15203 NE 72nd Ave, Vancouver, WA 98686

Comprehensive Integrated Care Consent Form

Welcome to The Villa Health PLLC. We are proud to serve Washington and Oregon with a comprehensive and integrative approach to wellness. Our model brings together behavioral health, psychiatric care, addiction medicine, aesthetic services, and holistic practices to address the full spectrum of mind, body, and spirit.

At The Villa Health, we believe every person deserves care that reflects their unique needs, values, and goals. We provide an environment where dignity, healing, and empowerment are central to the care experience. Our providers collaborate across specialties to design personalized treatment plans, ensuring that each aspect of your wellbeing is supported with compassion and excellence.

Our mission is simple: to transform healthcare by honoring the whole person and making high- quality, integrated services accessible to our communities.

1. Available Services

At The Villa Health PLLC, we provide a broad range of services that integrate behavioral health, medical care, and holistic wellness. Our goal is to support your whole person, mind, body, and spirit, through coordinated and personalized treatment options.

Behavioral & Mental Health Services

• Individual therapy and counseling (see Therapy Disclosure Statement for details)
• Psychiatric evaluation and treatment
• Ongoing medication management for mental health conditions

Medical & Wellness Services

• Hormone replacement therapy
• Weight management and lifestyle support
• Comprehensive medication management

Integrative & Holistic Practices

• East Asian Medicine
• Acupuncture
• Herbal, nutritional, and mind-body practices to complement medical and behavioral health care

Aesthetic & Confidence-Building Services

• Personalized aesthetic medicine treatments designed to enhance wellness and self-confidence

Our providers work collaboratively across these areas to design treatment plans tailored to your unique needs. You always have the right to ask questions, explore alternatives, or decline any service at any time.

2. Provider Licensure & Supervision

Your care at The Villa Health PLLC is provided by a team of professionals committed to safe, high-quality, and integrated care.

• Our team includes fully licensed providers as well as associate-licensed professionals who practice under clinical supervision.
• Each provider's licensure, credentials, and supervision arrangements will be reviewed with you at your first visit.

3. Leadership & Oversight

The Villa Health PLLC is led by Dr. Daniel Roa, DNP, ARNP-PP, AGPCNP-C, PMHNP-BC, who serves as President and Medical Director.

• Licensed in Washington and Oregon.
• Dual board-certified in Psychiatric-Mental Health and Adult-Gerontology Primary Care.
• Brings extensive experience in medical, psychiatric, and behavioral health care integration.

As President and Medical Director, Dr. Roa provides clinical oversight, supervision, and organizational leadership, ensuring that all services meet the highest standards of professional excellence, cultural responsiveness, and patient safety.

4. Technology & Documentation

We use secure technology to support your care and protect your health information. All systems comply with the Health Insurance Portability and Accountability Act (HIPAA) and other applicable federal and state privacy laws.

Electronic Health Records (EHR):

Your medical records are securely maintained in DrChrono, our HIPAA-compliant electronic health record system. You may access your records through the patient portal, and you have the right to request copies, corrections, or restrictions on your records in accordance with federal law.

Artificial Intelligence (Al)-Assisted Documentation

We may use HIPAA-compliant artificial intelligence (AI) tools to assist with transcription, documentation, and quality of care. These tools are covered under our Business Associate Agreements (BAAs) to ensure full compliance with HIPAA and the HITECH Act. All Protected Health Information (PHI) processed through these tools stays securely within our clinic's systems, used only for documentation and care-related purposes, and never shared, sold, or used to train external systems. Licensed providers always review and approve all documentation.

You have the right to know how your information is used and to make choices about it. You may ask questions or opt out of Al-assisted documentation at any time, for any reason, without affecting your care. You may also review or request corrections to your records as permitted under HIPAA.

Communication:

• Secure portal messaging is the preferred method of communication.
• Email and text may be used for limited, non-urgent purposes (e.g., scheduling), but they are not fully secure. If you choose to use these methods, you accept the associated risks of unauthorized access.
• Phone calls may be used for scheduling and care coordination.

Telehealth Services:

You may receive care by secure, HIPAA-compliant telehealth platforms. By consenting to telehealth, you agree to:

• Be in a private location during your session.
• Use the technology required for secure connection.
• Understand that some services require in-person visits for safety or clinical
• Telehealth services are provided only when the patient is physically located in a state where the provider is licensed.

Opt-Out Options:

You may decline portal access, AI documentation, or electronic reminders. Declining certain technologies may limit convenience or access to some services, but will not affect your right to receive care.

Confidentiality Reminder: All uses and disclosures of your protected health information (PHI) follow HIPAA, state privacy laws, and, when applicable, 42 CFR Part 2 for substance use disorder records.

