PSCS Forms :: Client

Approximate Date of Incident:

Do you currently have an open Workers Comp Claim?

Yes No

Category 1:

Visually witnessing the death, maiming, or immediate aftermath of such a death or maiming of one or more human beings.

Category 2:

Responding to or being directly involved in a criminal investigation of an offense involving a dangerous crime against children.

Category 3:

Requiring rescue in the line of duty where one’s life was endangered.

Category 4:

Using deadly force or being subjected to deadly force in the line of duty, regardless of whether the first responder was physically injured.

Category 5:

Witnessing the death of another peace officer or firefighter while engaged in the line of duty.

Category 6:

Responding to or being directly involved in an investigation regarding the drowning or near drowning of a child.

CONSENT FOR THE RELEASE OF CONFIDENTIAL INFORMATION (R.O.I.)

House Bill 2502 (Officer Craig Tiger Act) requires that the State of Arizona track specific information about program utilization. The intent of this information is to measure the success of the program. PSCS will make notifications of required information to the employee’s City designated or third-party administrator for this benefit.

Each member choosing to initiate this benefit will need to consent for the following information to be shared with your City Administrator or third-party administrator of this service. The information will be; name, number of sessions, and category of incident (1 through 6), or time-off requests as needed determined by you and your PSCS counselor. Your PSCS counselor will not be sharing sensitive information or details of treatment.

If an employee is off work due to a provider recommendation and exhausts their own leave time and is still deemed unable to work by a treating provider, then 30 days of leave will be covered through this program. Employee will also then be contacted to explore the process of filing a worker’s compensation claim or applying for long term disability. If a workers’ comp claim is filed this is also reported for statistical documentation.

This consent also allows PSCS Staff to coordinate care with our providers so that we can help manage treatment.

By checking this box, you are stating that you understand that your records are protected under Federal (42 CFR Part 2) and State Confidentiality Regulations. Authorization will remain in effect for the duration of your treatment. The authorization of consent to share the specific information described above may be withdrawn at any time in writing to PSCS except to the extent that PSCS is reliant on this disclosure for payment or processing. With this consent you further acknowledge an understanding of this information and consent is given of your own free will.

PSCS Intake Form