Teletherapy and Telemedicine Consent Form
(1) "Teletherapy" and "Telemedicine" includes consultation, treatment, emails, telephone conversations, and other medical information using interactive audio, video, or data communications.
(2) Teletherapy and Telemedicine occurs in the state ofNC (USA), and is governed by the laws of that state. In a manner of speaking, I am using this modality to visit my therapist in their NC office, where we meet to do our work.
(3) The laws that protect the confidentiality of my medical information also apply to teletherapy. Unless we explicitly agree otherwise, our teletherapy exchange is confidential. I will not include others in the session or have others in the room unless agreed upon.
(4) I accept that Teletherapy and Telemedicine does not provide emergency services. If I am experiencing an emergency situation, I understand that I can call 911 or proceed to the nearest hospital emergency room for help.
(5) In the event our Teletherapy and Telemedicine is not in my best interests, my therapist will explain that to me and suggest some alternative options better suited to my needs.
(6) I understand there are risks and consequences from Teletherapy and Telemedicine, including, but not limited to, the possibility, despite reasonable efforts on the part of my therapist, that: the transmission of my information could be disrupted or distorted by technical failures; the transmission of my information could be interrupted by unauthorized persons; and/or the electronic storage of my medical information could be accessed by unauthorized persons. I am responsible for information security on my computer.
I have read, understand, and agree to the above information.
CONSENT FO THE RELEASE OF CONFIDENTIAL INFORMATION
I, , authorize HOPE Counseling & Consulting
Services to disclose to
the following information:
The purpose of the disclosure authorized in this consent is to:
I understand theat my alchohol and/or drug treatment records are protected under the federal regulations governing Confidentiality of Alchohol and Drug Abuse Patient Records, 42 C.F.R. Part 2, and the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 C.F.R. Pts. 160 & 164 and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I also understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it, and that in any event this consent expires automatically as follows:
I understand that I might be denied services if I refuse to consent to a disclosure for purposes of treatment, payment, or health care operations, if permtted by state law. I will not be denied services if I refuse to consent to a disclosure for other purposes.
I have been provided a copy of this form.
Date: November 3, 2023
Client Consent for Clinical Services
COUNSELING is a confidential process designed to help you address your concerns, come to a greater understanding of yourself, and learn effective personal and interpersonal coping strategies. It involves a relationship between you and a trained therapist who has the desire and willingness to help you accomplish your individual goals. Counseling Involves sharing sensitive, personal. and private information that may at times be distressing. During the course of counseling. there :nay be periods of increased anxiety or confusion. The outcome of counseling is often positive; however. the level of satisfaction for any individual is not predictable. Your therapist is available to support you throughout the counseling process.
All interactions with Counseling Services, including scheduling of or attendance at appointments, content of your sessions, progress in counseling, and your records are confidential. No record of counseling is contained in any academic, educational, or job placement file. You may request in writing that the counseling staff release specific information about your counseling to persons you designate.
Should emergency medical services be needed from a physician or hospital you have the right to seek help where available / needed. We appreciate prompt arrival for appointments. Twenty-four hour notice of cancellation allows us to use the time för others. I have read and discussed the above information with my therapist. I understand the risks and benefits of counseling, the nature and limits of confidentiality, and what is expected of me as a client of the Counseling Services.
CONSENT TO TREATING PROVIDER ENTITY RECIPIENT
42 CFR Part 2 and HIPAA
REMINDER: Information disclosed pursuant to patient consent must be accompanied by the notice prohibiting redisclosure.
A "treating provider relationship " exists when a patient receives, agrees to receive, or is legally required to receive diagnosis, evaluation, treatment, or consultation, for any condition, from an individual or entity who undertakes or agrees to undertake that diagnosis, evaluation, treatment, or consultation. An in-person encounter is not required for a treating provider relationship to exist.
This consent form is for use when a patient wishes to authorize the disclosure of their substance use disorder information to an individual or entity with which the patient has a treating provider relationship.
I, , authorize
Assessment and treatment records:
(describe how much and what kind ofinformation may be disclosed, including an explicit description ofwhat substance use disorder information mav he disclosed; as limited as possible)
to HOPE Counseling & Consulting Services, Inc., 326 N Spring St, Winston Salem, NC 27101 for purpose of treatment / counseling services at HOPE Counseling
I understand that my substance use disorder records are protected under the Federal regulations governing Confidentiality and substance Use Disorder Patient Records, 42 C.F.R. Part 2, and the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), 45 C.F.R. pts 160 & 164, and cannot be disclosed without my written consent unless otherwise provided for by the regulations.
I understand that I may revoke this authorization at any time except to the extent that action has been taken in reliance on it. Unless I revoke my consent earlier, this consent will expire automatically as follows:
(describe date/event/condition upon which consent will expire; must be no longer than reasonably necessary to serve the purpose of this consent)
I understand that I might be denied services if I refuse to consent to a disclosure for purposes of treatment, payment, or health care operations, if permitted by state law. I will not be denied services if I refuse to consent to a disclosure for other purposes.
