HomeMy WebLinkAboutAgenda - 05-17-2011- 5uORANGE COUNTY
BOARD OF COMMISSIONERS
ACTION AGENDA ITEM ABSTRACT
Meeting Date: May 17, 2011
Action Agenda
Item No. J - U
SUBJECT: OPC Area Program -Partnership Proposed with Piedmont Behavioral Health
LME (Medicaid Waiver Expansion)
DEPARTMENT: County Manager's Office PUBLIC HEARING: (Y/N) No
ATTACHMENT(S):
A. Update Summary
B. Frequently Asked Questions
C. Public Information Efforts
INFORMATION CONTACT
Gwen Harvey, Asst Co. Mgr, 245 -2307
Judy Truitt, OPC/LME Director,
913-4037
PURPOSE: To authorize the Orange-Person-Chatham (OPC) Local Management Entity (LME)
to undertake formal merger negotiations with Piedmont Behavioral Health according to State
policies and statutes regarding 1915 (b) (c) Medicaid waiver expansion.
BACKGROUND: OPC is the local governmental agency with responsibility for oversight and
management of publicly-funded mental health, developmental disability, and substance abuse
services in Orange, Person and Chatham counties. OPC provides screening, triage and referral
for individuals needing services in the area; recruits and monitors an array of community service
providers; and manages the distribution of state monies for services to consumers. OPC is
governed by an Area Board comprised of one county commissioner from each of the three
counties and the three county commissions appointing remaining board members, which
exercises the powers and duties conferred by the North Carolina General Assembly.
OPC was approached in February 2010 by Piedmont Behavioral Health (PBH), the LME
currently operating under a successful 1915 (b) (c) Medicaid waiver pilot project, about the
possibility of forming an alliance. PBH currently serves Cabarrus, Davidson, Rowan, Stanly,
and Union counties. The Medicaid waiver is an agreement between the state and the Center
for Medicaid Services to be released from certain Medicaid rules. Waivers are used to improve
access to and quality of services and manage costs.
Preliminary negotiations for an OPC-PBH alliance were authorized, commenced, and paused
while sanction for LME waiver expansion gained support in the General Assembly. On March
31, 2011 the Department of Health and Human Services (DHHS) issued its final Request for
Applications (RFA) to allow statewide Medicaid waiver expansion under the model created by
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PBH. Applications must be received by May 20 2011. Following continued assessment by
OPC management with extensive discussion by the OPC Board, the vote was unanimous to
seek authorization from the three boards of county commissioners to re-engage in negotiations
to merge with PBH.
On April 18, 2011 the Person County Board of Commissioners and the Chatham County Board
of Commissioners each reviewed and approved the OPC Board recommendation to pursue
negotiations to merge with PBH.
The Orange County Board of Commissioners received an updated report from OPC LME
Director Judy Truitt in work session on May 10th. Ms. Truitt provided a summary of events and
responded to questions. Note that OPC, along with the Five County and Alamance-Caswell
LMEs are each petitioning the State to merge with PBH. Their addition, if approved by their
boards of county commissioners and subsequently the State, would enable PBH to encompass
a total population of 1,390,224, with 193,391 Medicaid eligible individuals (3 years of age and
older). Below is the specific breakdown of each county within the proposed expansion of PBH:
PBH member counties: Cabarrus, Davidson, Rowan, Stanly & Union
Total population: 744,402 (including birth to 3) 714,749 (excluding birth to 3)
Medicaid eligible individuals: 96,558 (excluding birth to 3)
Five County member counties: Vance, Franklin, Warren, Granville & Halifax
Total population: 236,449 (including birth to 3) 227,760 (excluding birth to 3)
Medicaid eligible individuals: 48,831 (excluding birth to 3)
Alamance Caswell member counties: Alamance & Caswell
Total population: 173,713 (including birth to 3) 167,138 (excluding birth to 3)
Medicaid eligible individuals: 25,630 (excluding birth to 3)
OPC member counties: Orange, Person & Chatham
Total population: 235,660 (including birth to 3) 227,963 (excluding birth to 3)
Medicaid eligible individuals: 22,372 (excluding birth to 3)
Attachment A provides a summary update from OPC including DHHS parameters guiding
waiver expansion and working partnerships. Attachment B is a Frequently Asked Questions
document on the possibility of OPC joining PBH. Attachment C outlines additional steps
underway by OPC to inform and involve consumers, families and community at-large on merger
potential
FINANCIAL IMPACT: There is no financial impact associated with authorizing formal merger
negotiations between OPC and PBH.