5. Financial Responsibility

We are committed to providing high-quality care in a transparent and respectful manner. To help avoid surprises, please review the following financial policies:

• Payment at Time of Service: Payment is due at the time of your appointment unless prior arrangements have been made. We accept credit/debit cards, HSA/FSA cards, cash, and personal checks.
• Insurance Billing:
  • If The Villa Health is contracted with your insurance provider, we will submit claims on your behalf. If we are not contracted with your insurance, you may be responsible for paying directly at the time of service. In some cases, we may bill your insurance as an out-of-network provider or provide you with a "superbill" that you can submit to your insurance for possible reimbursement.
  • You are responsible for all copayments, deductibles, coinsurance, and services not covered by your insurance plan.
  • It is your responsibility to understand your insurance benefits and to notify us promptly of any changes in your coverage.
  • Benefits quoted by your insurance company are an estimate only and do not guarantee payment.

Self-Pay Services:

• Self-pay rates are available upon request for patients without insurance or for services not covered by insurance.
• Some services (such as aesthetic medicine, certain wellness programs, or specific supplements) are not billable to insurance and require direct payment.

Cancellations & No Shows:

• If you need to cancel or reschedule, please provide at least 48 hours' notice. Late cancellations or missed appointments may result in a $50 fee, which cannot be billed to insurance.

Returned Payments:

• Returned checks are subject to a $25 fee.
• Outstanding balances must be resolved prior to scheduling additional appointments.

Outstanding Balances:

• Payment arrangements must be made for any balance not resolved within 90 days. Failure to do so may result in suspension or termination of services until the balance is addressed.
• Accounts that remain unpaid after reasonable attempts at resolution may be referred to a collections agency in accordance with applicable laws.
• We encourage patients to contact our billing team promptly if they are experiencing financial hardship, so we can discuss payment plan options.

6. Privacy Practices

• Your health information is protected under federal and state law. The Villa Health PLLC follows all applicable rules under HIPAA, 42 CFR Part 2 (for substance use records), and state-specific confidentiality laws in Oregon and Washington.

HIPAA (Federal)

• You have received The Villa Health PLLC's Notice of Privacy Practices (NPP), which explains how your health information may be used and disclosed. I acknowledge that I have received and reviewed The Villa Health PLLC's Notice of Privacy Practices.
• Under HIPAA, you have the right to:
  • Access and request copies of your records.
  • Request amendments to your records.
  • Request restrictions on certain uses and disclosures.
  • Receive an accounting of disclosures.
  • Request confidential communications
  • File a complaint if you believe your rights have been violated.

Psychotherapy Notes (Federal)

• Psychotherapy notes receive special protection under HIPAA.
• They will not be shared without your specific written authorization, except when required by law (e.g., to prevent imminent harm)

Substance Use Disorder Records - 42 CFR Part 2 (Federal)

• If you receive treatment for a substance use disorder, your records are protected by federal confidentiality rules. Your substance use disorder records cannot be disclosed without your written consent, except as specifically allowed by law.
• Probation on Redisclosure: This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR Part 2 The Federal rules prohibit you from making any further disclosure of this information unless expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by

State-Specific Privacy Laws (Washington & Oregon)

• Washington (RCW 71.34.530): Minors aged 13 and older may consent to their own outpatient mental health and substance use disorder treatment. Parents or guardians cannot access these records without the youth's written authorization, unless otherwise required by law. Washington law (RCW 70.02.230) prohibits redisclosure of mental health information without written consent, except as required by law.
• Oregon (ORS 109.675): Minors aged 14 and older may consent to their own outpatient diagnosis or treatment of a mental or emotional disorder or chemical dependency (excluding methadone) without parental consent. By law, providers are expected to involve parents before the end of treatment unless the minor refuses or doing so is clinically inappropriate. In both states, behavioral health records cannot be redisclosed without patient consent, except as allowed by law.

Mandatory Reporting

By law, The Villa Health PLLC providers must disclose information in specific circumstances, including:

• Suspected abuse or neglect of a child, dependent adult, or vulnerable person.
• When there is an imminent risk of serious harm to self or others.
• As otherwise required by court order or applicable law.

7. Emergency & Crisis Protocols

Your safety is our highest priority. While The Villa Health PLLC does not provide afterhours emergency coverage the following resources are available 24/7 for urgent needs.  Your safety is our highest priority. While The Villa Health PLLC does not provide after-hours emergency coverage, the following resources are available 24/7 for urgent needs:

Emergencies

• Call 911 immediately or go to the nearest emergency department.

Mental Health Crises

• 988 Suicide & Crisis Lifeline: Call or text 988 from anywhere in the United States to connect with crisis support.
• Washington Recovery Help Line: Offers 24/7 help for substance use, gambling, and mental health issues. Call 1-866-789-1511.
• Oregon Crisis Line: Call 988 or chat online: 988lifeline.org
• National Crisis Text Line: Text HOME to 741741 to connect with a trained

Important Note: If you are experiencing a life-threatening emergency or are at immediate risk of harm, call 911 or go to the nearest emergency department.

8. Acknowledgments & Consent

• I have received and reviewed the Notice of Privacy Practices.
• I understand my rights regarding minor consent, redisclosure, and mandatory reporting.
• I consent to receive care at The Villa Health PLLC, including the use of technology
• I understand I may withdraw consent or refuse treatment at any time.