Client Rights / Grievances
I understand my basic rights as a client. These rights include:
Fee Assessment and Collection Practices
Insurance: We are in network with most Insurance Companies that operate in this area. We do all the billing and assist with authorizations. Your insurance will often even pay for your assessment. If you have insurance it is often helpful for you to contact your insurance company and ask for authorization after your assessment and prior to entering counseling. This ensures the most likelihood that they will assist you with cost. We will contact your insurance company for authorization and benefits.
**In the rare case that they do not immediately authorize your counseling services, they will usually cover your services if you contact them and insist they provide authorizations and re-authorizations. Insurance companies do not handle substance abuse & mental health counseling, in the same manner, they do your typical doctor's treatment, despite the Parity Act. To save you money, client/patient involvement is sometimes necessary to ensure they assist you with paying for treatment. Insurance will usually pay for your DWI or alcohol and drug counseling programs except, typically, ADETS or education. However, keep in mind that this is for health insurance coverage for people who want treatment and follow the service plan.
Self-Pay/Cash: Allows those without insurance to pay cash for services. Our self-pay cost is among the lowest in the area. Payment plans may be arranged for post-trial DWI clients on a case-by-case basis.
Cancellations: Appointment times are set to accommodate our clients' schedules as often as possible. In order to receive the most success from therapy, it is in the client's best interest to keep their scheduled appointments on a regular basis. We encourage our clients to discuss any need to change an appointment. If you are unable to keep your scheduled appointment, we require that you contact our office at 336-631-1948. Once an appointment has been scheduled, we have a cancellation policy, which requires 24-hour notice.
**If you neglect to cancel your appointment with at least 24 hours advanced notice or miss an appointment entirely, there will be a late cancellation or "no show" fee of $25.00. By law, we are not permitted to submit a claim to any insurance company for late cancellations and missed appointments. At HOPE Counseling & Consulting Services, we recognize that unforeseen circumstances do occur. We do permit our clients a one-time exception to our late cancellation or "no show" fee within a six-month span during treatment.
I certify that I have read and understand this Fee Assessment and Collection Practices.
AUTHORIZATION FOR THE RELEASE OF INFORMATION
Date of Birth:
Phone: H) Phone: W)
Above listed patient authorizes the following facility to make record disclosure:
Facility Phone: Facility Fax:
The purpose of disclosure is:
I understand the information in my record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services, and treatment for alchohol and drug abuse.
This information may be disclosed and used by the following individual or organization:
I understand I may revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing and present my written revocation to the health information management department. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. Unless otherwise revoked, this authorization will expire on the following date, event, or condition: . If I fail to specify an expiration date, event, or condition, this authorization will expire 1 year from the date signed. I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment. I understand that I may inspect or obtain a copy of the information to be used or disclosed, as provided in CFR 164.524. I understand that any disclosure of information carries with the potential for unauthorized redisclosure and the information may not be protected by federal confidentiality rules. If I have questions about disclosure of my health information, I can contact the authorized individual or organization making disclosure.
I have read the above foregoing Authorization for Release of Information and do hereby acknowledge that I am familiar with and fully understand the terms and conditions of this authorization.
Advance Beneficiary Notice of Non-coverage (ABN)
NOTE: If your insurance doesn’t pay for r D. Mental Health below, you may have to pay.
Your insurance may not offer coverage for the following services even though your health care provider advises these services are medically necessary and justified for your diagnoses.
We expect may not pay for the D. Mental Health below.
D. - Mental Health Services
E. Reason Insurnace May Not Pay: - Various reasons. You will need to Various contact your insurance company.
F. Estimated Cost - Various
WHAT YOU NEED TO DO NOW:
G. OPTIONS: Check only one box. We cannot choose a box for you.
I want the D. listed above. You may ask to be paid now, but I also want my insurance billed for an official decision on payment, which is sent to me as an Explanation of Benefits. I understand that if my insurance doesn’t pay, I am responsible for payment, but I can appeal to . if . does pay, you will refund any payments I made to you, less co-pays or deductibles.
I want the D. listed above, but do not bill . You may ask to be paid now as I am responsible for payment.
I don’t want the D. listed above. I understand with this choice I am not responsible for payment.
H. Additional Information:
This notice gives our opinion, not a denial from your insurance company. If you have other questions on this notice please ask the front desk person, the billing person, or the physician before you sign below. Signing below means that you have received and understand this notice. You also receive a copy.
Leave this empty:
Your legal name
Your email address
Signed by Linda McRae
Signed On: December 13, 2022
If you have questions about the contents of this document, you can email the document owner.
Document Name: Client Consent Form
Agree & Sign