patient consent

"*" indicates required fields

Consent and Authorization for Treatment

My signature below authorizes my mental health provider to treat me. I understand this could include medications, lab or other diagnostic tests and education. I understand that my provider is available to explain the treatment and I have the right to refuse treatment. I may also be asked to sign additional forms indicating my consent for specific treatments. I also understand that after an initial in-person consultation, I may be eligible to receive telemedicine sessions if my Certus health care provider determines it could benefit me. I understand that this consent form includes important provisions specific to the use of telemedicine, and by my signature below I confirm I read, understand and accept those provisions.

Insurance and Financial Responsibilities

We participate in many insurance plans. If you are not insured by a company with which Certus does business or do not have an up-to-date insurance card, payment is expected in-full at each visit. When you provide Certus with current and complete information, Certus will bill primary and secondary insurance. Please note that Certus verify your benefits as a courtesy. It is not a guarantee of payments. We ask that you confirm your coverage and network status with your insurance company. If your insurance does not pay, the charges are your responsibility. Please contact your insurance company with any questions you may have about your coverage.

Payment

I accept responsibility for payment for all services and products received. All co-payments and deductibles must be paid at the time of service. This arrangement is part of your contract with your insurance company. You may pay by cash, check or credit card. I understand the requirement for an active method of payment stored for ease of future billing. There will be a processing fee if copay and/or deductible is not paid at the time of service. I also understand there will be a processing fee for any returned check or collection on accounts.

Method of Payment on File: I authorize Certus Psychiatry to charge the amount due for medical services rendered and owed by me (Copays, Deductibles, non-covered services, self pay amounts) to the method of payment I have provided and kept on file. As a courtesy, Certus will notify patient by text, calls and/or patient portal message before changing your method of payment if amount due is higher than $300.

If the office staff of Certus Psychiatry attempts to run a payment using the payment methods provided by the client and the payment declines, our staff will reach out to the client via the communication method(s) on file provided by the client.

If the client is unable to pay in full on the day of service, they must contact our billing department prior to being seen by the provider to make payment arrangements. If no advance notice is given, Certus Psychiatry reserves the right to run payment including copay/self-pay amount and additional balance due on the day of service, or by the end of the next business day.

If you decline to provide a Method of Payment on file, then you will not be able to schedule any Telehealth services, after hours services, phone consultations services, nurse calls or messages through the patient portal, since these options may be billable. Only IN PERSON services are available if you do not have a method of payment on file.

If your outstanding balance is not paid within 30 days, your may be discharged from the practice.

Check here if you Decline Method of Payment on file:

Non-Covered Services

Please be aware that some of the services you receive may be non-covered or not considered reasonable or necessary by some insurers. Payment for these services must be made up front at the time of your visit or will be billed to you after the visit.

Missed Appointments

The efficient operation of this practice requires that patients arrive at the facility on time for scheduled appointments. Failure to keep appointments interferes with facility operations and the delivery of quality care. When a patient misses an appointment without cancelling it within 48 hrs in advance it is considered a “Missed Appointment.”

I accept Certus Psychiatry charge directly my METHOD OF PAYMENT on file, for each missed appointment according to the following schedule:

First missed appointment: $75 charge.
Second missed appointment: $75 charge.
Third missed appointment within a period of 12 months, same charges, and possible dismissal from Certus Psychiatry and Integrated Care.

We understand that there may be exceptional circumstances beyond a client's control that lead to a missed appointment. In such cases, we maintain the discretion to waive or adjust the $75 fee. Clients who believe their situation qualifies for a fee waiver or adjustment are encouraged to reach out to our office as soon as possible, providing relevant documentation or details that support their claim.

Consent to Share Private Health Information

I authorize Certus Psychiatry & Integrated Care to send copies of my records to other health care providers and receive copies of records and prescriptions from my other providers or national databases (such as Surescripts) as needed for continuity of care to the extent that such authorization is consistent with Federal and State law and Certus Psychiatry & Integrated Care’s Notice of Privacy Practices. Records may also be sent to insurance companies and others responsible for payments. I agree and understand that a copy of my medical records including AIDS, HIV, Behavioral Health Service, Psychiatric Care and treatment for Alcohol and Drug abuse will be included as part of my health information that is shared. I also agree that Certus Psychiatry & Integrated Health can release my medical records to accrediting or regulatory agencies if those agencies request my records and if the law allows these agencies to see my records.

Telemedicine

I understand that telemedicine is the remote evaluation and treatment of patients by means of telecommunications technology. After an initial in-person consultation, I may be eligible to receive telemedicine sessions if my Certus health care provider determines it could benefit me. I have the right to withhold or withdraw my consent for the use of telemedicine at any time. My Certus health care provider may also determine that my telemedicine sessions should be terminated in place of in-person care.

I understand how to use telemedicine technology and equipment. In the case that the technology and/or equipment does not work during the session, then the session will be cancelled and rescheduled. However, some technology interruption is expected, and I understand it does not discount the fees of the session unless the session is terminated.

The laws that protect privacy and the confidentiality of medical information apply to telemedicine. Certus will also maintain a complete record of all telemedicine sessions just as they maintain records for in-person care. I understand that other Certus staff may be present during the session to operate equipment. My Certus health care provider will inform me of the presence of any Certus staff in the session and I have the right to request the following:

(1) omit specific details of my medical history/physical examination that are personally sensitive to me;
(2) ask non-medical personnel to leave the telemedicine examination room; and/or
(3) terminate the consultation at any time.

I may be prescribed medicine as a part of my telemedicine treatment. In accordance with State and Federal regulations, some medications may not be prescribed without an in-person physical examination, or in-person care as determined by my Certus health care provider.
I understand there could be some benefits to telemedicine such as improved access to medical care, more efficient medical management, reduced transportation barriers, and improved continuity of care, among others. But I also accept the risks of telemedicine such as inadequate quality of the transmitted information necessitating future sessions, delays in medical evaluation and treatment due to deficiencies or failures of the equipment, and failures in security protocols.

Patients Right to Privacy

In compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPPA), we have adopted a HIPAA Notice of Privacy Practices. This document describes in detail how information about you, the patient, can be used within our office and with others who need to know the reason for treatment, payment, and/or health care operations. Certus provides a copy of the HIPAA notice to all patients. You should carefully review that notice for information regarding how your medical information may be used and disclosed, and how you can get access to this information.

SMS/Text, Mail, Voice Messaging/AI

I consent to receive SMS Request for the purpose of my treatment (reminders and others), meaning a SMS / text message sent via a mobile telephone or the Internet by Certus Psychiatry to me to prompt an Information Message, to be sent to my mobile phone. I consent also to receive emails and voice messages for the purpose of my relationship with Certus Psychiatry. Certus uses AI technology to capture and transcribe what we talk during your visit and make a summary. This lets our care team focus more on you instead of typing notes. I agree to let AI technology capture and transcribe what we talk during my visit.

I have read this document carefully and understand the risks and benefits and have had the opportunity to have my questions answered. By signing below, I certify that I have read and understand the terms stated in this document I consent them and to my treatment by Certus providers.

Patient Name*

Name

Date*

Guarantor Name

(if different than patient)

Name

Date

Phone*

Email*

Patient signature required. If consenting as Guarantor, include signature below with patient's signature.

Comments

This field is for validation purposes and should be left unchanged.

Find balance and recovery here.

Winston-Salem Office

1255 Creekshire Way
(between Brixx and Firebirds)

Two Convenient
Locations!

833.701.3111

Raleigh Office

1350 Sunday Drive
Suite 101