CONSENT FORM
ACKNOWLEDGEMENT STATEMENTS
I have received the client Confidentiality handout which has been explained to me and I understand the contents to release,the need for information and that there are statutes and regulations protecting the confidentiality of information. I understand that PATHWAYS TO RELIANCE is required by law to release my protected health information without my consent if at any time I become a danger to myself or to others.
I further acknowledge that I have received the HIPPA Notice of Privacy statement and understand information containedinthedocument and this agency’s methods for protecting the privacy of my health information that is used in providing health care services to me.
I have received the client Rights Handout which explains my rights as a consumer and I understand the contents. REQUIRED REPORTING
Our group is required by state and federal regulations to report non-identifying client information for the purpose of evaluation and funding purposes. It will also be necessary for PATHWAYS TO RELIANCE to use and disclose certain information about myself in order to carry out treatment, payment and health care operations.
REPORTING OF SUSPECTED ABUSE/NEGLECT
Our group is required by state laws to report suspected abuse or neglect to the appropriate authorities. If you have any questions about this, please feel free to ask for a better understanding before you sign this document. Your signature below acknowledges receipt of this information.
EMERGENCY TREATMENT / EMERGENCY INFORMATION / EMERGENCY RESTRICTIVE INTERVENTIONIn case of sudden illness/accident/emergency, I hereby give permission to PATHWAYS TO RELIANCE and staff to seek emergency treatment on behalf of the below named client should the need arise. It is understood that this treatment will be provided by a qualified medical professional, physician, and/or hospital emergency room personnel. In addition, a copy of current medications and known medical conditions and allergiesmaybereleased. Efforts will be made to contact the identified emergency contact person prior to treatment, should this be possible. I also will hold harmless PATHWAYS TO RELIANCE any liability caused by their taking of any emergency procedures and/or contacts. PATHWAYS TO SELF RELIANCE, INCwill be available for URGENT / EMERGENCY visits for existing clients within a 48 hour time frame. The after-hours emergency number forthepractice is 704-732-2006. This number is for after hour emergencies ONLY. Issues regarding scheduling of appointments, medication refills, or other issues that can wait until the office reopens will not be addressed by the provider on call.
I agree to the emergency procedures as outlined above.
I will assume the full responsibility of all incurred emergency treatment expenses.
Emergency restrictive interventions will only be utilized when a consumer presents an imminent danger to him/herself or others or when substantial property damage is occurring. Whenever possible, less restrictive interventions will be used prior to the use of restrictive intervention.
CONSENT FOR SERVICES
I agree to participate in the treatment, services and support that are provided by PATHWAYS TO RELIANCE as outlined in the Client's serviceplan. I have been informed of the services in terms that I can understand. I have also been informed of the alleged benefits, potential risks and possible alternative methods of treatment. I understand that I may ask my provider for a copy of my treatment plan at any time and one will be provided at no cost to me. I understand that I am free to refuse treatment or services at any time.
I agree to accept the following checked services from PATHWAYS TO RELIANCE:
Individual/ Family/ Group Therapy
Family Therapy w/client
Comprehensive Clinical Assessment
Medication Management
Medication Management w/ Therapy
Psychiatric Evaluation
The above consents have been read by me or to me and explained to me by an employee of PATHWAYS TO RELIANCE in simple non-technical language, that all questions have been answered to my satisfaction and that I understand my rights.
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Client Rights
Each client of PATHWAYS TO RELIANCE shall be treated with respect to the basic human rights of dignity, privacy and humane care. An individual shall at all times retain the right to:
∙ Seek treatment without regard to age, race, disability, religious affiliation, ethnicity, nationality, or sexual orientation.
∙ The individual is informed of the rights to treatment including access to medical care and habilitationregardlessof age, or degree of MH/IDD/SA disability.
∙ Make wishes about future treatment known.
∙ Confidentiality (as spelled out in Policy, a copy of which is available upon request). ∙ Be informed of the qualifications of the professionals rendering services
∙ Exercise all civic rights.
∙ A copy of an individualized service plan which includes the anticipated goals, as well as services provided in order to achieve these goals will be provided.
∙ Be free from unnecessary or excessive medication. Medications shall be administered in accordance with accepted medical standards and only upon order of a physician as documented in the record. ∙ Refuse medications.
∙ Be informed of experimental or nonstandard forms of service.
∙ Expect reasonable continuity of care, i.e. to know in advance, what appointment times and clinicians areavailableand where.
∙ Be free from influences in my decision of services and providers.
∙ Be informed of the cost of service.