RECOMMENDATION(S): The Manager recommends the Board authorize merger negotiations
between OPC and PBH in accordance with State sanctioned 1915 (b) (c) Medicaid waiver
expansion.
A$cc~+.,~.~-~
SUBJECT: OPC Area Program Update -April 2011
PURPOSE: To receive a report on the expansion of the 1915(b)(c) Medicaid waiver &
the expected impact on the mental health, developmental disabilities & substance abuse
service system in Orange, Person & Chatham Counties.
BACKGROUND: On March 31, 2011 the Department of Health 8~ Human Services
(DHHS) released an RFA for the expansion of the 1915(b)(c) Medicaid waiver, which will
have significant impact on the organizational structure and governance of the existing
system.
HISTORICAL INFORMATION: House Bill 381, passed in October 2001, outlined a
major transformation of the public mental health system. Guiding principles included:
• Greater choice for consumers
• No wrong door for admission to services
• Services provided in the local communities
• Greater involvement by both consumers and the provider community
• State wide standardization and accountability
• Focused shift to best practice and evidence-based treatment
• Separation of management oversight from the provision of service
In response to the new legislation OPC initiated divestiture of service programs in
December 2003 and began its transition to a Local Management Entity (LME) with
responsibility for:
• screening, triage & referral for consumers entering the service system;
• authorization of all state and/or locally funded services;
• endorsement and monitoring of a comprehensive provider network;
• customer service and community planning for our three county region.
In 2007 the North Carolina General Assembly passed legislation that required that LMEs
have a total population of 200,000+ or cover a geographic region of six or more
counties. With a total population of 227,963 OPC is the fourth smallest LME in the state.
As noted above LMEs were given responsibility for management of state and locally
funded services, while management of Medicaid funded services was given to Value
Options, a private for-profit vendor. This remained true until April 2005 when DHHS
began operating a pilot project which allowed Medicaid funded services for mental
health, developmental disabilities and substance abuse treatment to be provided on a
capitation basis through a 1915(b)(c) combination waiver at PBH, the LME which covers
Cabarrus, Davidson, Rowan, Stanly ~ Union counties. This pilot project has been
successful and DHHS has made the decision to move forward with statewide expansion
of the 1915(b)(c) waiver.
What is a 1915(b)(c) Medicaid waiver? In 1965 amendments to the Social Security
Act (SSA) established the Medicaid program. Under the Medicaid program each state
establishes its own eligibility standards, benefits packages, payment rates, and program
administration. The Social Security Act authorizes multiple waiver and demonstration
authorities which allows for flexibility at the state level. Under Section 1915 (b) of the
SSA, waivers are granted which allow states to implement managed care delivery
systems and restrict consumer choice of providers. These specific waivers often target
individuals with mental health and substance abuse issues, although some services are
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available for people with intellectual/developmental disabilities (I/DD). States may
choose to simultaneously operate 1915 (b) and (c) waivers. Medicaid waivers are used
to improve access to and quality of services, as well as manage cost.
REQUEST FOR APPLICATIONS -1915(b)(c) Medicaid Waiver Expansion
KEY POINTS:
• This is the final RFA that will be issued for statewide expansion.
• Full expansion is expected to be completed by January 2013.
• LMEs applying to operate a waiver must have an unduplicated minimum
Medicaid eligible population of 70,000 individuals 3 years and older; a total
population size of 300,000 by July 2012, and a total population size of 500,000
by July 2013. [OPC =total population of 227,963; number of Medicaid
eligible individuals 3 years and older is 22,372]
• A single LME may apply if it meets all minimum requirements. If a single LME
does not all minimum requirements it will be expected to merge with one or more
other LMEs, with one entity being identified as the lead LME.
• Applications must be received by May 20, 2011.
• By the date of the RFA application submission, all LMEs must identify which lead
LME they will partner with to pertorm the required Medicaid managed care and
LME functions. If LMEs do not identify working partners, then DHHS will assign
LME catchment areas.
