CONSENT FOR OUTPATIENT MENTAL HEALTH TREATMENT

Consent to Evaluate/Treat both in-person and/or via telehealth: I voluntarily consent that I will participate in a mental health (e.g., psychosocial, psychiatric) evaluation and/or treatment by clinical staff at Families First Counseling and Psychiatry (FFCP). I understand that following the evaluation and/or treatment complete and accurate information will be provided concerning each of the following areas:

1. The benefits of the proposed treatment
2. Alternative treatment modes and services
3. The manner in which treatment will be administered
4. Expected side effects from the treatment and/or the risks of side effects from medications (when applicable).
5. Probable consequences of not receiving treatment

The evaluation or treatment will be conducted by licensed providers at FFCP.

Benefits to Evaluation/Treatment: Evaluation and treatment may be administered with psychosocial assessment, psychiatric evaluation, psychotherapy, medication management, as well as expectations regarding the length and frequency of treatment. Uses of this evaluation include diagnosis, evaluation of recovery or treatment, estimating prognosis, and education and rehabilitation planning. Possible benefits to treatment include improved cognitive or academic/job performance, health status, quality of life, and awareness of strengths and limitations.

Confidentiality, Harm, and Inquiry: Information from my evaluation and/or treatment is contained in a confidential record at Families First Counseling and Psychiatry, and I consent to disclosure for use by Families First Counseling and Psychiatry staff for the purpose of continuity of my care. Per Maryland law, information provided will be kept confidential with the following exceptions: 1) if I am deemed to present a danger to myself or others; 2) if concerns about possible abuse or neglect arise; or 3) if a court order is issued to obtain records.

Regarding Telehealth Specific Services: I understand that my provider may wish me to engage in a telehealth consultation, either exclusively or intermittently during my treatment. I understand that a telehealth consultation has potential benefits including easier access to care and the convenience of meeting from a location of my choosing. I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my provider or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation. I have had a direct conversation with my provider, during which I had the opportunity to ask questions in regard to this procedure. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which understand. I understand that telehealth includes the practice of diagnosis, consultation, treatment, transfer of mental health data and communication of my medical/mental health information. I understand that I need to be physically located in Maryland while receiving telehealth services through Families First Counseling and Psychiatry

I understand that I have the following rights with respect to telehealth: The right to withhold or withdraw consent at any time without affecting my right to future care or treatment. The laws that protect the confidentiality of my medical and mental health information also apply to telehealth services, and that there are mandatory exceptions to this confidentiality, including but not limited to reporting child, elder, and dependent adult abuse in addition to expressed threats of violence towards self and/or others.

Consent to Use the Telehealth by Selected Service Provider: Telehealth by Doxyme is the technology service we will use to conduct telehealth video conferencing appointments. However, FFCP reserves the right to change providers as they see fit as long as it is HIPPA compliant. It is simple to use and your provider will give you the link needed prior to your appointment time. By signing this document, I acknowledge:

1. Telehealth by Doxyme or any other provider is NOT an Emergency Service and in the event of an emergency, I will use a phone to call 911.
2. To maintain confidentiality, I will not share my telehealth appointment link with anyone unauthorized to attend the appointment.

In Case of an Emergency: I understand that my therapist may contact my emergency contact and/or appropriate authorities in case of emergency. Emergency Contact Person (ECP): {emergencyContact} Contact Telephone Number: {emergencyContact121}

If you have a mental health emergency: Call the 24/7 crisis hotline at 988 or 1-800-273-8255. You can also go to the emergency room of your choice.

Emergency Procedures specific to Telehealth services: 

There are additional procedures that we need to have in place specific to Telehealth services. These are for your safety in case of an emergency and are as follows: 
By signing this document, I understand that if I am having suicidal or homicidal intention, experiencing psychotic symptoms, or in a crisis that my clinician cannot solve remotely, my clinician may determine that I need a higher level of care and Telehealth services are not appropriate. 

I will verify that my ECP is willing and able to go to your location in the event of an emergency. If I am unable to do this, my clinician will do this on my behalf. Determination of what is needed will be made in collaboration with myself, my ECP and my clinician, which may include, but is not limited to, my ECP driving me to a hospital. 

Your signature at the end of this document indicates that you understand your clinician will only contact this individual in the extreme circumstances stated above. In a life-threatening emergency only, my Emergency Contact Person (ECP) that I have specified below will be contacted on my behalf.

Discharge Policy: There are circumstances under which I may be involuntarily discharged. I have read and understand the discharge policy of the clinic. 

