CONSENTS AND LEGAL FORMS
Please read the entire disclosure, attestation, and consent for treatment and the office policies and procedures. If you agree, please indicate your name and date of birth on the last part of this form.
DISCLOSURE, ATTESTATION AND CONSENT FOR TREATMENT
Notice Regarding Insurance Claims and Payments
I understand that I will be responsible for all billable services not covered by insurance. I authorize Haelan Psychiatry & Wellness to release medical information necessary for claim reimbursement from insurance companies. I assign to Haelan Psychiatry & Wellness all payments for medical services and supplies. I authorize payment of all third-party benefits to be made directly payable to Haelan Psychiatry & Wellness. I understand if after 60 days from the date of service, insurance has failed to pay the claim, any unpaid balance is my responsibility.
Copayments, Noncovered Services, and Guarantee of Payment
I understand that Haelan Psychiatry & Wellness cannot bill insurance for copayment. Any copayment or payments for non-covered services are due at the time services are provided. I acknowledge that the above information is correct and that I am responsible for the balance on my account for any and all services provided that are not covered or not paid for by my insurance plan.
Missed Appointments / Late Appointment Cancellations
I understand that Haelan Psychiatry & Wellness requires 24 hours of advanced notice for an appointment to be cancelled or rescheduled. A cancellation with less than 24 hours’ notice or a missed appointment is considered a “No-Show.” I understand that I will be charged $50 for each No-Show occurrence. Haelan Psychiatry & Wellness reserves the right to discharge a patient from services after three (3) consecutive missed appointments and/or failure to pay No-Show fees.
New Patient Appointments
ALL New Patient Appointments MUST be CONFIRMED WITHIN 24 HOURS prior to the scheduled appointment time. Not confirming the appointment within the required timeframe may result in automatic cancellation of the appointment.
Telehealth Guidelines
- Make sure to find a quiet and private space for your telehealth session to ensure confidentiality and minimize distractions.
- Test your audio and video settings BEFORE the appointment to ensure they are working correctly.
- Only relevant medical records, medications, or questions should be discussed with your provider.
- Be attentive and engaged during the session, and feel free to ask any questions or express any concerns.
- Please ensure you are present or logged in 5 minutes before the scheduled start time of the session.
- The telehealth link provided will expire after 30 minutes. Accessing the session after the link has expired or attempting multiple logins will result in a system lockout.
- Please avoid no-show appointments. Missing appointments or logging in late is disruptive to the continuity of your healthcare and affects the scheduling of other appointments.
- Please notify our office at least 24 hours in advance to reschedule to avoid any late rescheduling or cancellation fees.
- To avoid a no-show fee, please ensure that you are available and logged in promptly at the scheduled time.
- Arriving late does not extend the allotted time for the session and may require cancellation and rescheduling.
- Failure to comply with Telehealth Guidelines may lead to termination of telehealth services and require in-person sessions.
- You are advised to review clinic policies and contact the office with any questions or concerns.
Consent for Telehealth Services
By signing this consent, you are confirming that you have read, acknowledged, and agree to the Telehealth Guidelines for Haelan Psychiatry & Wellness.
I, the patient, understand that Telehealth involves the use of electronic communication technologies for the purpose of providing remote healthcare services and that these sessions may take place via video and/or audio communication. I agree to make sure that, when participating in telehealth services, I will be in a private and secure location during the Telehealth session to avoid potential interruptions, distractions, or violation of privacy. I commit to being fully present and focused during the telehealth session, avoiding any external distractions or other tasks. I will ensure that the technological and electronic equipment I use for the telehealth session is in working condition, and I will address any technical issues promptly.
I acknowledge that the failure to abide by the conditions noted above may impact the quality and effectiveness of the telehealth session. If I am unable to meet the requirements noted above, I understand that the provider may, at their discretion, require that I transition to continuing my appointment sessions in-person.
Consent for Treatment
Consent is hereby given to perform any and all examinations, tests, procedures, and treatments necessary and/or advisable, and in an emergency, without the presence of parents or responsible adults. I hereby authorize examination and treatment of the above-named patient by Haelan Psychiatry & Wellness providers, clinical staff, physicians, and physician extenders employed or contracted by Haelan Psychiatry & Wellness. I realize that the practice of medicine and psychiatry is not an exact science, and I acknowledge that no guarantees have been made to me as a result of treatments or examination in this practice. I understand that Haelan Psychiatry & Wellness participates in clinical education programs and may permit students/interns to observe and participate in patient care when appropriate and under the direct supervision of the student’s preceptor.
Medications / Stimulants
I understand that refills of any medication(s) classified by the FDA/DEA as a narcotic, benzodiazepine, stimulant, controlled substance, or other high-risk medication requires re-evaluation at least every 30 days. I understand that Haelan Psychiatry & Wellness reserves the right to require urine drug screening at the discretion of the provider. I understand that refill requests for any medication will be responded to within 72 business hours of when the practice receives the request, including refill requests submitted Fridays, Saturdays, and Sundays.
Court-Ordered Evaluations
I understand that Haelan Psychiatry & Wellness does not provide court evaluations or court testimony and is not a forensic psychiatry clinic.
Notification of Privacy / HIPAA Acknowledgement
I acknowledge that I have received a copy of Haelan Psychiatry & Wellness’s Notice of Privacy Practices. I understand the Notice of Privacy Practices and understand my rights relating to the use and disclosure of my personal health information.
Authorization to Access Prescription History
I understand that Haelan Psychiatry & Wellness uses the Prescription Monitoring Program and technology to review prescription history and consent to this review of records.
Communications Technology
I acknowledge that Haelan Psychiatry & Wellness utilizes HIPAA-compliant communication platforms, including Spruce or other communication technologies, for patient communication outside of the electronic health record. I acknowledge that some medical records and/or prescription history may be obtained through a database communication link within the electronic health record (e.g., Prisma feature within eClinicalWorks for medication history, hospital/emergency room visits, etc.).
Office Policies and Procedures
I understand that Haelan Psychiatry & Wellness has a ZERO TOLERANCE policy for abusive and/or aggressive behavior toward staff, including harassing, cursing, belittling, or disruptive behavior.
I understand that Haelan Psychiatry & Wellness has a 10-minute Late Policy in which case, if I arrive 10 minutes late, my appointment will be rescheduled to the next available time.
I understand that missed appointments will be rescheduled to the next available time, and any controlled medications may not be refilled prior to an appointment.
I understand that if I miss multiple appointments, dismissal or discharge from care is at the discretion of the Provider at the Haelan Psychiatry & Wellness clinic.
I understand that when I call the Haelan Psychiatry & Wellness clinic, the call may be routed to voicemail, and messages will be returned within 24 to 48 business hours. I understand that multiple calls on the same day for the same reason may cause a delay in response time.
I understand that Haelan Psychiatry & Wellness is not liable for loss or damage to any personal property.
My name and date of birth below are indications that I have had sufficient time to review and consider the contents of the documents above and agree to said terms, conditions, and policies as noted in the above policies, procedures, and acknowledgements for Haelan Psychiatry & Wellness. I have voluntarily accepted and acknowledged the contents of the above documents without any pressure or coercion. I also declare that the information I provide is true and correct and understand that any willful dishonesty may render a refusal of my appointment acceptance.