∙ Be considered of estimated length of service.
∙ Be considered legally competent unless there has been a court decision of incompetency. ∙ Refuse service or institute due process to terminate relations with PATHWAYS TO RELIANCE ∙ Free from searches or personal belongings except under critical circumstances.
∙ Expect special instructions and other requests to be honored when possible.
∙ Contact Disability Rights of NC (1-877-235-4210).This is the agency designated under federal andstatelawtoprotect and advocate the rights of persons with disabilities.
For further clarification of rights, I will ask PATHWAYS TO RELIANCE or other staff members. As a client, I'm aware that I have the right to request a different clinician/therapist/case manager at any time. I need to discuss this with my clinician/therapist/case manager or the Psychiatrist. For questions about availabilityofanotherprovider in the network call 1-800-898-5898. If I believe that my rights may have been violated, I can file a grievance and appeal, if I am not satisfied with the resolution. Any practice employee may assist me in doing this.
The above rights have been read by me or to me and explained to me by an employee of PATHWAYS TO SELF RELIANCE, INC
Client Choice of Services and Providers
PATHWAYS TO RELIANCE is committed to ensuring that clients have the right to choose the applicationoftheservice they qualify for, to decide the provider of the services they qualify for, and to select, if they desire, change in services and/or providers.
By signing this form, you are stating you understand that you, as the client, have the right to chooserelevantservices and which provider delivers those services and that you have been provided with that choice. Further,you acknowledge that PATHWAYS TO RELIANCE nor any employees have, in any way, advertised or inadvertently influenced your choice of services or providers.
Benzodiazepine and Controlled Substance Policy
You have been prescribed a medication called a benzodiazepine which has the potential to become habit forming. It is important that you understand the risks and safety issues related to use of these medications. For this reason, we have instituted a Benzodiazepine and Controlled Substance Policy. Please read the following information and sign below.
In the event that my treatment requires the use of the controlled substances, I WILL ADHERE to the following:
∙ I am reading and making the agreement while in full possession of my faculties and not under the influence of any controlled substances that might impair my judgment.
∙ I will not obtain any controlled medication from another medical provider (including referrals from this office) without informing PATHWAYS TO RELIANCE of the circumstances involved. This includes painpills,muscle relaxers, anti-anxiety, or stimulant medications.
∙ I will notify my provider of any new health concerns I may have even if not obviously related to my treatment.
∙ I will not be involved in the sale, transport, sharing of any controlled substance or medication.
∙ I will safeguard my medication from loss of theft. If I lose them, for whatever reason, I will not ask for early refills or for prescriptions to be called in.
∙ I will not ask for early refills for any reason.
∙ I will carry only the amount of the medication I need, in the prescription bottle for the time away from home, leaving the rest in a safe place.
∙ I will not take larger or more frequent doses than that written on the prescription bottles.
∙ I understand that I need to see the provider on a monthly or on a scheduled basis in order to get my prescription. I will not request for my medications to be called in without seeing the provider.
∙ I will bring all medication and bottles to the office for every appointment.
∙ I give my prescribing provider permission to discuss all diagnostic and treatment details (including prescription history) with dispensing pharmacists or other professionals who provide or have provided my health care for the purpose of maintaining accountability.
∙ I understand and agree that I am subject to random unannounced drug tests. Presence of unauthorized substances may result in my discharge from the practice. Refusal to take a drug test may also result in my discharge from the practice.
∙ In the event that I am arrested or incarcerated related to the legal or illegal drugs, refills oncontrolledsubstances will not be given and the provider will discharge me be immediate for all alleged criminal behavior.
∙ (FOR FEMALES) I also understand that if I become pregnant, or if I am suspicious that I am pregnant,
I will notify my provider immediately.
∙ Under no circumstances will any client get more than one month's supply of medication.
∙ I agree to use only one pharmacy for obtaining controlled medications. This practice must be notified of any pharmacy changes at least three (3) days prior to refill request.
I have read this document and agree to the guidelines. If I have had any difficulty understandingthecontent I have asked for clarification. If my prescription(s) is not helping improve daily function it maybe discontinued. A copy of this agreement is being provided to me. I understand that if this agreement is not followed, I may be discharged from the practice.
ESSENTIAL MEDICATION RELATED
INFORMATION FOR CLIENT/RESPONSIBLE GUARDIANS
1. The physician will explain expected actions, usual side effects, and possible adverse effects of the medication.
2. Additional medication related information is available from both your physician and your pharmacist.In any case, when a prescription is filled at the pharmacy you are asked whether you wouldlikeforthepharmacist to go over the medication with you, and also a print out of the effects and side effects of your specific medications are included with your prescriptions.
