I give permission to Future-Hope Behavioral Health Services, Inc, and its clinical employees and/or independent contractors to give me psychiatric mental health care. I understand that my treatment may be conducted in person and/or via telehealth. I understand some Physicians and prescribers may do supportive therapy along with medication management during a thirty-minute follow-up appointment.

Please be advised that Future-Hope Behavioral Health Services, Inc has a missed appointment policy that is strictly enforced. The standard charge for the service will be billed directly to the patient ($50).We require that you contact our offices 24 hours in advance during the business week to cancel or change your appointment if need be. If you are scheduled with a prescriber, you should call the receptionist, and if you are scheduled with a therapist, you should contact them directly. Prior to your next appointment, this fee must be paid.

We require patients to be on time. If you are going to be late, please contact the office to let your provider know. If you are more than 15 minutes late you will need to reschedule your appointment and will be responsible for the late cancellation fee.

At the time of your appointment with the provider, please schedule your follow-up visit according to the amount of medication that has been prescribed. It is your responsibility to be sure you schedule your next visit so that you see the doctor before you run out of medication. Refill requests will not be authorized without seeing your provider. If an appointment was canceled due to an emergency or a rare, unexpected, legitimate and unavoidable reason we would bridge the medication refills requests till the next available appointment. If a bridge refill is required for any other reason, except the provider needing to change the appointment, there will be a $10.00 bridge refill charge that needs to be paid prior to the provider completing the refill request.

For the protection of our patients/clients and staff, any activity that may be considered an invasion of privacy while in our offices will result in discharge of the offender from our practice. These activities include, but are not limited to, photography, recording of conversations, or similar behavior. Charges will be pressed against the offender to the fullest extent of the law.

Full payment of your financial responsibility is due at the time of service. We accept cash, some credit cards and checks with a valid driver’s license. If your insurance policy requires preauthorization for a service and you do not have that authorization information, you will be responsible for payment of the full fee at the time of service. If your insurance denies a claim because there is no initial authorization, you are responsible for payment of the entire fee.Payment of Deductibles and/or Copay/Coinsurance is expected at the time of service. In the event that your account becomes delinquent and is forwarded to an attorney for collection, that patient is responsible for the attorney fees and all court costs.Because of our contracts with insurance companies, we are unable to provide service without charging you the portion for which you are responsible. You are authorizing Future- Hope Behavioral Health Services, Inc to bill your insurance company directly and receive compensations for services rendered. You are authorizing Future-Hope Behavioral Health Services, Inc to send treatment plans to my Insurance Company and exchange information when it pertains to my treatment.All overpayments are credited to your account. They will be held and applied as needed until all services have been paid in full. Remaining overpayments will be applied against future services, unless the overpayment is at least $10.00 and you request reimbursement.Future-Hope Behavioral Health Services, Inc to send treatment plans to my Insurance Company and exchange information when it pertains to my treatment.

What is discussed in sessions with medication management and/or therapy is kept confidential. No content of sessions will be shared verbally with another party without written consent of the patient or legal guardian. Below is a list of exceptions to confidentiality:
-Duty to warn and protect: If you disclose a plan or threat to harm yourself, the provider must attempt to notify legal authorities and/or your emergency contact. In addition, if you disclose a plan or threat to harm another person, the provider is required to warn the possible victim and legal authorities.
-Abuse of children and vulnerable adults: If you disclose, or it is suspected, that there is abuse or harmful neglect of children or vulnerable adults (elderly, disabled/incompetent), the provider must report this information to the appropriate state agency and/or legal authorities. -Minors/guardianship: Parents or legal guardians of non-emancipated minor clients have the right to access the client’s records.
-Insurance providers: Insurance companies and other third-party payers are given information that they request regarding services to the clients. This includes type of services provided, dates/times of service, diagnosis, treatment plan, description of impairment, progress, clinical notes, summaries, etc.

