Consent for Care:
I authorize The SHOW Center, and any employee working under the direction of The SHOW Center to provide healthcare for me. This medical care may include services such as: preventative services, diagnostic, therapeutic, rehabilitative, maintenance, palliative care, counseling, assessment of physical and/or mental status, recommendations for care, referral, prescriptions and follow up care.
Consent for Release of Information:
I authorize The SHOW Center to furnish my medical information to identified insurance carriers for any and all submissions for out of network claims. In the event that I desire my medical information to be sent elsewhere, I understand a separate consent form will need to be signed.
I understand that my fee covers the time and expertise of the providers at The SHOW Center. While every attempt will be made to treat my concerns, I understand that in some cases, referral is required. I understand that The SHOW Center is an out of network provider, this allows us to spend more time with you without the limitations placed by insurance plan, and the fee will be due in full at the time of the appointment. If you are unable to pay at the time of your visit, we will reschedule your visit. We accept most major credit cards and you can utilize your HSA or FSA account. Because we are an out of network provider your insurances may or may not cover the visit and the reimbursement may vary in coverage, and it is the patient's responsibility to understand medical benefits and requirements. We recommend that the patient verifies insurance benefits for any procedures, surgeries, tests or other services scheduled. You will be responsible for 100% of your total out of pocket responsibility amount prior to any procedures, visits, testing, or services. We do our best to estimate your financial responsibility up front, but please understand this is only an estimate. We will give you a super bill after your visit and will make every effort to address and code such things that are typically covered by most commercial insurance plans. However, given the nature of many topics discussed, some insurance companies may deny coverage, and therefore decline payment. We are an out of network provider and have been told you can expect reimbursement of 30%-80% of your bill. Because every plan varies, I understand it is my responsibility to verify applicable coverage prior to receiving services. These decisions are, unfortunately, out of our control. We are hopeful that this will change in the near future, and that insurance companies will realize that sexual health is an important part of overall health. We appreciate your trust in our care and your help in trying to make important changes in the ever shifting landscape of healthcare.
The SHOW Center will not share my demographic or healthcare information with anyone except my insurance company, as noted above, or any other party unless another consent form giving this permission is signed. I understand that The SHOW Center will occasionally consult with other healthcare providers and in this case, they will not use any identifying information when presenting my case. I understand that the consultation is at the cost of The SHOW Center, and not myself, unless agreed otherwise. I understand that The SHOW Center will maintain my healthcare information in a secure electronic health record. I give permission to The SHOW Center to retrospectively evaluate my information in an anonymous fashion for possible publication of descriptive research. I understand that no research is currently being performed with me as a participant and another consent form would need to be completed if I desired to be involved in other research or clinical trials.
Communication about MY Healthcare
I agree that the provider and/or agent of the provider or the clinic office may contact me for the purposes of scheduling necessary follow-up visits recommended by the treating provider.
Use of Electronic Medical Health Record:
This practice/clinic uses an electronic health record that will update all your demographics and consents to the information you provided. Please note that this information will also be updated for your convenience to all our affiliated locations that share an electronic health record in which you have a relationship. I authorize this practice/clinic to use their electronic health record to keep all of my health records at this time.
Use of ePrescribing via our Electronic Medical Health Record:
Our practice participates in ePrescribing via our electronic medical record (EMR) which has achieved Certification Commission for Health Information Technology (CCHIT) certification. Electronic prescriptions are submitted to the pharmacy designated by the patient.
Use of Telemedicine/Telehealth Services:
I authorize and agree that some services may involve the use of telemedicine or telehealth equipment and interaction with providers that are outside of my physical presence. I understand that I will be advised in advance of any such use of technology.
Consent for Photographing or Other Recording for Security and/or Health Care Operations:
I consent to photographs, digital or audio recordings, and/or images of me being recorded for patient care, security purposes and/or the practice/clinic’s health care operations purposes (e.g., quality improvement activities). I understand that the practice/clinic retains the ownership rights to the images and/or recordings. I will be allowed to request access to or have copies of the images and/or recordings when technologically feasible unless otherwise prohibited by law. I understand that these images and/or recordings will be securely stored and protected. Images and/or recordings in which I am identified will not be released and/or used outside the facility without a specific written authorization from me or my legal representative unless otherwise permitted or required by law.
Consent to Email, Cellular Telephone or Text usage for Appointment Reminders/Healthcare Communications:
If at any time I provide an email address or cellular phone number at which I may be contracted, I consent to receiving unsecure instructions and other healthcare communications at the email or text address I have proved or you or your EBO Servicer have obtained, at any text number forwarded, or transferred from that number.
These instructions may include, but not limited to: post-procedure instructions, follow-up instructions, educational information, and prescription information. Other healthcare communications may include but are not limited to, communications to family or designated representatives regarding my treatment or condition, or reminder messages to me regarding appointments for medical care. I understand that I may opt out of these communications at any time. The practice/clinic does not charge for this service, but standard text messaging rates or cellular phone minutes may apply as provided in your wireless plan.
Social Media - Facebook, Twitter, LinkedIn, Instagram, Pinterest, Etc:
It is my policy not to accept "friend" or "connection" requests from any current or former client on my personal social networking sites such as Facebook, Twitter, Instagram, Pinterest, etc. because it may compromise your confidentiality and blur the boundaries of our relationship.
I may post therapeutic content on my professional blog. If you have an interest in following my blog, please feel free to do so. However, please be mindful that the general public may see that you're following my blog. Once again, maintaining your confidentiality is a priority.
Communication Response Time:
My practice is considered to be an outpatient facility, and I am set up to accommodate individuals who are reasonably safe and resourceful. I do not carry a beeper. I am NOT available at all times. If at any time this does not feel like sufficient support, please inform me, and we can discuss additional resources or transfer your case to a therapist or clinic with 24-hour availability. I will return phone within 24 hours. However, I do not return calls on weekends or holidays. If you are having a mental health emergency and need immediate assistance, please follow the instructions below.
In Case of an Emergency:
If you have a mental health emergency, I encourage you not to wait for communication back from me, but do one or more of the following:
Call Behavioral Health Link/GCAL: 800-715-4225
Call Ridgeview Institute at 770.434.4567
Call Peachford Hospital at 770.454.5589
Call Lifeline at (800) 273-8255 (National Crisis Line)
Go to the emergency room of your choice.
In the unfortunate event that your account is turned over to our Collection Agency a 30% fee will be billed to your account.
Due to federal regulations, you must be able to provide your current insurance card (for lab work when necessary) at every appointment, along with a photo ID. Without these cards we will not be able to see you or you may be responsible for payment (of labs) at the time of service.If you are under the age of 18, your parent or guardian must provide these items. Please call with any insurance questions. We are not currently accepting any new patients with Medicaid and we are opted-out of Medicare plans.
We look forward to working with and thank you for entrusting us with your care.
By signing below, I hereby agree to and understand the financial policy for The SHOW Center and give consent to the providers to treat my medical concerns and bill for professional services rendered.