Consent to the Use & Disclosure of Health Information for Treatment/ Payment/Healthcare Operations
I understand that as part of my/my minor’s healthcare, Heart Light Psychological Services, P.C. originates and maintains paper and/or electronic records describing my health history, symptoms, examination and test results, diagnoses, treatment, and plans for future care or treatment. I agree to assume financial responsibility for all outstanding balances not covered by the disclosure of services to the insurance policy. I understand and have been provided with a Notice of Privacy Practices that include the Health Insurance Portability and Accountability Act (HIPPA) that provides a more complete description of information uses and disclosures. I do hereby consent and acknowledge my agreement to the terms set forth in the HIPPA information form. I understand that this consent shall remain enforced from this time forward. I understand that I have the following rights and privileges: the right to review the notices prior to signing this consent and the right to request restrictions as to how my/my minor’s health information may be used or disclosed to carry out treatment, payment, or healthcare operations. I understand that Heart Light Psychological Services, P.C. is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing to Heart Light Psychological Services, 2201 Waukegan Rd. Suite #145, Bannockburn IL 60015, except to the extent that the organization has already taken action in reliance thereon. I also understand that refusing to sign this consent or revoking this consent, the practice may refuse to treat me/ my minor. I further understand that Heart Light Psychological Services reserves their rights to change their notices and practices. Prior to implementation, Heart Light Psychological Services will send a copy of the revised notice to the address/ contact information I have provided.
TELEHEALTH: Confidentiality still applies for telepsychology services, and no one will record the session without permission from the other person(s). We both agree to use the video- conferencing platform selected for our virtual sessions, and the provider will explain how to use it. You need to use a webcam or smartphone during the session. It is important to be in a quiet, private space, that is free of distractions (including cell phone or other devices) during the session. It is important to use a secure internet connection rather than public/free Wi-fi. There are potential benefits and risks of video-conferencing (e.g. limits to patient’s confidentiality) that differ from in-person sessions. Informed consent for all parties involved or present during telehealth session is required, whether it is consent from a parent of a minor or someone helping to set up the technology equipment during the telehealth session. It is important to be on time for the telehealth appointment. If you need to cancel or change your tele-appointment, you must notify the provider 24 hours in advance by phone or email. We need to agree on a back-up plan (e.g. phone number where you can be reached) to restart the session or to reschedule it, in the event of technical problems. We need to agree on a safety plan that includes at least one emergency contact and the closest emergency room to your location, in the event of a crisis situation. If you are not an adult, we need the permission of your parent or legal guardian (and their contact information) for you to participate in telepsychology sessions. As your provider, we may determine that due to certain circumstances, telepsychology is no longer appropriate, and recommend that we complete sessions in-person or refer you to another provider and agency. You have the right to choose your treatment modality, although the provider may not be able to accommodate in-person sessions due to concerns of health and safety for all parties involved.
I understand as a part of this organization’s treatment, payment, or healthcare operations, it may become necessary to disclose my protected health information to another entity. Your provider may be required by law to release information without your permission to specific professionals and authorities if there is a serious and specific threat of imminent harm to self or others, there is reasonable cause to believe a child or elder adult has been abused or neglected, and in some judicial and administrative proceedings (e.g. court proceedings, court orders, lawsuits). This disclosure may occur via phone and/or fax. I agree to the above confidentiality, general policies of Heart Light, and consent to disclosure for permitted uses.