I authorize Future-Hope Behavioral Health Services, Inc and its employed and contracted licensed health care providers and staff (collectively, the “Practice”) to use email to communicate clinical information to me pertaining to mental health care services that I may receive from the Practice. I acknowledge and understand that the most secure method of communication is by telephone call; however, if I choose to communicate with the Practice by email, these communications may contain my personal and private medical information (including, but not limited to, my name, address, date of birth, types and dates of mental health care services received, medications, insurance coverage information, and/or test results).I understand that although the Practice will take reasonable measures to attempt to protect the privacy of the contents of emails sent to me; the emails sent to me travel over the Internet. As a result, there is a risk that emails may be intercepted and read by unauthorized third parties. By choosing to communicate with the Practice via email, I assume this risk.I acknowledge and understand the following as it relates to email communications:1. Email is not appropriate for conveying information relating to urgent or emergency medical matters. If I am experiencing an urgent or emergency situation, I understand that I should dial 911 immediately.2. If an email has not been answered within twenty-four (24) hours, I should call to make sure that it has been received and I may make an appointment to discuss the email.3. I will not use email communications for discussion of sensitive or highly confidential issues. If there are specific types of information that I do not want included in emails, it is my responsibility to notify the Practice.4. Certain other health

care providers who are permitted access to my medical records (such as consulting health care providers) may have access to my email address and email message.5. I, and not the Practice, am responsible for the security of emails sent from or stored on my computer, tablet, or phone.6. My decision to allow the Practice to communicate with me by email is voluntary, and treatment is not conditioned upon my election to do so.7. The Practice or I may stop email communications at any time for any reason.8. I agree to notify the Practice when my email address changes.9. I will not to hold the Practice responsible for damages resulting from its use of email or the failure of any of the Practice’s information systems to facilitate email communications.10. I understand that all emails related to my care, received or generated by the Practice, may be maintained in my medical record.

I have received the Future-Hope Behavioral Health Services, Inc Patient Information Packet, which includes information regarding access, fees, Patient Rights and Responsibilities and Privacy Practices. I accept these policies and practices. I have been given the opportunity to review both "Rights and Responsibilities" and "Privacy Practices. I understand I may request a copy of these notices if I wish to keep them for my personal reference.I understand that behavioral health treatment offers no guarantees. By working with my healthcare providers, I should get help with the problems and concerns I bring to Future- Hope Behavioral Health Services, Inc. However, I recognize that things may get worse. I understand that I will probably need to do homework--that is, try new ways of dealing with my problems which I develop with my healthcare providers. If I do not do these things outside the office, I understand that the effectiveness of treatment will be limited.I agree to cooperate fully with my healthcare provider(s) or to discuss any reasons why I cannot. I agree to ask any questions I have to clarify my therapeutic goals and how treatment is addressing them.I understand that treatment will end when the problems and concerns I initially had been resolved. I also understand that I can terminate my treatment at any time I wish. I agree to notify my healthcare providers of my intent to end therapy and to discuss the possible risks of premature termination of therapy.I also understand that my healthcare provider(s) may end my treatment if we do not make progress, or if our relationship becomes too strained to continue working together. If I am no longer able to pay for services and treatment is to be terminated early, my healthcare provider(s) will make suggestions to guid

e me in finding another provider of my choice. I will make every effort to follow the suggestions.

Telehealth in General: Telehealth involves the real-time evaluation, diagnosis, consultation on, and treatment of a health care condition using advanced telecommunications technology, including interactive audio & video. Electronic systems used have network and software security protocols in place to protect the confidentiality of patients’ information.
Expected Benefits: Future-Hope Behavioral Health Services, Inc (the “Practice”) offers telehealth services to its patients to improve access to health care by enabling a patient to remain at home (or at a remote site) while receiving care from a distance.
Potential Risks:
•In the event of interruption or disconnection of the audio/video connection, the continuity or completion of a particular telehealth visit will depend upon whether the information transmitted is sufficient for the patient’s condition. If the audio/video connection is inadequate for that purpose or is disconnected, the Practice may require an in-person visit.
•Your health information will be transmitted electronically by audio and video. In accordance with HIPAA regulations, the Practice has implemented strict privacy and security precautions to protect its patients’ health information; however, the security and confidentiality of information transmitted electronically may be compromised by the failure of these security safeguards or illegal or improper tampering.
•While the Practice has taken reasonable and appropriate efforts to eliminate any confidentiality risks associated with your telehealth appointment, the Practice cannot control your environment or any company you may have with you during the telehealth appointment.
Medical Records: All existing State and federal laws regarding the privacy and security of your medical records apply to this tele

