Purpose of the Emergency Contact Form:

This form ensures we have the necessary information to contact your trusted individuals for emergencies only.

Acknowledgment and Consent:

I acknowledge that I have provided accurate and up-to-date emergency contact information on this form. I understand that the individuals and/or Primary Care Physician listed will only be contacted in the event of an emergency or as required to ensure my safety and continuity of care. I also understand that it is my responsibility to notify Pathways Behavioral Health Group of any changes to the information provided.

Policy Summary
Pathways Behavioral Health Group (PBHG) is committed to providing convenient, accessible, and high-quality behavioral health services. To support continuity of care and access to behavioral health services, it is essential for clients to maintain appropriate insurance coverage. PBHG currently accepts the following payment options:

• Maryland Medicaid
• Care First/Blue Cross and Blue Shield
• Cigna
• Aetna
• Private Pay (cash or private contract agency agreement)

Fee rates for the above-listed insurances are determined by the individual insurance companies contracted with PBHG. Additional costs, outlined below, apply only to non-Medicaid recipients, as Medicaid recipients incur no out-of-pocket expenses for services provided.

For clients with insurance plans that PBHG is not contracted with, we may assist by submitting insurance claims on your behalf to help streamline the reimbursement process. Please note, however, that if the insurance claim is denied or the reimbursement amount does not fully cover the fee, the client will be responsible for the remaining balance.

Explanation of Charges and Fees
For self-pay, the following are a list of fees:

• 90791-Psychiatric Diagnostic Evaluation (Mental Health Assessment) - $195
• 90832-Individual Psychotherapy (16 to 37 minutes) - $95
• 90834-Individual Psychotherapy (38 to 52 minutes) - $110
• 90837-Individual Psychotherapy (53 to 60 minutes) - $175
• 90839-Psychotherapy for Crisis (30 to 74 minutes) - $175
• 90846-Family Psychotherapy (without the patient present) (26 to 60 minutes) - $175
• 90847-Family Psychotherapy (with the patient present) (26 to 60 minutes) - $175
• 90853-Group Psychotherapy (45 to 60 minutes) - $65

Additional costs not covered by non-Medicaid recipients’ insurance

• Consultation Only (Mental Health Assessment) - $300
• Relational Therapy (Couples) (26 to 60 minutes) - $175
• Brief Therapy Phone Session (if less than 16 minutes) - $50
• Crisis Session/Call (per 5 minutes if less than 30 minutes) - $45
• Letter or Forms - $35
• Record Requests - $30
• Reports/Psychiatric Report (per half hour) - $50
• Bounced Check Fee - $30
• No Show Fee - $75

Payment Plans
PBHG offers flexible payment options, including credit cards, health savings accounts (HSA), checks, and cash. Payment is expected and accepted at the close of each session to ensure continuity of care. Please inform us if you would like to set up a flexible payment option.

Medicare/Dual Insurance
PBHG does not accept dual insurance coverage. For example, if you are covered by both Medicaid and Medicare simultaneously, you are considered to have dual insurance. In such cases, Medicare is designated as the primary payer, and Medicaid will not cover your services.

If you are seeking services covered by Medicare, please inform us, and we will gladly provide you with alternative resources or refer you to agencies that accept dual insurance coverage. Your access to care is important to us, and we are committed to helping you find the support you need.

Existing Service Recipients Who Acquire Medicare After Admission

• When you have dual insurance coverage, one insurance is designated as primary and the other as secondary. For example, Medicare will become your primary insurance, and Medicaid will become your secondary insurance.
• When dual insurance coverage occurs, Medicaid may retract (take back) payments previously made to the clinic for your mental health services during a specified period. As a result, you will become responsible for the outstanding balance.
• An invoice detailing the amount owed will be generated and sent to you. You will be responsible for paying this bill.
• Services will be suspended until payment arrangements are made with PBHG. Please contact us to establish a payment plan as soon as possible.

If you are already receiving disability benefits but have not yet received your Medicare card (the red, white, and blue card), please note that you will likely become eligible for Medicare. We encourage you to discuss this with your caseworker for clarification and further assistance.

Insurance & Responsible Parties
It is the client’s responsibility to verify behavioral health benefits with their insurance provider. Clients are responsible for all co-payments, co-insurance, and deductibles at the time of service, as well as any portions of fees not covered by insurance. Copayments will be charged to the card on file. Please inform PBHG of any changes to your insurance policy. Many insurance plans provide partial reimbursement for out-of-network providers and/or allow office visit fees to contribute toward your out-of-pocket maximum. Upon request, we can provide a “superbill” to submit to your insurance for potential reimbursement.

No Surprises Act
The No Surprises Act aims to enhance price transparency, and we have consistently provided fee information for client review. If you are an uninsured or self-pay client and wish to receive a Good Faith Estimate, please contact our office. Please be aware that some services may not have associated CPT/service codes or diagnostic codes.

Cancellation and No-Show Policy
PBHG requires 24-hour advance notice for appointment cancellations, including group therapy sessions, to avoid a missed appointment charge unless other arrangements have been made in advance with your counselor or therapist. Missing a courtesy reminder call does not waive the responsibility to attend or cancel. A credit card authorization may be requested for balances over $300, after two no-shows, or at the counselor’s or therapist’s discretion.

Fees and Payment
All fees are due at the time of service. For clients using insurance, PBHG will submit claims to your primary insurance on your behalf. There is a $30 fee for checks returned due to insufficient funds. Statements are typically sent by email but can be mailed upon request. PBHG will only submit claims to primary insurers for covered services. If insurance payments are delayed beyond 30 days, we may ask you to follow up with your insurer to ensure payment is expected. If your claim is denied or payment remains outstanding, you will be responsible for the full balance. Payments may be made by cash, check, or credit card. PBHG may request a credit card authorization on file for clients utilizing telehealth services, self-pay clients, accounts with high balances, or services not covered by your insurance.

