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 & 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.

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

 

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.

 

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.

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.

We encourage notifying your Primary Care Physician (PCP) about your behavioral health treatment to improve care coordination. This ensures your PCP considers any medications or health conditions affecting your mental health or substance use are considered.

If yes, complete the information below:

I understand the following:

1. By signing this form, I am authorizing that the health information specified in Section 5 be shared between the party named in Section 3 and the party named in Section 4.
2. I may revoke this authorization at any time by writing to the individual(s), program(s), organization(s) or facility/facilities authorized to release information. If more than one individual, program, organization, or facility has been authorized to release information, a written revocation request must be submitted to each party.
3. If an individual, program, organization or facility has already released health information based on this authorization, revoking it will only prevent future disclosure by the party to whom a written revocation has been submitted.
4. My treatment, payment for my treatment, enrollment, or eligibility for services/benefits cannot be conditioned on the signing of this authorization, unless authorization is required to determine eligibility for services/benefits.
5. The information disclosed may be subject to redisclosure by the recipient and no longer protected by HIPAA.

We encourage notifying your other behavioral health providers about your behavioral health treatment to improve care coordination. Sharing of information allows your providers to work together, addressing any related mental health or substance use issues that could affect your treatment. This helps ensure that treatment methods, medications, and therapies align with your overall care plan.

If yes, complete the information below:

I understand the following:

1. By signing this form, I am authorizing that the health information specified in Section 5 be shared between the party named in Section 3 and the party named in Section 4.
2. I may revoke this authorization at any time by writing to the individual(s), program(s), organization(s) or facility/facilities authorized to release information. If more than one individual, program, organization, or facility has been authorized to release information, a written revocation request must be submitted to each party.
3. If an individual, program, organization or facility has already released health information based on this authorization, revoking it will only prevent future disclosure by the party to whom a written revocation has been submitted.
4. My treatment, payment for my treatment, enrollment, or eligibility for services/benefits cannot be conditioned on the signing of this authorization, unless authorization is required to determine eligibility for services/benefits.
5. The information disclosed may be subject to redisclosure by the recipient and no longer protected by HIPAA.

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.

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.