I authorize Serenity Bay Health which consists of physicians, mid-levels, and other qualified healthcare personnel to treat me and also to recommend and/or order laboratory tests and other specialized tests as indicated for my medical/psychiatric condition. I am consenting to treatment for both in person appointments and telehealth visits. I understand that my involvement with Serenity Bay Health will likely involve multiple appointments and therefore this consent will carry full force and effect from the time of signature until I am no longer a patient at Serenity Bay Health.

Privacy Notice

The Health Insurance Portability and Accountability Act governs the use and release of a patient’s personal health information also known as protected health information or PHI. Under the HIPAA privacy regulations, patients must be informed about how their PHI will be used and given the opportunity to object to or restrict the use or release of their information.

HIPAA does allow for some exceptions which includes but is not limited to the following:

1.     Healthcare facilities, including Serenity Bay Health, may use and disclose PHI without a patient’s consent for purposes of treatment, payment, and clinic operations. We also may share your health information with others who provide care to you, such as hospitals, doctors, nurses, therapists, pharmacies, and others involved in your care.

2.     When an individual poses a serious and imminent threat to themselves or someone else, HIPAA does allow a provider to disclose necessary protected health information to anyone who may be in a position to prevent or lessen the threat of harm without a patient’s consent. This may include family, friends, caregivers and/or law enforcement.

Informed Consent for Psychotropic Medications

I understand that my treatment at Serenity Bay Health may involve the use of psychotropic medications. My provider will be discussing all changes to my medications during my scheduled appointment. There will be a discussion about risks and benefits, and I understand that my provider will be asking for my verbal consent prior to the initiation of any medication. I also understand that educational materials for each medication will be provided to me within the patient portal that I can access at any time. This information may also be provided in paper form upon request. These educational materials will provide a list of common side effects and contraindications and it will also inform me of the potential benefits. I understand that my provider will be available to answer any additional questions regarding medications that are prescribed at Serenity Bay Health. By signing this form, I am giving my consent to the use of psychotropic medications for the treatment of my underlying psychiatric condition.

Financial Policy

I understand my insurance company will be billed on my behalf.  I authorize the release of any information including the diagnosis and the records of any treatment or examination rendered to myself or my child to third party payers.

Full payment for services is due at the time of service. This includes any copayments, coinsurance, and deductibles. If full payment is not paid at time of service, Serenity Bay Health may not schedule future appointments until full payment is made. Serenity Bay Health does reserve the right to cancel my appointment if proof of insurance cannot be verified. 

I understand I’m responsible for providing proof of insurance and identification at each visit. I understand there are services that may not be covered by my insurance and there are insurance carriers that do not currently contract with Serenity Bay Health. In these circumstances, I’m responsible for payment not covered by my insurance carrier. For example, Serenity Bay Health does not currently contract with Medicaid. If you only have Medicaid insurance, you are responsible for cash payment for services provided. If Medicaid is your secondary insurance, you are required to cover what your primary insurance doesn’t cover in cash. 

In the case that you do not have insurance coverage or Serenity Bay Health does not contract with your insurance carrier, you can elect to self-pay for services rendered. Please call the office for self-pay options. 

While Serenity Bay Health strives to be transparent about insurance coverage and your financial obligations, it is ultimately your responsibility to understand what your insurance covers and what it does not cover. Furthermore, there may be occasions when additional costs are incurred. For example, medical record requests and requests for Serenity Bay Health staff to complete paperwork such as FMLA, disability paperwork, etc.

• Missed appointments will be charged $100 for initial Psychiatric evaluation, $75 for Psychiatric follow-up visit and $75 for psychotherapy. You are required to provide at least a 24 hour notice if you need an appointment to be changed or canceled. 

• If you have three or more no shows and/ or late cancellations in a rolling calendar year, you may be discharged from Serenity Bay Health.

• Returned checks will be charged $50.