Failure to Pay
Clients agree that non-payment of service fees within 14 business days of the service date may be considered a voluntary termination of services by the client, at PBHG’s discretion. Accounts sent to collections will be assessed as the outstanding balance plus all associated collection fees. Clients consent to the release of relevant information to third-party collection agencies or attorneys for the purpose of debt recovery. If legal action is required to collect payment, clients agree to cover attorney fees and any legal costs. Legal proceedings will occur in Baltimore, Maryland, with the client waiving any objections related to jurisdiction or venue.

Understanding of Separate Practices
Clients acknowledge that Pathways Behavioral Health Consulting, LLC (Pathways Behavioral Health Group (PBHG)) and Treyway Multi Treatment Services LLC (TMTS) are independent practices, despite sharing physical space, and therefore require separate client records. Clients understand that insurance benefits applied to PBHG services cannot be transferred to TMTS. Clients may choose to receive services from one or both practices as needed. Furthermore, clients consent to the exchange of relevant information between PBHG and TMTS to facilitate coordinated care, as indicated by their signature below.

Telehealth/Telephonic Services
Clients typically seen in-office may schedule telehealth sessions, as most insurance providers cover these services; however, we encourage you to confirm with your insurance provider. If a scheduled appointment is missed, counselors or therapists may choose to offer a brief phone session (if less than 16 minutes) during the originally scheduled time for individual or family therapy. This phone session will be billed at a rate of $50, which is lower than the standard missed appointment fee. This phone option for missed appointments is available twice every 30 days.

Court Appearances, Legal Requests, Associated Costs, and Legal Fees
PBHG may be required to provide information or participate in legal proceedings, such as court appearances, depositions, custody reviews, or documentation requests (“Legal Requests”). These services involve additional time and preparation beyond standard care, and the associated costs will be billed to the client or their legal guardian. The cost for these services is calculated based on the hourly rate equivalent to a self-pay client’s 60-minute individual therapy session. This rate applies to activities such as preparation, document review, travel, consultations, waiting time, and any other work related to the Legal Request.

Provider Contact Outside of Sessions
Our priority is to offer you the highest quality of care. For emergencies, please contact emergency services at 911, 988, or the Crisis Hotline at 410-433-5175. For appointment scheduling or billing inquiries, please reach out directly to your counselor or therapist, who will share their contact information with you for these needs. If you need to speak with your provider outside of your scheduled session and cannot wait until your next appointment, please be mindful of their time.

Policy & Fee Agreement Acknowledgment
By signing below, you acknowledge that you have reviewed, understood, and accepted the policies outlined in this document. Please feel free to reach out with any questions before signing.

Client Rights and Responsibility

No client of Pathway Behavioral Health Group (PBHG) will be discriminated against due to ethnic background, gender, religion, sexual orientation, nationality, age or disability. Additionally, as a client, you have the following rights and responsibilities:

1. The right to be treated with dignity, respect and courtesy. The responsibility to treat other clients with dignity, respect and courtesy.
2. The right to confidentiality regarding your treatment, as stipulated by Federal Law. You have the right to refuse observation by others, tape recorders, video recorders, photography, etc. The responsibility to keep any information pertaining to other clients confidential.
3. The right to be free from physical, sexual, psychological, and financial abuse, harassment, physical punishment, and humiliation, threatening, or exploiting actions. The responsibility to inform/report staff if any of these rights has been violated.
4. The right to information regarding your treatment, including access to your records, as stipulated by Federal law. The responsibility to provide accurate information and to inform your counselor or therapist of major events and important issues related to your life or treatment.
5. The right to consent to individualized treatment and express your preferences regarding type of services, release of information, concurrent services, and the people involved in your treatment. The responsibility to participate fully in the development and implementation of your treatment plan.
6. The right to refuse treatment and not to be required to participate In research projects unless fully informed and having given written consent. The responsibility to understand the possible consequences of refusing treatment.
7. The right to access other support services. The responsibility to follow through on referrals made on your behalf and to cover the expense of these services, when applicable.
8. The right to present grievances, complaints, and/or suggestions in relation to any aspect of treatment. The responsibility to initiate grievances, complaints, and/or suggestions.

Program Rules and Regulations
Clients are expected to adhere to the following guidelines to maintain a safe and respectful environment:

1. Clients will be required to have at least one formal therapy session per month. Therapy sessions may be weekly, biweekly, or monthly as determined by your counselor or therapist. Thirty (30 days) without contact will result in the termination of services and the referral source will be notified.
2. Failure to keep three (3) consecutive therapy sessions will result in a review of the client’s status. If the reasons for missing the scheduled appointments are unacceptable, the client will be discharged and the referral source notified.
3. Clients who appear for therapy sessions while under the influence of any non-prescribed drug, including alcohol, will have that appointment cancelled.
4. Clients will exhibit appropriate behavior while on premises and through telehealth sessions. Disorderly behavior, (i.e., excessive profanity, fighting, threatening behavior, vandalism, theft, possession of drugs or weapons), will result in termination of services. No weapons of any kind will be permitted on the premises. Disregard of this rule will lead to immediate discharge and/or arrest. Verbal abuse is not tolerated and will also lead to discharge. All state, county, and federal laws must be observed, and any violations will be reported to the appropriate authorities while maintaining confidentiality as required by 42 CFR, Part II.
5. Clients are expected to dress appropriately when attending appointments. Clients should not wear clothing that has vulgar language and/or inappropriate pictures, excessively revealing clothing, clothing considered to be pajamas or undergarments, etc.
6. Clients should refrain from using their cell phones during appointments.
7. Clients should attend appointments alone and avoid bringing family members and friends to appointments when they are not a part of your treatment.
8. Parents and guardians are strongly encouraged to participate in therapy; however, neither their permission nor their participation is necessary for a minor 12 years or older to receive services.
9. A client’s ability to pay for services will be assessed during the intake interview. The assessed fee must be paid in full and on a timely basis.

