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 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.
Payments
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 up front 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 a patient 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 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 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.
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 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.
For TELEMED appointments, I agree to leave a Credit Card on file and be charge at the time of the appointment applicable copays and deductibles.
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 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, and Voice Messaging
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.
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.
