Statement of Understanding; Your Rights and Responsibilities as a Client; Telehealth Informed Consent

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Request for Services and Consent:

By signing, you are requesting diagnostic evaluation and/or treatment that may include psychotherapy and psychopharmacological services, Integrated Health, Jail Diversion and/or Behavioral Health Intervention Services from Center Associates. These services are outlined in a brochure you receive. Services may be face to face or telehealth and may contain some risk to include exposing sensitive topics of events with which you may have difficulty coping; receiving an inaccurate diagnosis; developing side effects from medications; rendering a clinical opinion or recommendation that is not aligned with your desired resolution (i.e. psychiatric hospitalization that is against your wishes); and misidentifying or underestimating the severity of a problem. The Center makes every effort to minimize risk to individuals using our services. You have the right to be informed about your treatment. You will receive a copy of the Client Rights & Responsibilities, which outlines your right to be informed about your treatment, express concerns or formal grievances regarding your care, and appeal any Center decision.

Confidentiality:

According to federal and state law, information given to any member of our staff is considered to be privileged and cannot be released to others without your written consent unless you are court ordered for treatment or evaluation. Alcohol and drug treatment information is protected under the Confidentiality and Drug Abuse Patient Records regulations, 42 C.F.R., Part 2. Substance use disorder information under this law is confidential and can be kept from the parents of the minor unless an authorization to release information is approved by the minor. The minor has rights pertaining to information regarding substance abuse to include decision-making in regards to release of information. The parent or legal guardian is responsible for releasing confidential information regarding minors, for mental health information. The following exceptions apply to all individuals receiving services:

  • All clinicians are mandated to report abuse or neglect of minors or dependent adults.
  • If you are a danger to self or others, we shall act in your or others’ best interest.
  • Accreditation and insurance surveys occur in which individual records are reviewed. Surveyors must adhere to state and federal confidentiality guidelines.
  • For individuals with persistent mental illness, there are certain situations in which we may disclose information to a family member or guardian.

Termination/Denial of Services:             

Termination or denial of services may occur when individuals repeatedly fail to show for appointments or make multiple last minute cancellations (significant efforts to include walk-in status will be made to continue services prior to termination); fail to provide payment for services rendered; are uncooperative with treatment, assessment, or recommendations; consistently impede the Center’s ability to carry out treatment; speak or act in a manner that is seen as threatening and/or harassing toward Center staff or other individuals; represent a conflict of interest or ethical dilemma; demonstrate potential risk management issues; or present for services based solely on legal custodial issues.

When requesting treatment for a minor child, consent for services is required from both parents unless custodial rights have been terminated or it is proven that the child does not have any current, active involvement with the parent. These situations will be reviewed on a case-by-case basis to determine if services will be provided.

E-Mail and Social Networking:

If you choose to email Center Associates staff, you are giving consent for communication to occur via this method. E-mail is not encrypted. There is a low risk that confidentiality may be breached in e-mailed communications. If you choose to communicate with your providers via email, you will be asked to sign an informed consent document. Additionally, the Center has policies in regards to Social Networking. Clinical staff is not allowed to be “friends” with patients on social networking sites. Center Associates will not use Social Networking to contact you.

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YOUR RIGHTS AND RESPONSIBILITIES AS A CLIENT

Regarding your mental health treatment, you have the right to:

  • Receive services provided in ways that respect and enhance your sense of autonomy, privacy, dignity, self-esteem and involvement in the treatment process.
  • Be treated in a manner that respects your individual needs and attempts to avoid causing re-traumatization.
  • Feel safe and secure in a welcoming environment free from abuse or harassment.
  • Participate meaningfully in services that take language barriers, cultural differences, and cognitive deficits into consideration.
  • Be treated without discrimination based on race, religion, national origin, gender, age, sexual orientation, past experiences, or disability.
  • Refuse treatment to the extent permitted by law and be informed of the possibly consequences of refusal. You may request a list of alternative service providers in the area.
  • Receive information (either in verbal, written or electronic format) about aspects of your treatment in terms you can understand. This may include explanation of diagnoses, interventions, and outcomes.
  • Know the names and professional titles or your providers. You may request to change your provider(s) or obtain a second opinion throughout the course of your treatment.
  • Use the services of an interpreter and/or have access to assistive devices when needed.
  • Be involved in discharge planning.
  • Ask questions and receive prompt, courteous, and reasonable responses from all of our staff.
  • Express concerns and register complaints regarding decisions made by Center Associates.   All staff members are able to document complaints. These are forwarded to a member of the Administrative Team for resolution. 