Confidentiality in Group Setting
Group therapy sessions may be led by one or more leaders, including staff in training or interns. All staff and participants must adhere to confidentiality standards. All clients are expected to maintain the confidentiality of others, including refraining from sharing the names or personal stories of group members and ensuring that no one else is present to overhear or view telehealth sessions. Violations of confidentiality may result in removal from the group. Despite confidentiality expectations, there is a risk that group members may not fully uphold confidentiality. If you have questions about specific situations or any aspect of confidentiality, please discuss them with your counselor or therapist. Additional information can be found in the Notice of Privacy Practices.

Discharge/Termination of Services
Clients who choose to end services will be discharged immediately. Clients who have not attended sessions for 30 days or more and do not have an upcoming appointment scheduled may be discharged without prior notice. Once discharged, clients are no longer under the care of Pathways Behavioral Health Group (PBHG) or its counselor’s or therapist’s. Discharged clients may request re-admission, which will be considered at the discretion of PBHG.

Missing 2 consecutive appointments or 3 out of 5 appointments may result in discharge, as active participation in treatment is essential. Clients who choose not to engage in treatment may also be discharged. Payment for services is required, and refusal to pay may lead to discharge. Sessions will begin and end on time, and clients arriving more than 10 minutes late may be marked as a no-show unless notified. Clients who arrive under the influence of drugs or alcohol will not be treated during that session. The manufacture, distribution, dispensing, possession, use, or being under the influence of controlled substances without a prescription is strictly prohibited, and violations may result in immediate discharge and referral to other services. Finally, clients are expected to respect the confidentiality of other clients at all times.

If you are unable or not interested in returning to PBHG for services for any reason, the following resources may be helpful to you:

• Emergency Services: Call 911 if you are experiencing a life-threatening emergency or require immediate assistance.
• Maryland 988 Crisis Hotline: Call or text 988 for 24/7 confidential support for mental health, substance use, or suicide-related crises.
• 211 Maryland: Call 211 for weekly mental health check-ins with trained professionals for suicide prevention and referrals for mental health, housing, or other support services in your area.
• SAMHSA’s National Helpline: 1-800-662-HELP (4357) for free, confidential, 24/7 treatment referral and information for mental health or substance use disorders.
• Crisis Text Line: Text HOME to 741741 to connect with a trained crisis counselor.
• Primary Care Provider: For general health or mental health support, consult your primary care physician.

Records Request
All requests for records must be submitted in writing. PBHG will respond within 21 working days. Records copies are provided for a fee at the discretion of the counselor or therapist (except Medicaid clients), payable prior to preparation, or at a rate consistent with state and federal guidelines.

Grievance Procedure
Clients have the right to address treatment concerns, and if needed, to review any disagreements regarding treatment, discharge, or status changes with the Privacy Official. There will be no retaliation against clients who file a grievance. Clients are first encouraged to discuss their concerns with their counselor or therapist, who will work to resolve the issue. If the client remains unsatisfied, they may submit a written complaint to the Privacy Official using the contact information provided below. The Privacy Official will review the situation with all parties to fully understand the circumstances. A resolution will then be created to best address the needs of those involved, and a written response will be provided to the client within ten business days.

Byran T. Lee, M.S., LCADC
Privacy Official
admin@pathwaysbhc.com

If you remain dissatisfied with the response from the Privacy Official, you may contact the following agencies:

Behavioral Health System of Baltimore (BHSB)
Compliance Coordinator
Tower II, 100 S Charles St 8th floor, Baltimore, MD 21201

Maryland Department of Health
Office of Health Care Quality
55 Wade Avenue, Catonsville, MD 21228

By signing below, you acknowledge that you understand and accept the terms outlined in this document.

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Pathways Behavioral Health Group (the “Practice”) is committed to protecting your privacy. The Practice is required by federal law to maintain the privacy of Protected Health Information (“PHI”), which is information that identifies or could be used to identify you. The Practice is required to provide you with this Notice of Privacy Practices (this “Notice”), which explains the Practice's legal duties and privacy practices and your rights regarding PHI that we collect and maintain.

YOUR RIGHTS
Your rights regarding PHI are explained below. To exercise these rights, please submit a written request to the Practice at the address noted below.

To inspect and copy PHI:

• You can ask for an electronic or paper copy of PHI. The Practice may charge you a reasonable fee.
• The Practice may deny your request if it believes the disclosure will endanger your life or another person's life. You may have a right to have this decision reviewed.

To amend PHI:

• You can ask to correct PHI you believe is incorrect or incomplete. The Practice may require you to make your request in writing and provide a reason for the request.
• The Practice may deny your request. The Practice will send a written explanation for the denial and allow you to submit a written statement of disagreement.

To request confidential communications:

• You can ask the Practice to contact you in a specific way. The Practice will say “yes” to all reasonable requests.

To limit what is used or shared:

• You can ask the Practice not to use or share PHI for treatment, payment, or business operations. The Practice is not required to agree if it would affect your care.
• If you pay for a service or health care item out-of-pocket in full, you can ask the Practice not to share PHI with your health insurer.
• You can ask the Practice not to share your PHI with family members or friends by stating the specific restriction requested and to whom you want the restriction to apply.

To obtain a list of those with whom your PHI has been shared:

• You can ask for a list, called an accounting, of the times your health information has been shared. You can receive one accounting every 12 months at no charge, but you may be charged a reasonable fee if you ask for one more frequently.

To receive a copy of this Notice:

• You can ask for a paper copy of this Notice, even if you agreed to receive the Notice electronically.

To choose someone to act for you:

• If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights.

To file a complaint if you feel your rights are violated:
You can file a complaint by contacting the Practice using the following information:

Pathways Behavioral Health Group
2530 Maryland Avenue #2F
Baltimore, MD 21218
Privacy Officer: Byran T. Lee, M.S., LCADC
Phone: (410) 204-1983
Email: admin@pathwaysbhc.com

You can also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.