OPTIONS AVAILABLE TO OPC: In February 2010 OPC was approached by PBH, the
LME currently operating the 1915(b)(c) pilot project, about the possibility of forming an
alliance. With approval of the OPC Area Board negotiations were initiated. In June
2010 legislation was passed which restricted PBH from expanding their geographic
region and limited the number of sites for expansion of the Medicaid waiver. OPC's
negotiations with PBH were put on hold. Legislative support now exists for removal of
the restrictions on PBH, as well as expansion of the waiver, and the OPC Area Board
has authorized the Area Director to re-engage in negotiations.
OPC AREA BOARD RECOMMENDATION TO BOCC: At their April 11~' meeting the
OPC Area Board reviewed the RFA and after extensive discussion the following motion
was approved by unanimous vote.
The OPC Area Board authorizes management of OPC to pursue negotiations with PBH
to be identified as the lead LME to operate Medicaid funded services through a 1915
(b)(c) combo waiver for the OPC catchment area; to pursue a merger arrangement with
PBH for the provision of services in the Orange, Person and Chatham counties
catchment area; and to seek authorization of the Boards of Commissioners of Orange,
Person & Chatham counties to proceed with negotiations with PBH towards these ends.
Because Chapter 122C of the North Carolina General Statutes empowers and requires
counties to determine the area authority through which they provide services, the OPC
Area Board requests authorization from each county to proceed in accordance with
the motion it adopted. Successful negotiations would result in the necessity at a later
date of a resolution from each Board of County Commissioners to both join PBH for the
provision of services and to dissolve OPC. The only action needed at this time is the
Board of County Commissioners' concurrence in the negotiations recommended by the
OPC Area Board.
OPC and Waiver Expansion
Frequently Asked Questions
1. Is OPC merging with another LME (Local Management Entity)?
OPC is currently talking to PBH about the possibility of joining them.
At their regularly scheduled meeting on April 14th the OPC Area Board
reviewed the Request for Application (RFA) that was recently released by
the Department of Health 8~ Human Services (DHHS) related to the
expansion of the 1915(b) (c) waiver. After extensive discussion the OPC
Board voted unanimously to move forward in negotiations with PBH and
to seek authorization from the Boards of Commissioners in Orange, Person
8~ Chatham counties to do so.
2. Who is PBH and why is OPC in discussions with them?
PBH is an LME (ike OPC. They currently operate a Medicaid waiver and
have asked us to partner with them.
PBH is a Local Management Entity (LME) like OPC which covers Cabarrus,
Davidson, Rowan, Stanly 8~ Union counties. In 2005 PBH was chosen to
operate a pilot project which allowed Medicaid funded services for
mental health, developmental disabilities and substance abuse treatment
to be provided on a capitation basis through a 1915(b)(c) combination
waiver. This pilot project has been successful and DHHS has made the
decision to move forward with statewide expansion of the 1915(b)(c)
waiver based on the model created by PBH.
In February 2010 OPC was approached by PBH about the possibility of
forming an alliance. With approval of the OPC Area Board negotiations
were initiated. In June 2010 legislation was passed which restricted PBH
from expanding their geographic region and limited the number of sites
for expansion of the Medicaid waiver. OPC's negotiations with PBH were
put on hold. Legislative support now exists for removal of the restrictions
on PBH, as well as expansion of the waiver.
3. Why would OPC want to merge?
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Under proposed legislation, OPC is currently not large enough to operate
as we currently exist.
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The number of LMEs in the state has been reduced over the years from 41
to 23. Given the current economic climate, LMEs have been encouraged
to continue consolidation efforts in order to create efficiencies and
savings. OPC is the fourth smallest LME in the state based on the
population of our three counties (227,963), so with the recent release of
the RFA and related legislation, it is no longer an option for OPC to remain
"as is". The minimum population threshold for LMEs will be increased to
300,000 by 7/1/12 and 500,000 by 7/1/13, and the number of LMEs in the
state will be reduced to 8-10. While we are very proud of OPC and its
accomplishments over the last 40+ years, we recognize that we will need
to change, and we have tried to be thoughtful and proactive in
considering our future options.