Regarding your mental health treatment, you are responsible for:

  • Acting in a considerate and cooperative manner.
  • Following Center Associates’ policies and procedures.
  • Respecting the rights and property of others.
  • Providing accurate and complete information about all current and past matters pertaining to your mental and physical health.
  • Expressing your desired goals and outcomes for treatment.
  • Reporting changes in your condition or symptoms to your provider(s).
  • Informing your provider(s) when you are experiencing mental and physical health symptoms.
  • Asking for different treatment options if you feel that current interventions are not helping to improve symptoms.
  • Following the recommendations and strategies given by your provider(s). If you refuse treatment or do not follow the given recommendations, you must accept the consequences of your decision.
  • Identifying and reporting any safety concerns that may affect your care.
  • Keeping your scheduled appointments or cancelling appointments in advance when possible.

Responsibility for Payment:

  • Payment is due at the time of service. We accept cash, check, money order, Visa, Discover and Mastercard as payment. We will file your claim with your insurance carrier as a courtesy. If the insurance carrier fails to respond, the claim is ultimately your responsibility. We will work with you to find funding sources for your treatment.
  • You are responsible for keeping your account in good standing. If you need assistance, a payment plan is available through the Business Department. If your bill is over 90 days old and reasonable payment has not been made, we reserve the right to send your account to a collection agency with agency fees added. If you are unable to pay because of a financial hardship, please discuss this with the Business Department.
  • I understand that the agreement of the insurance company to pay for medical care is a contract between me and the company. I am responsible for the payment of my bill whether or not I have insurance coverage.
  • I authorize the release of any information necessary for health insurance claims.
  • I authorize payment to Center Associates for all medical benefits.
  • When applicable, I request payment of Medicare benefits either to myself or to the party who accepts assignment on the Medicare billing form.
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TELEHEALTH INFORMED CONSENT

I hereby consent to participate in telehealth services with Center Associates as part of my psychotherapy, psychopharmacology, Integrated Health Services, Jail Diversion and/or Behavioral Health Intervention Services.

I understand that telehealth is the practice of delivering mental health services via technology assisted media or other electronic means between a practitioner and a client who are located in two different locations. This could be in the form of video conferencing and/or telephonic call. All appropriate measures will be taken to ensure safety and security of all PHI (personal health information) and be protected through HIPAA.

I understand the following with respect to telehealth:

  • I understand that I have the right to withdraw this consent at any time without affecting my right to future care, services, or program benefits to which I would otherwise be entitled.
  • I understand that there are risk and consequences associated with telehealth, including but not limited to, disruption of transmission by technology failures, interruption and/or breaches of confidentiality by unauthorized persons, and/or limited ability to respond to emergencies.
  • I understand that there will be no recording of any of the online sessions by either party. All information disclosed within sessions and written records pertaining to those sessions are confidential and may not be disclosed to anyone without written authorization, except where the disclosure is permitted and/or required by law.
  • I understand that the privacy laws that protect the confidentiality of my protected health information (PHI) also apply to telehealth unless an exception to confidentiality applies (i.e. mandatory reporting of child, elder, or vulnerable adult abuse; danger to self or others; I raise mental/emotional health as an issue in a legal proceeding).
  • I understand that if I am having suicidal or homicidal thoughts, actively experiencing psychotic symptoms or experiencing a mental health crisis that cannot be resolved remotely, it may be determined that telehealth services are not appropriate and a higher level of care is required.
  • I understand that during a telehealth session, we could encounter technical difficulties resulting in service interruptions. If this occurs, end and restart the session.
  • I understand that my therapist may need to contact my emergency contact and/or appropriate authorities in case of an emergency.

 

Emergency Protocols: I need to know your location in case of an emergency. I also need a contact person who I may contact on your behalf in a life threatening emergency only. You agree to inform me of the address where you are at the beginning of each session. This person will only be contacted in the event of an emergency.

                             

I understand and agree to the above terms and conditions and acknowledge receipt of the brochures containing

Client Rights & Responsibilities, Service Description, and HIPAA Privacy Notice.

At your request, you may receive a copy of this document

Relationship *
 
Signature ( Electronically signed by) *
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