The Practice will not retaliate against you for filing a complaint.

To opt out of receiving fundraising communications:

• The Practice may contact you for fundraising efforts, but you can ask not to be contacted again.

OUR USES AND DISCLOSURES

1. Routine Uses and Disclosures of PHI
The Practice is permitted under federal law to use and disclose PHI, without your written authorization, for certain routine uses and disclosures, such as those made for treatment, payment, and the operation of our business. The Practice typically uses or shares your health information in the following ways:

• To treat you: The Practice can use and share PHI with other professionals who are treating you. Example: Your primary care doctor asks about your mental health treatment.
• To run health care operations: The Practice can use and share PHI to run the business, improve your care, and contact you. Example: The Practice uses PHI to send you appointment reminders if you choose.
• To bill for your services: The Practice can use and share PHI to bill and get payment from health plans or other entities. Example: The Practice gives PHI to your health insurance plan so it will pay for your services.

2. Uses and Disclosures of PHI That May Be Made Without Your Authorization or Opportunity to Object
The Practice may use or disclose PHI without your authorization or an opportunity for you to object, including:

• Public health and safety issues: To prevent the spread of disease, assist in product recalls, and report adverse reactions to medication.
• Health oversight: For audits, investigations, and inspections by government agencies that oversee the health care system.
• Serious threat to health or safety: To prevent a serious and imminent threat.
• Abuse or neglect: To report abuse, neglect, or domestic violence.
• Required by law: To comply with federal, state, or local law.
• Judicial and administrative proceedings: To respond to a court order or subpoena.
• Law enforcement: For locating or identifying individuals or disclosing information about a victim of a crime.

3. Uses and Disclosures of PHI Based Upon Your Written Authorization
The Practice must obtain your written authorization to use and/or disclose PHI for the following purposes:

• Marketing, sale of PHI, and psychotherapy notes: You may revoke your authorization, at any time, by contacting the Practice in writing. The Practice will not use or share PHI other than as described in this Notice unless you give your permission in writing.

OUR RESPONSIBILITIES

• The Practice is required by law to maintain the privacy and security of PHI.
• The Practice is required to abide by the terms of this Notice currently in effect. Where more stringent state or federal law governs PHI, the Practice will abide by the more stringent law.
• The Practice reserves the right to amend this Notice. All changes are applicable to PHI collected and maintained by the Practice. Should the Practice make changes, you may obtain a revised Notice by requesting a copy from the Practice, using the information above, or by viewing a copy on the website.
• The Practice will inform you if PHI is compromised in a breach.

This Notice is effective on January 1, 2025.

Summary of Services
Pathways Behavioral Health Group (PBHG) provides comprehensive behavioral health therapy services to children, adolescents, and adults. These services are offered both in-office and via telehealth, addressing a wide range of behavioral health concerns, including mental health challenges and co-occurring substance-related conditions.

Therapy Process
Therapy is a collaborative process focused on addressing psychological issues, exploring beliefs, and processing emotions. It is built on a foundation of trust between the client and the counselor or therapist. PBHG utilizes a person-centered approach and other therapeutic techniques, offering individual and group therapy sessions designed to promote personal growth, enhance self-awareness, and improve overall well-being. Active participation from clients is essential to achieving the best outcomes. The process begins with an initial assessment, during which your counselor or therapist will discuss your current concerns, personal history, and any prior treatments. Using this information, an individualized treatment plan will be developed to address your unique goals and needs.

Benefits
Therapy offers numerous benefits, including the opportunity to gain deeper self-awareness, improve emotional regulation, and enhance your overall mental health and well-being. By working collaboratively with your counselor or therapist, you can develop effective coping strategies, resolve conflicts, and build healthier relationships. Therapy also provides a supportive environment to explore thoughts, feelings, and behaviors, empowering you to make meaningful changes and achieve your personal goals. As you progress, you may experience increased self-confidence, reduced stress, and an improved ability to manage life's challenges.

Risks and Barriers
While therapy can be highly beneficial, there may be some risks involved. These can include addressing difficult emotional experiences, confronting unresolved issues, or being challenged in ways that may feel uncomfortable. The process can also bring up strong emotions and may sometimes lead to unanticipated changes in behaviors, thoughts, and feelings. To enhance your experience, it’s important to discuss any questions or discomfort with your counselor or therapist as they arise. Your counselor or therapist will help you understand these experiences and may use different methods, techniques, or referrals as needed to support you in achieving the growth you desire.

Treatment Protocol for Minors 12 years or older
Parents and guardians are strongly encouraged to participate in minors’ treatment. In Maryland, minors aged 12 and older may consent to their own mental health treatment. If the provider assesses that the minor is mature and capable of providing informed consent, they may seek and receive treatment independently, as an adult would. It is at the counselor’s or therapist’s professional discretion to determine if, when, and how to inform parents and guardians, except in cases where the provider believes that such disclosure would cause harm to the minor.

Confidentiality Agreement
To provide you with the highest quality of care and ensure compliance with State and Federal regulations, certain members of your treatment team or supervising staff may access your records. All team members are committed to upholding confidentiality, which is crucial to effective counseling. Your counselor or therapist and treatment team will safeguard your private information to create a safe environment where you can openly share personal information. In most instances, your information will not be disclosed to another party without your written consent. However, certain situations allow for legally permissible disclosures without your permission. The following is a list of exceptions:

• Legal Proceedings: In most legal proceedings, counselors and therapists are prevented from providing information about the treatment. However, a judge may ask your counselor or therapist to testify and/or provide a summary of treatments, documents of treatment planning, or other treatment documents.
• Duty to Warn and Protect: Counselors and therapists are required to warn a potential victim if a client is threatening serious injury to someone. Counselors or therapists may be required to hospitalize a client and/or contact family members if the client threatens to harm him/herself.
• Abuse of Children and Vulnerable Adults: Counselors and therapists are required by law to report if a child, an elderly person, or a disabled person is being abused. Counselors and therapists are also required to report past instances of child abuse when specific information about the abuser is available.
• Telehealth Services: Security protocols can fail, causing breach of privacy of confidential health information.
• Insurance Providers: Insurance companies and other third-party payers are given information that they request regarding services to the service recipient.