4. Will OPC still exist?
Yes, although we may look a little different in the future.
We are currently in discussions with PBH about what the local presence in
the OPC community will look like. OPC will most definitely still exist and will
be available to respond to the needs of the local community, although
our internal structure may look different than it does currently.
5. What is a waiver?
A waiver is an agreement between the state and Center for Medicaid
Services in Washington to be released from certain Medicaid rules.
In 1965, amendments to the Social Security Act (SSA) established the
Medicaid program. Under the Medicaid program each state establishes
its own eligibility standards, benefits packages, payment rates, and
program administration. There are two major types of serviced delivery
systems in Medicaid; fee for service and managed care. States wishing to
operate managed care service delivery systems must apply for a waiver
of certain Medicaid rules. The Social Security Act authorizes multiple
waiver and demonstration authorities which allows for flexibility at the
state level. Under Section 1915 (b) of the SSA, waivers are granted which
allow states to implement managed care delivery systems and restrict
consumer choice of providers. These specific waivers often target
individuals with mental health and substance abuse issues, although some
services are available for people with intellectual/developmental
disabilities (I/DD). Under Section 1915(c) of the SSA, waivers exist to
provide a continuum of services in the community to individuals who are
disabled. Presently North Carolina operates a 1915 (c) waiver for
individuals with I/DD referred to as the CAP-MR/DD program. States may
choose to simultaneously operate 1915 (b) and (c) waivers.
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Medicaid waivers are used to improve access to and quality of services
and manage cost. Entities that operate waivers are generally referred to
as Managed Care Organizations (MCO). NC has chosen to operate its
waiver through a single prepaid inpatient health plan (PIHP). PIHPs are
managed care organizations that provide, arrange for or otherwise have
the responsibility for the provision of specialty care (including inpatient
and institutional) for individuals with MH/DD/SAS needs. PBH currently
operates a PIHP and is the only combined 1915(b) (c) waiver in North
Carolina. North Carolina has obtained approval from the Centers for
Medicare and Medicaid Services (CMS) to transition the entire state to a
combined 1915 (b) (c) waiver replicating the PBH model statewide.
For more information about waivers, please see the waiver section on the
OPC website, www.opcareaproaram.com
6. What does OPC think about managed care?
We think it is the right thing to do.
OPC supports the concept of managing care to assure that all individuals
receive appropriate services, and we strongly support the concept of
public management of the behavioral .healthcare system.
7. Why are some groups opposing the waiver?
Some people are worried about what this change will mean for providers
and consumers.
Expanding the waiver statewide is a big change for North Carolina, and
as with any change of this magnitude, there is some anxiety about what it
all means. Some advocacy groups, particularly those representing the
interests of individuals with I/DD, have been very vocal about their
concerns for that population in a waiver environment. While it is true that
care for these individuals (as well as individuals with mental health and
substance use disorders) will be managed differently in the future, PBH, as
well as other states, have successfully operated waivers that appropriately
serve all disabilities. An article by the National Leadership Consortium on
Developmental Disabilities that looked at the experiences of four states
concludes...
Smith and Ashbaugh, in a groundbreaking 1995 analysis of
potential applications of managed care within the developmental
disabilities services sector, wrote: "Whatever mistrust there might be
about managed care has to be balanced against its trinity of
promises: -ower costs, better access, and higher quality. Curbing
Medicaid payments to the states means developmental disabilities
systems will face a far different fiscal landscape in the foreseeable
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future than has been true over the past decade. This altered (low
growthj fiscal landscape has enormous implications for the health
and vitality of these systems and even more profound implications
for the people and families who depend on these systems for
supports. In this vein, dismissing managed care makes no sense.
DD service systems will need to take advantage of every tool
available in order to survive and be responsive to the people they
support." These words were written at a time when Congress
appeared to be on the brink of imposing an across-the-board cap
on federal Medicaid spending. Today, our nation is rapidly
approaching another crisis in financing not only of Medicaid
services but of other major social entitlement programs as well
(e. g., Medicare; Social Security, SSI, Food Stamps, etc.J. Given the
circumstances, Smith and Ashbaugh's admonition to consider all of
the "arrows in our quiver" seems as relevant today as it was thirteen
years ago. And, as unsettling as it may seem, managed care is one
of those arrows.