1) The client exhibits physical violence, verbal abuse, carries weapons, or engages in illegal acts at the clinic.

2) The client refuses to comply with stipulated program rules, refuses to comply with treatment recommendations or does not make payment in a timely manner.

3) Frequent no shows for treatment. 

The client will be notified of the non-voluntary discharge by letter. The client may appeal this decision with the Area Director or request to re-apply for services at a later date.

Right to Withdraw Consent: I have the right to withdraw my consent for evaluation and/or treatment at any time by providing a written request to the treating clinician. 

Expiration of Consent: This consent to treat will expire 24 months from the date of signature, unless otherwise specified.

By signing this form, I certify that: I have read or had this form read and/or explained to me and I understand its contents, including the risks and benefits of the procedure(s), I have been given the opportunity to ask questions, and those questions have been answered. I consent to the evaluation and treatment. I also attest that I have the right to consent for treatment. I understand that I have the right to ask questions of my service provider about the above information at any time.

CONSENT FOR PATIENT EMAIL AND TEXT MESSAGING

I confirm that I wish to communicate with Families First Counseling and Psychiatry, if given the option, by email/text and have read and understand the following information:

Risks of using Email/Text Messaging: Transmitting patient information by email and/or text messaging has a number of risks that clients should consider prior to the use of email and/or text messaging. These include, but are not limited to, the following risks:

1. Email and text senders can easily misaddress an email or text and send information to an undesired recipient. Backup copies of emails and texts may exist even after the sender and/or the recipient has deleted his or her copy.
2. Emails and texts can be intercepted, altered, forwarded or used without authorization or detection.
3. Employers and on-line services have a right to inspect emails sent through their company systems.
4. Email and texts can be used as evidence in court.
5. Emails and texts may not be secure and therefore it is possible that the confidentiality of such communications may be breached by a third party.

Conditions for the use of email and text messages: Providers at Families First Counseling and Psychiatry cannot guarantee, but will use reasonable means to maintain security and confidentiality of email and text information sent and received. Providers are not liable for improper disclosure of confidential information that is not caused by the provider's intentional misconduct. Patients/parents/legal guardians must acknowledge and consent to the following conditions:

1. It is my request to use email/text.
2. Any decisions to use email/text communication will be discussed in staff supervision and an entry will be made into my electronic medical record.
3. I understand that email and text are not a secure way to communication, and that this communication is not protected and the confidentiality of this communication cannot be guaranteed.
4. No emails/texts with urgent messages will be sent. Email and texting are not appropriate for urgent or emergency situations. Providers cannot guarantee that any particular email and/or text will be read and responded to within any particular period of time.
5. When sending emails/texts I will not identify anyone by name.
6. All communications will be documented in my medical record.
7. It is my responsibility to inform the providers at Families First Counseling and Psychiatry of any changes in email addresses, mobile numbers or lost mobile devices as soon as possible.
8. Any decision by either me or the provider to stop the use of email/text will be respected. Any resumption will therefore require a new consent form.
9. Confidentiality will be respected by providers at all times.
10. Email and texts should be concise. The patient/parent/legal guardian should call and/or schedule an appointment to discuss complex and/or sensitive situations.
11. All emails will be entered into the patient's electronic medical record; texts may be filed as well.
12. Patients/parents/legal guardians should not use email or texts for communication of sensitive medical
13. Provider is not liable for breaches of confidentiality caused by the patient or any third party.
14. It is the patient/parent/legal guardian's responsibility to follow up and/or schedule an appointment if warranted.

I have read and understand the above, have had an opportunity to ask questions about this information, and I consent to the use of text messaging and emails. I understand the risks associated with the communication of email and/or text messaging between my provider and me, and consent to the conditions and instructions outlined, as well as any other instructions that my provider may impose to communicate with me by email or text.

CLINIC INFORMATION POLICIES AND PROCEDURES

Click the link to review and/or download the above documents as confirmation of receipt: FFCP Patient Handbook

I have read and understand the above information confirmed by my signature below. I further confirm that I have received a physical or electronic copy of the above policies and have been given an opportunity to ask questions.

HIPAA Disclosure and Consent

Purpose of Disclosure:

I, the undersigned, hereby authorize the use and disclosure of my protected health information (PHI) for the purpose of treatment, payment, and healthcare operations.

Permitted Disclosures:

I understand that my PHI may be disclosed to healthcare providers involved in my treatment, for billing and payment purposes, and for quality improvement and compliance activities.

Other Disclosures:

I acknowledge that my PHI may be disclosed as required by law or when necessary to prevent a serious threat to health or safety.