Notice of Privacy Practices
The Notice of Privacy Practices (NPP) for PBHG explains how your protected health information (PHI) may be used and disclosed. The NPP states that PBHG may revise its terms, and any updates will be made available in the office. You have the right to revoke this consent in writing, except where PBHG has already relied on your prior consent for disclosures. You also have the right to request restrictions on how your PHI is used or disclosed for treatment, payment, and health care operations. While PBHG is not obligated to accept such restrictions, it will adhere to any agreed-upon limitations.

Confidentiality of Records and Records Request
Federal law and regulations protect the confidentiality of patient records maintained by PBHG. Generally, PBHG is prohibited from disclosing information to individuals outside of the company that would reveal a client’s attendance or identify them as an alcohol or drug user, except under the following conditions:

1. Consent is given by clients aged 12 and older who are receiving services (written consent may be required);
2. Disclosure is authorized by a court order; or
3. Disclosure is made to medical personnel in an emergency, or to qualified personnel for research, audit, or program evaluation purposes.

Violations of federal law and regulations by a program are considered a crime. Suspected violations may be reported to the appropriate authorities as per federal guidelines. Please note that federal law and regulations do not protect any information regarding a crime committed by a patient at the program or against any program staff, or any threats of such crimes. Likewise, information regarding suspected child abuse or neglect is not protected and must be reported to state or local authorities under state law. The policies regarding record requests are outlined in the Fee Agreement and Policies.

Communication
PBHG uses a HIPPA compliant Electronic Health Records platform to engage clients in their care. We aim to communicate with you efficiently, which may include phone calls, emails, or text messages. However, please note that these communication methods carry inherent privacy risks. We advise against using email for emergencies, urgent matters, or sensitive information. Appointment reminders, statement notifications, and general information may be sent via email, text, or phone call. By signing below:

• I authorize PBHG to communicate with me electronically via telephone, email, text messaging, faxing, the clinic website, internet and patient portal. These communications will be used for scheduling, and for collecting or sending pertinent clinical, insurance information and claims, billing &/or collections information as is necessary to provide your treatment and or to correspond.
• I understand that communications via the means described above are not always secure. Although it is unlikely, there is a possibility that information you send to us, or that we send to you, may be intercepted and read by other parties besides the person to whom it is addressed.
• I understand that by federal law, PBHG, may not use/disclose my healthcare information without my authorization.
• I acknowledge and accept these privacy risks associated with electronic communications.

Cancellation, Fees, and Payments
The policies regarding cancellations, fees, and payments are outlined in the Fee Agreement and Policies. Medicaid clients will not be billed for services provided by mail, telephone, or other non-in-person means; for the completion of forms or reports; or for missed or broken appointments.

Termination of Services
You have the right to terminate the therapeutic relationship at any time. While your counselor or therapist may wish to discuss this decision with you, you are free to discontinue treatment. Upon termination, you will be provided with a list of community providers and, if appropriate, refer back to your original referral source. Please note that you will be responsible for any outstanding fees for services already rendered.

Legal Information
Please be advised that your counselor or therapist is not qualified to provide legal advice. For legal questions or guidance, it is recommended that you consult with an attorney to ensure your best interests are represented.

Coordination of Services
Your counselor or therapist may coordinate with other service providers within our program, or the community as needed, such as for care coordination, crisis intervention, veteran services, vocational support, medical services, and more. Coordination with community providers will require the client to sign a release of information form.

Consent for Treatment and Acknowledgement
The information above is intended to provide an overview of your services and is not exhaustive. Your signature below confirms that you have read the provided information, have had the opportunity to ask questions, and voluntarily agree to participate in treatment.

• I hereby attest to reading this document and understand its contents.
• I hereby give my voluntary permission to PBHG to provide outpatient mental health services via in-office services and/or telehealth services to my child or myself.
• I give my voluntary consent to release of information and authorization to pay insurance benefits.
• I authorize payment directly to PBHG.
• I understand that all of the rules and regulations that apply to the provision of healthcare services in the state of Maryland also apply to telehealth.

Purpose of Telehealth Services
Pathways Behavioral Health Group (PBHG) provides behavioral health services through secure video calls, phone calls, and other electronic methods to make services accessible. These sessions require private space and reliable technology (e.g., computer or smartphone). While PBHG uses HIPAA-compliant platforms to protect your information, online communication carries some risks, such as unauthorized access or breaches due to unsecured internet or outdated software.

Emails are used for scheduling and general information. Some telehealth options that are not HIPAA-compliant may not have the same level of protection for your information. These systems might not use the highest security measures and could be more at risk for unauthorized access. They may also store your data in places that have different privacy rules, which could mean less control over how your information is stored or deleted. It’s important to understand these risks and choose the option that makes you feel comfortable. Always try to have your sessions in a private space to help keep your information safe and confidential.

Telehealth Consent
By signing below, I consent to telehealth services and understand the following:

• I must be physically located in Maryland to participate in telehealth services.
• I can withdraw consent at any time without affecting future care or benefits.
• Individual and group sessions must be held in a private, secure space to protect confidentiality.
• Neither party will record sessions, and confidentiality laws apply unless legally required to disclose (e.g., mandatory reporting, legal proceedings, safety risks).
• Telehealth may not be suitable in emergencies or severe mental health crises; higher care levels may be recommended.
• Technical issues may interrupt sessions; reconnection or rescheduling may be necessary.
• I understand the strengths and limitations of each method and have been informed of the security measures PBHG takes to protect my confidentiality in each type of transmission. I consent to the use of these transmissions as deemed appropriate for my treatment needs.
• I understand that there may be instances where a non-HIPAA-compliant platform is required. If such a platform is used, I am informed of the associated privacy and confidentiality risks, including:

a. reduced data protection;
b. risk of unauthorized access;
c. heightened cybersecurity vulnerabilities;
d. varied data storage and privacy policies; and
e. limited control over data deletion.