For access to the full article referenced above as well as
information about waivers from several advocacy groups, please
see the waiver section on the OPC website,
www.oacarea proclram.com
8. What will happen to my (or my child's) services?
In general, most services should remain the same, although who approves
them will change.
Expansion of the waiver should be a fairly seamless process for consumers.
It should result in greater consistency across the state in the services that
are provided, in how services are accessed, and in expectations and
requirements for providers. If savings are realized, they can be put toward
creative, innovative services that may not be typical Medicaid
reimbursable services. The biggest change will be that Medicaid services
will no longer be authorized by the state's current vendor, Value Options,
but instead will be authorized by the LME. How case management is
provided may also change for some consumers (see question # 12)
9. Will I be able to keep my same provider?
As much as possible, OPC will work to help consumers keep their current
provider if they so desire.
As indicated in the 1915 (b) waiver amendment
(http://www.ncdhhs.gov/mhddsas/waiver/2011 /section 1915-bwaiver-
renewal l 1-13.pdf) "Enrollees will have free choice of providers within the
prepaid inpatient health plan (PIHP) and may change providers as often
9
as desired. If an individual joins the PIHP and is already established with a
provider who is not a member of the network, the PIHPs will make every
effort to arrange for the consumer to continue with the same provider if
the consumer so desires. In this case, the provider would be required to
meet the same qualifications as other providers in the network. In
addition, if an enrollee needs a specialized service that is not available
through the network, the PIHP will arrange for the service to be provided
outside the network if a qualified provider is available. Finally, except in
certain situations, enrollees will be given the choice between at least two
providers. Exceptions would involve institutional services or highly-
specialized services which are usually available through only one facility
or agency in the geographic area."
10. Under the waiver will OPC serve all the consumers that are currently being
served without a cut in any services?
We don't know. In addition to changes that will be created by the
waiver, we also anticipate cuts to the rates paid for services. It is hard to
say what impact those cuts will have on services.
To answer yes to this question would assume that all current treatment
plans match the needs of all individuals, which we do not believe has
been proven to be the case when records have been audited. In a
managed care environment you assess needs at the individual level and
create treatment plans that are responsive to those needs within a very
formal framework. To answer yes to this question would also assume that
the resources currently available would remain so without change. As we
are all well aware, North Carolina is facing a serious fiscal shortfall. We are
expecting budget reductions at the administrative level and possibly at
the service level. Medicaid 8~ Medicare rate reductions are already being
rolled out, so the service system will likely face changes unrelated to
implementation of the 1915(b) (c) waiver.
11. What will happen to OPC providers?
As much as possible, OPC will work to keep our current provider network.
One of the rules that is waived under a 1915(b) waiver is freedom of
choice. That means waiver sites can have a closed provider network,
limiting it to those providers with good outcomes. OPC has been
fortunate to have a long-standing relationship with many excellent
providers in our community, and that should not change. In fact, PBH has
recommended to LMEs interested in becoming waiver sites that current
providers be included when the waiver is opened in the LME's community.
10
If a provider then subsequently is not performing, they would be removed
from the network.
12. Who is going to do case management?
Based on the latest information we have received, it appears that LMEs
will do care management and coordination.
According to the latest waiver fact sheet published by the Division of
MH/DD/SAS
(http://www.ncdhhs.ctov/mhddsas/factsheets/ 1915bcwaiverddfactsheet4
-11.pdf), targeted case management will not be a stand-alone service for
any disability group under the waiver. The functions of care management
and coordination will be performed by the LME. However, individuals with
Intellectual/Developmental Disabilities (I/DD) may receive a different type
of direct service, called Community Guide, from provider agencies.
13. Will OPC have any type of forums to educate the community about what
is going on?
Absolutely.
We are currently working on a strategic plan for educating the
community about the waiver and will be publishing details as soon as we
have them.
14. Are the counties going to be at risk if the waiver loses money?
It is our understanding that the counties will not be at risk.
