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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.

Insurance and Financial Responsibilities

We participate in many insurance plans. If you are not insured by a company with which we do business or you do not have an up-to-date insurance card, payment in full is expected at each visit. When you provide us with current and complete information, we bill primary and secondary insurances. Please contact your insurance company with any questions you may have about your coverage.


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 that the credit card will be 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.

Non-Covered Services

Please be aware that some of the services you receive may be non-covered or not considered reasonable or necessary by insurers. Payment for these services must be paid upfront at the time of your 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 misses an appointment without cancelling it within 48 hrs in advance it is considered a “Missed Appointment”.

I accept the Practice charge for each missed appointment according to the following schedule:

First missed appointment: $75. 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.

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. 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.


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 the 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 benefit 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 on HIPAA Notice of Privacy Practices on display in the reception area. This document describes in detail how information about you, the patient, can be used within our office and with others who need to know reason for treatment, payment, and/or health care operations. If we were to disclose your information for any reason. we would first need your written approval. A printed copy of the HIPAA notice will be provided upon request. A copy of Patient Rights is also posted and can be provided.

Patient Name*
Guarantor Name
(if different than patient)
Patient signature required. If consenting as Guarantor, include signature below with patient's signature.
This field is for validation purposes and should be left unchanged.

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