• I understand these potential privacy and confidentiality risks associated with using a non-HIPAA-compliant platform. I accept these risks and consent to receive telehealth or telephonic services via this transmission if necessary, recognizing that PBHG will prioritize secure, HIPAA-compliant platforms whenever possible.
• I understand that the same privacy laws protecting the confidentiality of my protected health information (PHI) apply to telehealth sessions, except in specific cases requiring mandatory reporting (e.g., child, elder, or vulnerable adult abuse; danger to self or others; legal proceedings involving my mental or emotional health).
• I understand that my counselor or therapist may need to contact my emergency contact or relevant authorities in case of an emergency. I agree to provide my current location and an emergency contact at the start of each session.

I have read and understand this consent form. By signing, I agree to telehealth services, including understanding potential risks and security measures taken to protect my privacy.

1. CareFirst’s Quality Assessment and Improvement Activities

CareFirst conducts a variety of quality assessment and improvement activities. This consent allows CareFirst to disclose and use participants’ data for the purpose of quality assessment and improvement activities.

2. Consent/Authorization

• My participation is voluntary. I may choose not to participate in these quality assessment and improvement activities and still maintain my insurance coverage with CareFirst.
• CareFirst will not condition payment of medical benefits, enrollment, or eligibility of medical benefits on my participation in the quality assessment and improvement activities.
• CareFirst may disclose my personal health information as required or allowed by law.
• CareFirst may share data and information supplied by health care providers (for example: a health care professional, hospital, clinic, laboratory, pharmacy, or medical facility) who have provided treatment or services on my behalf.
• My health care provider, including my treating mental health and substance use disorder providers, may share my information with CareFirst.
• Information about me that could be disclosed includes information contained in my general medical record, my mental health information, including substance use disorder records and counseling notes, and health care claims as a result of: medical encounters, treatments, diagnostic tests, screenings, prescriptions, patient centered medical home, and other case management activities.
• It may also include, but will not necessarily be limited to, any of my medical records related to:
  • Drug, alcohol or substance use disorder;
  • Psychological, psychiatric or other mental impairment(s) or developmental disabilities (excluding “psychotherapy notes”);
  • Metabolic disorders such as sickle cell anemia,
  • Birth control and family planning;
  • Records which may indicate the presence of a communicable disease or non-communicable disease;
  • Records of HIV/AIDS or sexually transmitted diseases;
  • Genetic (inherited) diseases or tests; and laboratory test results directly from the clinical laboratory.
• Health care providers and CareFirst’s health care related contracted partners are required by law to maintain the privacy of my medical information consistent with applicable federal and state privacy laws, including HIPAA privacy rules. CareFirst cannot control unauthorized re-disclosures of my information by persons to whom CareFirst discloses such information.
• I have the right to inspect any record of my mental health medical information.
• Upon my request and consistent with 42 CFR Part 2, I will be provided a list of entities to which my substance use disorder records have been disclosed.
• I understand that I may revoke this authorization at any time without adverse consequences by completing an Opt-Out of Information Sharing form found at Patients' Rights & Legal Forms | CareFirst BlueCross BlueShield and this revocation will be effective for future uses and disclosures of protected health information. However, I further understand that this revocation will not be effective: (i) for information that my health plan has already used or disclosed, relying on this authorization or (ii) if the authorization was obtained as a condition for coverage in my health plan and, by law, the health plan has a right to contest the coverage.
• This consent will expire after one year if not revoked.
• By providing my phone number and email address, I understand that CareFirst and its partners may contact me related to quality assessment and improvement activities by phone, cell phone, text messaging or email. I understand that consent to contact me survives the expiration of this Election to Participate unless I otherwise revoke consent.

 

4. Notice to Recipients

This information has been disclosed to you from records the confidentiality of which may be protected by federal and/or state law. Maryland law prohibits re-disclosure of medical information without authorization from the member. The unauthorized disclosure of mental health information violates the provisions of the District of Columbia Mental Health Information Act of 1978 (§§7- 1201.01 to 7-1207.02 42 CFR part 2 prohibits unauthorized disclosure of these records.

5. Execution by Minors or Guardians

If the person signing this form is not the member, the parent, or guardian of a dependent under the age of 18, you must submit to CareFirst a full copy of the official document indicating your legal authority to sign on behalf of the member (i.e. Power of Attorney, Court Assigned guardian, Personal Representative, etc If the parent or guardian has not consented to the provision of services and instead the minor has provided legally sufficient consent, the minor may authorize disclosure him or herself. When the minor has consented to such treatment, except by specific legal requirement, no information regarding sexually transmitted disease, substance use, pregnancy, or emotional illness shall be disclosed unless such information is necessary to the health of the minor and the public, and only when the minor’s identity is kept confidential. In D.C. and Virginia, if this consent relates to mental health information (including inpatient psychiatric hospitalization when the minor is 14 years or older and has consented to the admission), and the patient to whom this consent applies is over the age of 14 and under the age of 18, the minor and his or her custodial parent must provide joint consent. In D.C., if the patient is less than 14 years of age, then only the parent or guardian must provide consent. In Virginia, the concurrent consent of a minor and his or her custodial parent is required to disclose inpatient substance use disorder records.

Mental Health Advance Directives:
A mental health advance directive (sometimes called a psychiatric advance directive) is a legal document you can prepare now to express specific needs and preferences for your mental health treatment in the event you are unable to make or communicate such decisions in the future. This allows you to appoint someone to assist with various health care matters, including a mental health crisis, and provides your specific directions regarding mental health treatment.

