Patient Consent/Contract for Treatment:
This form is called a Consent for Services (the "Consent"). Your therapist, counselor, psychologist, doctor, or other health professional ("Provider") has asked you to read and sign this Consent before you start therapy. Please review the information. If you have any questions, contact your Provider
As a participant in treatment for medications and/ or therapy, I freely and voluntarily agree to accept this treatment contract as follows:
CONSENT FOR MEDICAL TREATMENT
I hereby consent to the performance of such medical treatment, as deemed necessary or advisable by my provider and/or their associates. I hereby consent to the performance of all technical procedures and tests as directed by my provider. I am aware that the practice of Medicine is not an exact science and I acknowledge that no guarantees have been made to me as a result of treatments or examination
1.) I agree to keep and be on time to all my scheduled appointments.
2.) I agree to adhere to the payment policy outlined by this office. Payments must be made PRIOR to the visit via credit card. (Unless other arrangements have already been made with your assigned provider).
3.) I agree to conduct myself in courteous manner in the doctor's office.
4.) I agree not to sell, share, or give any of my medication to another person. I understand that such mishandling of my medication is a serious violation of this agreement and would result in my treatment being terminated without any recourse for appeal.
5.) I agree not to deal, steal, or conduct any illegal or disruptive activities in the doctor's office.
6.) I understand that if dealing or stealing or if any illegal or disruptive activities are observed or suspected by employees of the pharmacy where my medications are filled, that the behavior will be reported to my doctor's office and could result in my treatment being terminated without and recourse for appeal.
7.) I agree that my medication/prescription can only be given to me at my regular office visits. A missed visit may result in my not being able to get my medication/prescription until the next scheduled visit.
8.) I agree that the medication I receive is my responsibility and I agree to keep it in a safe, secure place. I agree that lost medication will not be replaced regardless of why it was lost.
9.) I agree not to obtain medications from any doctors, dentists, pharmacies, or other sources without telling my treating provider.
10.) I will let my provider know of all medications that I am being currently prescribed including those given by other treatment providers.
11.) I agree to take my medication as my provider has instructed and not to alter the way i take my medication without first consulting my doctor.
12.) I understand that medication alone is not sufficient treatment for my condition, and I agree to participate in counseling as discussed and agreed upon with my provider and specified in my treatment plan.
13.) I agree to abstain from alcohol, opioid, marijuana, cocaine, and other addictive substances( except nicotine)
14.) I agree to provide random urine samples or testing( if requested) and have my provider test my blood alcohol level.
15.) We do not take any responsibility for any failure of insurance reimbursements. you will be billed for any balances you are responsible for * Suboxone treatment is a service that is unable to be reimbursed from insurance and is private pay only.
16.) If you have not been compliant with your treatment visits for a period of 90 days, your case will be considered closed/inactive and be terminated from treatment of which we will send you a notification on the 90th day.
17.) If you are terminated from the practice you will not be able to reschedule with our practice. you will be referred to other providers whom provide similar services.
18.) I agree to inform my providers if I am, maybe, or planning to become pregnant.
19.) You must let your provider or the staff know of any changes in your insurance policy, otherwise, you will be responsible for the charges incurred.
20.) I agree to present a valid insurance card (if applicable) and driver's license or photo ID.
21.) I understand payment will be collected at every office visit prior to being seen by the physician. All copayments for the date of service of your scheduled appointment will be collected each morning in the beginning of the business day.
22.) I understand that South Shore Psychiatry, is not an emergency service and if it is not a detrimental emergency, South Shore Psychiatry will respond to your inquiry within a reasonable time frame.
23.) I understand that I will need to call 7 days prior of you “running out” of your medication.
24.) I authorize South Shore Psychiatry to provide my insurance plan or managed care plan any information reasonably required to obtain health benefits and authorization for services.
25.) I authorize South Shore Psychiatry to obtain at any time during my treatment, any and all relevant clinical information from clinicians and facilities who have treated me and to furnish clinical information to providers who will continue to treat me. I will indicate in writing any exceptions to this.
26.) I understand that South Shore Psychiatry reserves the right to stop treating me if I do not adhere to this agreement.
27.) I consent for South Shore Psychiatry to view the NYS Prescription Monitoring registry - a list of all controlled substances will appear on this registry if prescribed by a doctor.