Patient Rights and Responsibilities

Serenity Bay Health strives to provide comprehensive, quality healthcare to address your personal care, safety, and concern. To accomplish this goal, we believe that you, as our patient, have the responsibility to make decisions regarding your healthcare and have the right to the following:

• Receive unbiased access to treatment. Treatment will be provided to our patients without regard to sex, or cultural, economic, educational, or religious backgrounds.

• Have cultural and personal values, beliefs and preferences respected.

• Be treated by medical and non-medical staff with consideration, dignity, and respect, in a safe environment that is free from all forms of abuse, neglect, harassment and/or exploitation.

• Access protective and advocacy services or have these services accessed on your behalf.

• Examine and receive an explanation of your bill regardless of source of payment.

• Information regarding office policies.

• Receive treatment which is appropriate and complies with the standard of care in the community.

• Receive reasonable continuity of care.

• Be informed of continuing healthcare treatments and requirements. 

• Have knowledge of the name of the physician who has the primary responsibility for coordinating your care and the names of other physicians and nonphysician staff who are involved in your treatment.

• Seek a second opinion and to seek specialty care. 

• Receive information from your provider about your illness, course of treatment, outcomes of care (including unanticipated outcomes), and your prospects for recovery in a manner you understand.

• Participate in the development and implementation of your care and actively participate in decisions regarding your care. To the extent permitted by law, this includes your right to request or refuse treatment. 

• Obtain from your physician information concerning current diagnosis, treatment plan (including risks and benefits), and alternate plans and prognoses to give informed consent or refuse treatment. If you choose to refuse treatment, you have the right to be informed of the medical consequences of that decision. 

• Formulate advance directives regarding your healthcare and have office staff and practitioners who provide care in the office comply with these directives (to the extent provided by state laws and regulations).

• Be informed that all information concerning your medical care and records will be treated in a confidential manner. Written permission will be obtained from you, or the person who has legal responsibility to make decisions for you, before medical records are released to anyone not directly related and/or involved in your care.

• Access information contained in your medical record within a reasonable time frame.

• Receive a response to any reasonable request for service. 

• Have all your patient’s rights apply to the person who may have legal responsibility to make decisions regarding medical care on your behalf.

• Be aware that Serenity Bay Health is committed to high standards of care, safety, and hospitality for patients and their families. 

You have the responsibility to:

• Keep appointments and notify clinic personnel 24 hours prior, if unable to keep scheduled appointment.

• Be involved and follow the plan of care.

• Provide a complete medical history, medications, and other matters relating to your health.

• Inform the provider of any changes in your health condition.

• Provide a copy of your Medical Advance Directive and/or Medical Power of Attorney (if applicable and in effect) and guardianship documentation.

• Ask questions about specific problems and request information when not understanding your illness or treatment.

• Accept results or consequences if you refuse treatment, do not follow the provider’s recommendations, or leave the clinic against medical advice.

Telemedicine involves the use of electronic communications to enable health care 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.

Expected Benefits

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

Possible Risks

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

• In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision making by the physician and consultant(s).
• 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 reaction or other judgment error.

BY SIGNING THIS FORM, I ATTEST TO AND UNDERSTAND THE FOLLOWING:

1. I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine, and that no information obtained in the use of telemedicine which identifies me will be disclosed to researchers or other entities without my consent.
2. I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment.
3. I understand that I have the right to inspect all information obtained and recorded in the course of telemedicine interaction, and may receive copies of this information for a reasonable fee.
4. I understand that a variety of alternative methods of medical care may be available to me, and that I may choose one or more of these at any time.
5. I understand that telemedicine may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including out of state.
6. I understand that it is my duty to inform Serenity Bay Health of electronic interactions regarding my care that I may have with other healthcare providers.
7. I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.

PATIENT CONSENT TO THE USE OF TELEMEDICINE

I have read and understand the information provided above regarding telemedicine, 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 hereby give my informed consent for the use of telemedicine in my medical care.

I understand a copy of this form will be available for me to print upon request.

I hereby authorize Serenity Bay Health to use telemedicine in the course of my diagnosis and treatment.