Benefits:

• Protects you from unwanted treatment.
• Provides clear instructions about medication and treatment to guide decision making.
• Improves communication between medical, support, and treatment networks, which may prevent involuntary treatment or admission to a hospital.
• Enhances your recovery.

Mental Health Advance Directives include:

• Your preferred hospitals and service providers.
• People you have authorized to make health decisions and with whom information may be shared or not shared.
• Any allergies, adverse reactions, and other health issues.
• Desired visitors.
• Specific preferences regarding treatment.

Resources:

• Flyer for the general public
• Mental Health Association of Maryland's Information about Mental Health Advance Directives
• SAMHSA's App: My Mental Health Crisis Plan

Acknowledgement:
I acknowledge that I am 16 years of age or older and have been given the opportunity to be educated about and/or make an advance directive for mental health services. This directive includes a directive regarding provision of health care, withholding or withdrawal of life-sustaining procedures or appointment of an agent to make healthcare decisions for me. I also understand that this form is valid for one year from the date of completion, and it is my responsibility to notify Pathways Behavioral Health Group of any changes to the information provided.

Tuberculosis (TB)
Tuberculosis (TB) is an infectious disease that primarily affects the lungs but can also impact other parts of the body. It spreads through the air when someone with active TB in the lungs or throat coughs, sneezes, or talks. While TB is not easily contracted, prolonged close contact with someone infected, such as among family members or in shared spaces, can increase the risk. Untreated TB can be fatal, but it is treatable and curable with proper medication. Travelers are advised to avoid prolonged contact with TB patients in enclosed spaces.

• American Lung Association. (n.d.). Tuberculosis. Retrieved from https://www.lung.org/lung-health-diseases/lung-disease-lookup/tuberculosis
• Centers for Disease Control and Prevention. (2022). Tuberculosis (TB). Retrieved from https://www.cdc.gov/tb/

Tobacco Smoking
Cigarette smoking is a leading preventable cause of disease and premature death, responsible for approximately 443,000 deaths annually in the U.S., including indirect fatalities from secondhand exposure and prenatal smoking effects. Quitting smoking is critical for improving health and life expectancy, with many resources available to support cessation efforts.

• American Lung Association. (n.d.). Quit smoking. Retrieved from https://www.lung.org/quit-smoking

HIV/AIDS
HIV is the human immunodeficiency virus that damages the immune system by targeting CD4+ T cells. It is primarily transmitted through unprotected sex, sharing needles, or from mother to child during birth. Early symptoms can be mild or absent, so testing is essential if exposure is suspected. Preventive measures include consistent condom use, limiting sexual partners, and consulting with healthcare providers about pre-exposure prophylaxis (PrEP) or post-exposure prophylaxis (PEP).

• Centers for Disease Control and Prevention. (n.d.). HIV/AIDS. Retrieved from https://www.cdc.gov/nchhstp/
• HIV.gov. (2022). HIV basics. Retrieved from https://www.hiv.gov/hiv-basics/hiv-prevention/using-hiv-medication-to-reduce-risk/hiv-treatment-as-prevention

Sexually Transmitted Diseases (STDs)
Sexually transmitted diseases, or STDs, are infections often spread through sexual contact. Common symptoms include painful urination, unusual discharge, and sores. Practicing safe sex, reducing partners, and getting vaccinated (e.g., for HPV or hepatitis B) are effective ways to lower STD risks. Prompt medical attention is advised for symptoms, and testing can confirm any suspected infections.

• Centers for Disease Control and Prevention. (2022). Sexually transmitted diseases (STDs). Retrieved from https://www.cdc.gov/STD/
• Mayo Clinic. (n.d.). Sexually transmitted diseases (STDs). Retrieved from https://www.mayoclinic.org/diseases-conditions/sexually-transmitted-diseases-stds/diagnosis-treatment/drc-20351246

Hepatitis
Hepatitis refers to liver inflammation, which can result from viruses (types A, B, C, D, and E), alcohol use, or autoimmune disease. Hepatitis B and C can lead to chronic liver conditions, including cirrhosis and cancer. Preventive measures include good hygiene practices, safe food handling, and vaccinations for hepatitis A and B, especially when traveling to areas with high hepatitis rates.

• World Health Organization. (2022). What is hepatitis? Retrieved from https://www.who.int/news-room/q-a-detail/what-is-hepatitis
• WebMD. (n.d.). Understanding hepatitis prevention. Retrieved from https://www.webmd.com/hepatitis/understanding-hepatitis-prevention

For Treatment or Testing
For testing or treatment, individuals can visit their primary care physician or request a referral from their counselor or therapist.

Acknowledgment
By signing below, I confirm that I have read and understand the information provided about infectious diseases, including tuberculosis, tobacco smoking, HIV/AIDS, sexually transmitted diseases (STDs), and hepatitis. I acknowledge that I am aware of the risks, prevention methods, and the importance of seeking testing or treatment as necessary. I understand the recommendations provided and agree to follow up with my healthcare provider or the suggested resources if I have any concerns or questions.

PURPOSE

Overdose Prevention Education ensures all clients, regardless of substance use history, are educated on recognizing and responding to overdose risks, equipping them with lifesaving knowledge and harm reduction strategies. This universal approach fosters safety, reduces stigma, and empowers clients to protect themselves and their communities.

WHAT IS AN OVERDOSE?

An overdose occurs when a person consumes more of a substance—or a combination of substances—than their body can process. This can result in the central nervous system (CNS) being unable to regulate essential life functions, such as breathing, heart rate, and consciousness. Overdose symptoms vary depending on the substance but may include unconsciousness, slowed or stopped breathing, seizures, irregular heartbeat, or a blue tint to the skin or lips. Overdoses can be fatal, but fatalities are often preventable with timely intervention.

WHO IS AT RISK?