health appointment, as detailed in the Practice’s Notice of Privacy Practices. In accordance with HIPAA, the Practice will not record or store any video, images, or audio of your telehealth appointment, and by signing below you agree not to record or store any video, images, or audio of your telehealth appointment. Your provider will document the medical information conveyed during the appointment into your medical record the same as if it was an in-person office visit. You have the right to obtain copies of your medical records; any requests to inspect and obtain copies of medical records associated with telehealth will be made in accordance with the Practice’s standard policies and procedures.Data and Devices. The Practice does not warrant that its telehealth services will be compatible with any updates to, or prior versions of, your devices’ operating systems. To the extent that your telehealth appointment requires the use of wireless, cellular data, or internet access, you are responsible for securing the necessary data access service. E.g., your mobile phone provider may charge you data access fees in connection with your use of telehealth services. You are solely responsible for all such charges payable to third parties.Patient Rights: You may withhold or withdraw your consent to telehealth at any time without affecting your right to future care or treatment. You may contact the clinic at 1-667-304-8308 for any questions you have related to telehealth services. Risks, Consequences, and Benefits: By signing below, you acknowledge that: (i) you have been advised of the potential risks, consequences, and benefits of telehealth; (ii) you have had an opportunity to ask questions about the information presented on this form; and (iii) all your questions have been answered and you understand the information provided above.

I understand that I/my dependent may be diagnosed with or treated for a medical condition that requires use of controlled substance medication(s) (benzodiazepines, stimulants, etc.) because this medical condition has not been adequately managed with non-controlled medications and my function is limited by this medical condition. I understand that the intent of this medication is to increase my/my dependent’s ability to function, though the controlled substance medication is unlikely to eliminate my/ my dependent’s condition.I/my dependent will take the medication only as prescribed. I/my dependent will not take any additional sedatives, alcohol or other pain medications without the prior approval of my provider.I/my dependent understand that the medication will be prescribed only according to the agreed upon schedule. Prescriptions will be provided only during regular business hours. Medications will not be called in to the pharmacy.I/my dependent will not seek or accept any additional controlled substance medications (i.e. pain, anxiety or stimulants) other than those prescribed by my provider. This includes prescriptions from other providers, medications borrowed or accepted from family or friends and any illicit or street drugs.Medication refills will be provided as written prescriptions only. No refills will be given prior to 30 days. I understand that I must make appointments with my provider at least every (3) months or sooner if my provider recommends. No refills will be given if I do not keep these appointments. Two (2) no show appointments will constitute grounds for immediate dismissal from the practice.I understand that my provider is under no obligation to provide these medications to me, and that he/she reserves the right to discontinue these medications at any time. If I refuse, I understand the medications will be stopped.I understand that lost or stolen medications will not be refilled under any circumstances. It is my responsibility to protect and secure my medications. This includes keeping the medication out of reach of children. A copy of a police report will be required for any lost or stolen controlled substance prescriptions.I understand that my provider may request specialist evaluation of my treatment and I agree to keep appointments. My provider will send a copy of my medical record and care to the referred physician.I understand that my provider by law is required to report all controlled substances dispensed to me to the state monitored prescription monitoring program.

In addition to the above agreements, I accept the right of my provider's staff to terminate this agreement for any of the following reasons:
a) I seek or obtain any controlled substance(s) from a source other than my provider.
b) I in any way attempt to forge or alter a prescription.
c) I distribute my prescribed medication(s) to any other person.
d) My medical condition declines to the point at which, in the judgment of my provider, continued therapy with this medication presents danger to my wellbeing or safety.
e) There is evidence that I am no longer receiving a reasonable therapeutic benefit from the medication, or my provider determines that I am no longer a good candidate to continue the medication.

We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this notice about our privacy practices, our legal duties, and your rights concerning your health information we must follow the privacy practices that are described in this notice while it is in effect. The notice takes effect 5/30/03 and will remain in effect until we replace it. We reserve the right to change our privacy practices and the terms of this notice at any time without any prior notification for, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new items of our notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make significant changes in our privacy policies, we will change this notice and make new notice available upon request. You may request a copy of her notice at any time.
For more information about her privacy practices, or for additional copies of this notice, please contact the HR Department using the information listed at the end of this notice.

