose not to. I also understand that any information I give after being discharged is still protected under the Federal Confidentiality Regulations (42 DFR part 8)
    The following notice will Accompany Any Disclosure

    This information has been disclosed to you from records protected by Federal Confidentiality rules (42 CFR part 2)
    The Federal rule prohibits you of making any further disclosure of this information unless further disclosure is expressly permitted by 42 CFR part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute an alcohol or drug patient.
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