Anyone who uses substances can experience an overdose—whether it’s their first time or they are a long-time user. Factors like tolerance, drug potency, and mixing substances can make it difficult to predict how a drug or combination of drugs will affect someone. It’s essential to emphasize that there is no completely “safe dose.”

FACTORS THAT INCREASE OVERDOSE RISK

• Tolerance: Tolerance can change due to weight fluctuations, new medications, periods of abstinence, or changes in physical or mental health. After a break in use, even a previously tolerated dose can lead to overdose.
• Mixing Substances:
  
  • Combining depressants (e.g., opioids, alcohol, benzodiazepines) can dangerously suppress breathing and heart rate.
  • Mixing stimulants (e.g., cocaine, methamphetamine) with depressants can mask overdose symptoms, increasing risk.
  • Alcohol is a frequent factor in mixed-drug overdoses, worsening dehydration and CNS depression.
  • Prescription drugs mixed with street drugs can lead to unpredictable effects and overdose.
• Drug Potency and Quality: Street drugs often vary in potency and may contain unknown substances like fentanyl, a synthetic opioid significantly more potent than heroin. Testing drugs with fentanyl test strips can reduce risk.
• Using Alone: Using alone increases the risk of fatal overdose since no one is available to call for help or administer naloxone.
• Health and Drug Accumulation: Poor health, dehydration, or recent illness can make it harder for the body to process substances. Repeated dosing before the body has metabolized prior doses can also lead to overdose.
• Past Overdose Events: Individuals who have overdosed before are at a higher risk of experiencing another overdose.
• Route of Administration: Injecting substances carries a higher overdose risk than smoking or snorting due to the rapid onset of effects.

SIGNS AND SYMPTOMS OF OVERDOSE BY SUBSTANCE

Opioids (e.g., Heroin, Fentanyl, Prescription Painkillers)

• Unresponsiveness or unconsciousness
• Slow or stopped breathing
• Pinpoint pupils
• Blue or grayish lips, skin, or nails
• Weak, slow, or absent pulse
• Gurgling or choking sounds

Action: Administer naloxone immediately if available and call emergency services.

Stimulants (e.g., Cocaine, Methamphetamine, MDMA)

• Chest pain or rapid heartbeat
• Elevated body temperature (hyperthermia)
• Agitation, paranoia, or confusion
• Seizures
• Excessive sweating or dry, hot skin
• Sensations of skin crawling
• Difficulty breathing

Action: Cool the person down, ensure they have access to air, and call emergency services.

Benzodiazepines (e.g., Xanax, Valium, Ativan)

• Extreme drowsiness or unconsciousness
• Slow or stopped breathing
• Slurred speech
• Unsteady gait or lack of coordination
• Weak or slow pulse
• Paradoxical agitation (rare)

Note: Naloxone has no effect on benzodiazepine overdoses. However, if opioids are involved, administer naloxone and seek emergency care.

Alcohol

• Confusion, stupor, or unresponsiveness
• Vomiting while unconscious
• Slow or irregular breathing (less than 8 breaths per minute)
• Hypothermia (cold, clammy skin)
• Blue or pale skin, especially around lips or fingernails

Action: Turn the person on their side to prevent choking and call emergency services.

Hallucinogens (e.g., LSD, Psilocybin, PCP, Ketamine)

• Agitation or extreme confusion
• Violent behavior (especially with PCP)
• Seizures
• Elevated blood pressure or heart rate
• Nausea or vomiting
• Respiratory distress (in rare cases with ketamine or high doses of other hallucinogens)

Action: Provide a calm environment and seek emergency help if symptoms escalate or if the person is a danger to themselves or others.

Synthetic Cannabinoids (e.g., "Spice," "K2")

• Extreme agitation or paranoia
• Rapid heart rate
• Seizures
• Nausea and vomiting
• Chest pain
• Difficulty breathing

Action: Call emergency services immediately, as synthetic cannabinoids can cause unpredictable and severe reactions.

Inhalants (e.g., Nitrous Oxide, Paint Thinners, Glue)

• Confusion or hallucinations
• Slurred speech
• Loss of motor control or coordination
• Unconsciousness or coma
• Irregular or rapid heartbeat
• Seizures

Action: Remove the person from the source of inhalants, provide fresh air, and call emergency services.

Depressants Combined with Alcohol (e.g., Opioids, Benzodiazepines, Barbiturates)

• Severe CNS depression
• Respiratory arrest (stopped breathing)
• Unresponsiveness or inability to wake up
• Pale, cold, or clammy skin

Action: Administer naloxone if opioids are involved, seek emergency medical assistance, and ensure the person is not left alone.

HARM REDUCTION STRATEGIES
The best way to prevent an overdose is ABSTINENCE. Below is a list of harm reduction strategies to prevent an overdose:

1. Carry Naloxone (Narcan): Naloxone can reverse opioid overdoses if administered promptly. It is safe, widely available, and easy to use. While naloxone does not reverse cocaine or stimulant overdoses, it can save lives in cases involving opioid use.
2. Test Your Drugs: Use fentanyl test strips to check substances for contamination. This is especially important for non-opioid drugs like cocaine, which are increasingly contaminated with fentanyl.
3. Don’t Use Alone: If using, let someone you trust know or use overdose prevention tools like supervised consumption sites or apps that alert emergency responders if you stop responding.
4. Start Low, Go Slow: If you haven’t used recently or are trying a new batch, start with a small amount.
5. Avoid Mixing Substances: Mixing substances increases the risk of overdose. If possible, avoid using alcohol or benzodiazepines with opioids.
6. Stay Hydrated and Nourished: Proper hydration and nutrition help the body metabolize substances and reduce overdose risk.

ACKNOWLEDGMENT OF OVERDOSE EDUCATION
By signing below, I acknowledge that I have read and received information about overdose prevention, the risks associated with substance use, and harm reduction strategies. I understand the importance of taking proactive steps to reduce overdose risk.