Patient Registration Form

We have implemented a policy requiring a credit card held on file. As you may be aware, the current healthcare market has resulted in insurance policies increasingly transferring costs to you, the insured. Some insurance plans require deductibles and copayments in amounts not known to you or us at the time of your visit. 

Similar to hotels and car rental agencies, you are asked for a credit card number at the time you check-in, and the information will be held securely until your insurance(s) have paid their portion and notified us of the amount of your share, then you will receive a statement. This card can be charged for the following reasons:

• Visit payments not collected from you at the beginning of your visit
• No-show or late cancellation charges
• Insurance discrepancies that are not resolved within 90 days of the date of service
• Outstanding balance greater than 90 days past due.

This is an advantage since it makes checkout easier, faster, and more efficient. This in no way will compromise your ability to dispute a charge or question your insurance company's determination of payment.

By signing this form, I am authorizing Center for New Pathways to charge my credit card for copays 24 hours prior to the session, and any balances that are left after insurance payments.

I understand that I am eligible to receive a range of services from my provider. The type and extent of services that I receive will be determined following an initial assessment and thorough discussion with me. The goal of the assessment process is to determine the best course of treatment for me. Typically, treatment is provided over the course of several weeks.

I understand that I have the right to ask questions throughout the course of treatment and may request an outside consultation. (I also understand that my provider may provide me with additional information about specific treatment issues and treatment methods on an as-needed basis during treatment and that I have the right to consent to or refuse such treatment). I understand that I can expect regular review of treatment to determine whether treatment goals are being met. I agree to be actively involved in the treatment and in the review process. No promises have been made as to the results of this treatment or of any procedures utilized within it. I further understand that I may stop treatment at any time but agree to discuss this decision first with my provider. 

I am aware that I must authorize my provider, in writing, to release information about my treatment but that confidentiality can be broken under certain circumstances of danger to myself and others. I understand that once information is released to insurance companies or any third party, that my provider cannot guarantee that it will remain confidential. When consent is provided for services, all information is kept confidential, except in the following circumstances:

• When there is risk of imminent danger to myself or to another person, my provider is ethically bound to take necessary steps to prevent such danger.
• When there is suspicion that a child or elder is being sexually or physically abused, or is at risk of such abuse, my provider is legally required to take steps to protect the child or the elder, and to inform the proper authorities. 
• When a valid court order is issued for medical records, my provider is bound by law to comply with such a request. 

While this summary is designed to provide an overview of confidentiality and its limits, it is important that you read the Notice of Privacy Practices which was provided to you for more detailed explanations, and discuss with your provider any questions or concerns you may have. 

By my signature below, I voluntarily request and consent to behavioral health assessment, care treatment, or services and authorize my provider to provide such care, treatment or services as are considered necessary and advisable. I understand the practice of behavioral health treatment is not an exact science and acknowledge that no one has made guarantees or promises as to the results that I may receive. By signing this Informed Consent to Treatment Form, I acknowledge that I have both read and understood the terms and information contained herein. Ample opportunity has been offered to me to ask questions and seek clarification of anything unclear to me.

Our Notice of Privacy Practices provides information about how we may use or disclose protected health information. The notice contains a patient's rights section describing your rights under the law. You ascertain that by your signature you have reviewed our notice before signing this consent. The terms of the notice may change; if so, you will be notified at your next visit to update your signature/date. You have the right to restrict how your protected health information is used and disclosed for treatment, payment, or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations. 

By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive. 

By signing this form, I understand that: 

• Protected health information may be disclosed or used for treatment, payment, or healthcare operations.
• The practice reserves the right to change the privacy policy as allowed by law.
• The practice has the right to restrict the use of the information, but the practice does not have to agree to those restrictions. 
• The patient has the right to revoke this consent in writing at any time, and all full disclosures will then cease.
• The practice may condition receipt of treatment upon execution of this consent. 

Telehealth involves the use of electronic communications to enable healthcare providers at different locations to share individual patient medical information for the purpose of improving patient care. Providers may include primary care practitioners, specialists, and/or subspecialists. The information may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following:

• Patient medical records
• Medical images
• Live two-way audio and video
• Output data from medical devices and sound and video files

Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption. Responsibility for the patient care should remain with the patient's local clinician, if you have one, as does the patient's medical record.

Expected Benefits:

• Improved access to medical care by enabling a patient to remain in his/her local healthcare site (i.e., home) while the physician consults and obtains test results at distant/other sites.
• More efficient medical evaluation and management.
• Obtaining the expertise of a specialist.

Possible Risks:

As with any medical procedure, there are potential risks associated with the use of Telehealth. These risks include, but may not be limited to: 

• In rare cases, the consultant may determine that the transmitted information is of inadequate quality, thus necessitation a face-to-face meeting with the patient, or at least a rescheduled video consult;
• Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment;
• In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information;
• In rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors;
   

By checking the box associated with "Informed Consent," You acknowledge that you understand and agree with the following:

1. I understand that the laws that protect privacy and the confidentiality of medical information also apply to Telehealth, and that no information obtained in the use of Telehealth, which identifies me, will be disclosed to researchers or other entities without my written consent. 
2. I understand that I have the right to withhold or withdraw my consent to the use of Telehealth in the course of my care at any time, without affecting my right to future care or treatment.
3. I understand the alternatives to Telehealth consultation as they have been explained to me, and in choosing to participate in a Telehealth consultation, I understand that some parts of the exam involving physical tests may be conducted by individuals at my location, or at at testing facility, at the direction of the consulting healthcare provider. 
4. I understand that Telehealth may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including out of state. 
5. I understand that I may expect the anticipated benefits from the use of Telehealth in my care, but that no results can be guaranteed or assured.
6. I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. Others may also be present during the consultation other than my healthcare provider and consulting healthcare provider in order to operate the video equipment. The above-mentioned people will all maintain confidentiality of the information obtained.
7. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history/physical examination that are personally sensitive to me; (2) ask non-medical personnel to leave the Telehealth examination room; and/or (3) terminate the consultation at any time. 

Patient Consent To The Use of Telehealth:

I have read and understand the information provided above regarding Telehealth, have discussed it with my physician or such assistants as may be designated, and all of my questions have been answered to my satisfaction. I have read this document carefully, and understand the risks and benefits of the teleconferencing consultation and have had my questions regarding the procedure explained and I hereby give my informed consent to participate in a Telehealth visit under the terms described herein. By checking the Box containing "INFORMED CONSENT FOR TELEHEALTH SERVICES," I hereby state that I have read, understood, and agree to the terms of this document.