3. A Client's lost, misplaced, or stolen medication will only be refilled earlier that the next datethat itisdue to be filled once in a lifetime. No controlled medications will be replaced. As such, please keep all your medications under lock and key, keep only what you need for the day on you at one time, and use only as directed. Only the provider can increase your medications; please do not take this up on yourself.
4. If a change in your medication was made by the physician at your last appointment, and a new prescription was not given at that time, then please have your pharmacy call us for updatingyourmedication related orders.
5. If a refill is due before your next appointment you will need to call us at least 2 days before the medication is going to run out. Please note however, if you are running out of medications due to you not attending your appointment, no medications will be called in for you. When callingpleasemakesure include the following information:
1. Name of medication
2. Dose (milligrams) and directions of the medication
3. Date the medication was last filled
4. Quantity that was given when the medication was filled last
5. How many pills you have at the time you call
6. Pharmacy where you had the medication filled
7. Telephone number of the pharmacy
6. Frequently changing your pharmacy is discouraged.
Thank you for your cooperation.
FINANCIAL POLICY
1) PAYMENT is expected at the time of your visit, unless prior arrangements have been made. We accept cash, debit,credit cards, and money orders. After you have become established as a client, personal checks may be accepted at the discretion of the provider.
2) INSURANCE CLAIMS- as a courtesy to our clients, we will file your primary insurance policy. Please remember insurance coverage is a contract between the client and the insurance company. We expect the client to be responsible for the payment in full.
HMO’s, PPO’s, and MANAGED CARE- We belong to a number of managed care plans. It will be important that you check with your insurance company to verify whether you need authorization for psychiatric outclient treatment. The initial authorization must be obtained by the client; otherwise, you will be responsible for payment. Upon initial authorization, you will be responsible for the co-payment.
MEDICARE- This office accepts Medicare assignments. Mental Health is covered at 62.5%. You will be expected to pay your percentage of what Medicare does not cover if you have met your deductible. You will be expected to pay in full if your deductible has not been met.
MEDICARE & MEDICAID- Medicare and Medicaid do not cover Medicare approved psychiatric charges at 100%. Combined they pay 62.5% of the approved charges. The client is responsible for the 37.5% co-pay.
3) NO INSURANCE- clients who do not have insurance are expected to pay for treatment in full at the time of service.
4) MINOR CHILDREN- It is the responsibility of the accompanying parent to see that payment is made in full, at the time of service.
5) CREDIT- We can arrange a monthly budget payment plan, if credit is determined to be necessary due to hospitalization. clients who arrange credit and who have agreed to a monthly payment plan are required to comply with all scheduled payments. A monthly rebilling fee will be charged if payment is not received within 30 days.
6) RETURNED CHECKS- A service fee of $35.00 will be applied to all returned checks. You will be asked to bring cash to our office to cover the amount of the check, plus the service charge.
7) ACCOUNTING PRINCIPLES- Payments and credits will be applied to the oldest charges first, except for the insurance proceeds, which are applied to the charges for which received.
8) NO SHOW/CANCELLATION FEE- If you must cancel or reschedule your appointment, then you must do it 24 hours before your appointment time or you will be charged a fee of $50.00, if you “no show” for your appointment, then the same fee of $50.00 will apply. (This fee is assessed to the client and is not covered by insurance companies). However, please note that if you are a Self-Pay client, you will be charged the full price of the missed visit at your next visit.
“I HAVE READ, UNDERSTAND, AND AGREE TO THE PROVISIONS OF THE FINANCIAL POLICY.”
INFORMED CONSENT FOR TREATMENT OF EMOTIONAL CARE
I hereby give permission to PATHWAYS TO RELIANCE to provide emotional care for me and/or my child named above. I understand that my treatment may include discussion of alternative diagnosis, methods and modalities to be used in treatment and possible outcomes. I understand that treatment outcomes cannot be guaranteed,andthat treatment can at times be painful and difficult. I understand that I may withdraw from treatment at any time but I agree to discuss my plan with my therapist/doctor before doing so. I further agree to complywithmytreatment recommendations including taking medication as prescribed and will inform my doctor of any side-effects immediately. I further acknowledge that I have read and understand PATHWAYS TO RELIANCE’s policies and procedures. It has been clearly explained to me and I understand the limits of confidentiality regarding treatment, office policies regarding scheduling, emergency coverage, fees and billing, insurance filling, missed appointments, court appearance, copying records, phone consultations, client rights, etc.
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