We use them disclose health information about you for treatment, payment and health care operations. For example:
Treatment: we may use or disclose your health information to a physician or other health care provider who treats you.
Payment: we may use and disclose your health information to obtain payment for services we provide to you.
Health care operations: we may use and disclose your health information in connection with our health care operations. Health care operations include quality assessment and improvement activities, reviewing the competence or qualifications of health care professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certifications, licensing or credentialing activities.
Your authorization: In addition to our use of your health information for treatment, payment, or health care operations, you may give us written authorizations to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. The revocation will not affect any use of disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this notice.
To your family and friends: we must disclose your health information to you, as described in the patient rights section of this notice. We may disclose your health information to a family member, friend, or other persons to the extent necessary to help with your health care or with payment for your health care, but only if you signed a release to do so.
Persons involved in care: we may use or disclose health information to notify or assist in the notification, includ

ing licensing or locating the family member, your personal representative, or other persons responsible for your care, of your location, your general condition, or death. If your present, then prior to use or disclosure over your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment, disclosing only health information that is directly relevant to the persons involvement in your health care we will also use our professional judgment and our experience with a common practice to make responsible inferences to your best interest in allowing a person to pick up filed prescriptions, medical supplies or other similar forms of health information.
Marketing health related services: we may not use your health information for marketing communications without your written authorization.
Research: we may disclose your health information for research in conjunction with privacy board. We will make a reasonable attempt to obtain your authorization for such disclosures and or to notify you of disclosures should they occur. Identifiable information will not be used for any other research purposes without your specific consent.
Required by law: we may use or disclose your health information when we are required to do so by law.
Abuse or neglect: we may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to prevent a serious threat to your health or safety or the health or safety of others.

National security: we may disclose to military authorities the health information of armed forces personnel under certain circumstances. We may disclose to a prized federal officials health information required for a lawful intelligence, counterintelligence, and other national security activities. We may disclose 2 correctional institutions are law enforcement official having lawful custody be protected health information of inmate or patients under certain circumstances.
Appointments and reminders: we may use or disclose your health information to provide you with the appointment reminders or changes such as voice mails messages, postcards or letters.

Access: you have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies in the formal other than photo-copies. We will use the format you request unless we cannot practically do so. You must make a request in writing to obtain access to your health information. You may obtain a form or to request access from office staff of your provider. We will charge you a reasonable cost-based fee for expenses such as copies, staff time, and postage. If you request an alternative format, we will charge a cost-based fee for providing health information in that format. You prefer, we will prepare a summary of an explanation of your health information for a fee. Contact our office staff for a full explanation of our fee structure.
Disclosure accounting: you have the right to receive a list of instances in which we are business associates disclosed your health information for purposes other than treatment, payment, health care operations another certain other activities for the last six years. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.
Restrictions: you have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement except in cases of emergencies.
Alternative communications: you have the right to request that we communicate with you about your health information through tentative means or two alternative locations. You must make your request in writing. Your request must specify the alternative means or location, an provide satisfactory explan

ation how payment will be handled under the alternative means or location you request. We will honor the request unless we cannot practically do so.
Amendment: you have the right to request that we amend your health information. Your request must be in writing and it must explain why the information should be amended. We may deny your request under certain circumstances.
Electronic notice: if you received this notice on our website by electronic Mail, you are entitled to receive this notice in written form upon request.

I, the patient named below, while navigating the website searching for providers, found Future-Hope Behavioral Health Services, Inc as my provider of choice and did not solicit for me. As a patient, I ultimately and rightly seek out a provider of my choice for my psychiatric and therapeutic needs. Future-Hope Behavioral Health Services, Inc. met my needs and came highly on the list and did not solicit or persuade me to come to them, but their services, patient’s approach, objectives, and caring attitude toward patients attracted my attention.

By submitting this form, the patient/client acknowledges that their electronic signatures, submission date/time, and available submission metadata such as IP information may be retained in Future Hope BHS submission records for verification and audit purposes.