Rights to Revoke:

I retain the right to revoke this consent at any time, except where information has already been disclosed based on this authorization.

I have read and understand the above information confirmed by my signature below that I have received a physical or electronic copy of the above policies and have had an opportunity to ask questions.

Advance Directive

If you are interested in information about Advance Directives, please review or download the following: Mental Health Advance Directive

Authorization For Release of Confidential Information

I understand that Families First Counseling and Psychiatry LLC are not contingent upon my decision to permit the release of this information and I have consented freely, voluntarily, and without coercion, and that the above information is accurate to the best of my knowledge. I understand that I have the right to revoke this authorization at any time to the extent that action has already been taken to comply with it. Information will NOT be disclosed to any other party without written consent of the parent or legal guardian. This release is protected under state and Federal Confidentiality Regulations (4s, CPR Part 2 and FS 90.503). A copy is valid in lieu of the original. This consent will expire twelve months after the date signed. I understand that this does not affect information released prior to this date. This document can be revoked at any time with the written consent of the client and/or guardian.

Financial Agreement and Policy

In consideration of services rendered to {clientName44} ("Patient), by Families First Counseling and Psychiatry ("Provider"), we the undersigned, jointly and severally agree to the terms and conditions of this Agreement. This Agreement covers all services rendered by the provider beginning {system date} and continuing for as long as the patient receives services.

Release of Information and Authorization to Pay Insurance Benefits: I hereby authorize the Provider to release any information related to the care and treatment of the Patient to third-party payors and their review agents which may be necessary to obtain benefits payable under any medical insurance plan for services rendered by the Provider. I understand that any benefit quotes or coverage information given to us by any member of the staff or representative of the Provider is not guaranteed and is only what the Provider has been told by our insurer, review agencies, and/or third party payors. I assign to the Provider all benefits due me from insurers, health management agencies, and/or third-party payors. I further authorize the Provider to discuss financial information with third parties for the limited purpose of collecting payment for services rendered.

Responsibility for Payment: I hereby guarantee payment to the Provider for services rendered to the Patient in accordance with the rate schedule that is in effect at the time of the service. If I notify the Provider that the patient is an enrollee or subscriber of a Health Maintenance Organization ("HMO") or other third-party payor that requires preauthorization for services, I understand that for services covered and authorized, I will be responsible for copayments or co-insurance payments. If a service is not covered by the third-party payor, I agree to pay the full amount of the service. If I do not give immediate notice to the Provider of any third-party that may pay for services but requires preauthorization or timely filing, I agree to pay for any charges not otherwise paid. I understand that it is my responsibility to provide a referral from my primary care physician should one be required for payment by my insurance company.

Medicare Assignment and Authorization (for Medicare Patients only): I certify that the information given by me in applying for payment under Title SVIII of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration or its intermediaries or carriers any information needed for this or a related Medicare claim. I request that payment of authorized benefits be made on my behalf for any services furnished by the Provider to this Patient. I assign the benefit payable for physician services to the physician or organization furnishing the services or authorizing such physician organization to submit a claim to Medicare for me. I understand that I am responsible for any health insurance deductible and co-insurance. 

This document serves to confirm that I wish myself/child to receive services from Families First Counseling and Psychiatry.

I hereby represent that the above listed client is eligible to receive the services as a Maryland Medicaid beneficiary. I understand that I am required by law to provide, at this time, information on any and all alternative insurance that may provide coverage for myself/my child, and I represent that the following coverage may be applicable.

I fully understand that any deliberate omission or failure to accurately report all insurance information may result in my being prosecuted for Medicaid fraud. In addition, I acknowledge that if any information provided herein by me proved to be incorrect or inaccurate, I may be personally liable for the cost of the services provided to me/my child.

I understand that it is the policy of Families First Counseling and Psychiatry to require that I/my child maintain a relationship with a therapist within the clinic. In addition to therapy services, therapists maintain the authorization for your insurance to pay your claims and they provide necessary treatment planning services. I understand that failure to keep the required therapist appointments will result in my not being allowed to schedule further appointments with the psychiatrist nor receive any prescription until I have done so.

Patient Information Regarding Credit Card on File

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 insurances 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 discrepanceis that are not resolved within 90 days of the date of service
• Outstanding balance greater than 90 days past due

Collection of credit card information makes payment collection easier, faster, and more efficient. This in now way will compromise your ability to dispute a charge or question your insurance company's determination of payment.

By signing this document, I agree and consent to the parameters explained in this Financial Agreement and Credit Card on File policy.