In a waiver the "risk" (of losing money) is transferred from the state to the
LME, which serves as a Managed Care Organization (MCO). The waiver
requires the MCO to have an adequate risk reserve. Concerns have been
expressed about the counties' responsibilities if the. LME overspends. It is
our. understanding that the Institute of Government has researched this
issue and provided information which would not support the assertion that
the counties would be at risk in a waiver setting. Also, Secretary Cansler
reported on April 5th that there was consideration being given to either
new or revised legislation which would assure that counties would not be
at "risk" in a waiver setting.
15. Will money be taken away from developmental disability services and
given to mental health and substance abuse services?
We have no reason to believe that this would happen.
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We are aware that there is concern that developmental disability funding
will be used to serve other disability areas in a waiver setting. We are also
aware, however, that this is the same argument that was made when
area authorities were shifted to a single stream funding model. We have
no information to suggest that has ever occurred in a program with single
stream funding; no evidence to suggest that it has occurred at PBH; and
no reason to believe that it would occur in any new waiver site.
16. Where can I find more information about waivers?
OPC has created a section on our webpage that contains links to
resources as well as various documents that have been written about
waivers. You can access our site at www.opcareaprogram.com
17. Who can I call if 1 have questions?
If you have questions, you can contact OPC's customer service line at
(888)277-2303 or (919)913-4120 or you may e-mail your questions directly
to waiverquestions@opc-mhc.org We will be posting the questions and
answers and will be updating this FAQ document on a regular basis. The
Division of MH/DD/SAS is also responding to questions sent to:
1915BC.Waiver.Contact@dhhs.nc.gov
~~,~r,~ ~
From: Judy Truitt-.
Sent: Tuesday, April 26, 2011 2:49 PM
To: Steve Yuhasz; 'Lynn Ikenberry' (ikenbel@mindspring.com); 'Mary Cay
Corr' (marycaycorr@mindspring.com); Mike Rosenthal (pmrmms@aol.com);
jimmyb60@embargmail.com; 'Amandab' (amandab51 @charter.net); 'Rachel O..
Winstead' (Wnstead@Bennett.edu); 'Carol Mitchell' (msch48@esinc.net); Gentry, Bill
(wgentry@unc.edu); Brian Bock (brian.bock@chathamnc.org); edwardsbrooks@earthlink.net;
geogreg@chatham.k12.nc.us; Tom Glendenning (goaglen@embargmail.com); Heather
Johnson (Chathambooks@gmail.com); john@levineandstewart.com; 'Heather
Nash' (heathnash27@yahoo.com); vbeckt@aol.com
Cc: .Frank Clifton; Gwen Harvey; hyork@personcounty.net; ghodges@personcounty.net; Charlie
Horne (charlie.horne@chathamnc.org); Renee Paschal (renee.paschal@chathamnc.org);
Inease@brownandbunch.com; Management Team
Subject: OPC Update April 26, 2011
Attachments: Waiver FAQ.pdf
Dear Board members & County partners, as a quick update please find the following information.
• On April 18th the Person County Board of Commissioners reviewed and approved OPC moving forward
in negotiations with PBH.
• On April 18th the Chatham County Board of Commissioners reviewed and approved OPC moving
forward in negotiations with PBH.
• The Orange County Board of Commissioners has scheduled time on their May 10th and May 17th
meeting agendas - I will present at both meetings.
• On April 21St Debra Farrington and I met with the OPC Consumer & Family Advisory Committee (CFAC).
The meeting went well and it is my understanding that CFAC is working on a letter of support, which will
be ready early next week.
On April 21St we uploaded a significant amount of information to the OPC webpage at
www.opcareaprogram.com. Included would be:
• A Question and Answer (Q&A) document with the questions that we have received thus far. I have
attached a copy for your review - we will be updating this on a routine basis.
• We also posted information regarding both PBH and Medicaid waivers in general - we will continue to
add new information as it becomes available.
Other planning efforts:
We are planning to release a series of articles in local newspapers -several editors have already
indicated that they are willing to work with us as to educate our consumers, families & communities.
We are planning to hold public forums in each of our three counties beginning in mid-June.
Finally, OPC staff participate on approximately 80+ committees/collaboratives/forums - we are
developing formal talking points and will ask that staff members educate stakeholders as part of their
participation with these groups.
Please do not hesitate to let me know if you have any questions and as always thank you for your on-going
support of our system. Judy
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5/2/2011
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Judy R. Truitt
OPC Area Program
919-913-4010
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