Telehealth client consent form

Patient's Name
First Last
Date of Birth
MM slash DD slash YYYY
-BILLING AND SCHEDULING: The cost share of in-person office visits is due at the time of service. The cost share for Telehealth visits will be run on the day of the appointment. In the event you are unable to pay your cost share or the credit card on file declines, your appointment will be canceled for that day and rescheduled. If a credit card declines and you have already been seen that day, all future appointments will be canceled until the outstanding balance is paid.
Telehealth sessions can be scheduled like normal sessions. Mood Treatment Center requires a credit card to be placed on file for any appointments. The card placed on file will be run on the day of the appointment. Please note, that the estimated cost share charged to the card will be based on what your insurance company tells us you will owe for each visit.

The card placed on file will be run for the late cancellation or missed appointment within 48 hours of the charge being posted on the account.

Medication Visit: Late Cancellation and No-Show Fee: $50.00
-CREDIT CARD ON FILE: This section is REQUIRED for ALL appointment types. (exception: Veteran Affairs)

Your credit or debit card information is kept confidential and secure within our electronic health record system. A Credit Card Change Form will need to be completed for any updates to the credit card on file.
Payment Method*
- Visa
- Mastercard
- American Express
- Discover
Cardholder Name*
Cardholder Billing Address*
City*
State*
Zip*
Last 4 digits of Card#:*
Expiration Date*
Patient Signature*
By signing below, I agree to the terms listed above and I consent to receive treatment at the Mood Treatment Center and to participate in Telehealth using secure HIPAA compliant systems unless otherwise indicated. This authorization will expire 12 months from the date signed.
Today's Date*
Month
Day
Year
Cardholder Signature*
Today's Date*
Month
Day
Year
If patient is under 18, we must receive a parent/guardian signature
Today's Date
Month
Day
Year
Prior to your appointment, you will be required to provide detailed credit/debit card information to store electronically in our billing system. If this information is not provided 24 hours before the appointment, the appointment will be canceled and rescheduled.

By signing this form, you authorize Mood Treatment Center to charge fees that you are financially responsible for to the credit or debit card listed above. This authorization will remain in effect for 12 months from the date signed or upon termination of services with the organization.
-INSURANCE AND UNCOVERED SERVICES: If using insurance, I accept responsibility for any charges not covered by my plan. If my insurance has not been verified, is out of network, or my deductible still needs to be met, I will pay the full patient cost-share at my visit. I authorize payment of medical benefits to the Mood Treatment Center and the release of any diagnostic, medical, psychiatric, and substance abuse information to my insurer that is needed to process my claims.
-CRISIS: If you are in crisis outside of an office appointment or telehealth session, please contact the MTC crisis line (336-525-9090), the National Suicide Prevention Hotline (1-800-273-8255), 911, or visit https://crisissolutionsnc.org for your local crisis team.
-PRIVACY NOTICE: I have received the Privacy Notice (at bottom of page).
-NATURE OF TELEHEALTH VISIT: Telehealth involves the use of electronic communications to enable clinicians to provide virtual individual or group sessions either through HIPAA-compliant software or over the phone. You will receive a link by text or e-mail to access each session. Please be aware that session access should be accessed by clicking the link received and not through the Zoom mobile app.
-CONFIDENTIALITY: We will uphold the same principles of confidentiality whether your visit is conducted in person or via telehealth. There are risks associated with using technology as a means of transmitting sensitive information, and there may be authorized or unauthorized access to such transmissions and records. To ensure confidentiality to the best of our ability, MTC will be using encryption software during telehealth visits. You are strongly encouraged to receive your telehealth visits in a private setting.
-TELEHEALTH GROUPS: If you are participating in a telehealth group, be aware that the group facilitator upholds confidentiality but other group members may not. Telehealth groups are strongly encouraged to respect the privacy of other members and keep private whatever is disclosed during group. To ensure this privacy, group members are strongly encouraged to participate in the group from a private setting and not to share links to telehealth group meetings.
-IDENTIFICATION: To avoid breaches of confidentiality, your clinician will take steps to confirm your identity at the beginning of each telehealth session. Clinicians will also verify your current phone number and physical address to retain contact should connectivity be lost or should emergency personnel be needed to help you in a medical emergency. For telehealth group meetings, you will only be asked to identify yourself by name.
-RISKS, CONSEQUENCES, & BENEFITS: Telehealth visits help to maintain access to care when in-office visits are not feasible. However, you may experience technological difficulties such as interrupted internet connection, lagging or freezing of video transmission, delays in sound, etc., that could impair the quality of therapy you receive should connection or format issues cause misunderstandings between you and your therapist. Should the technology fail during a session, please plan to continue via phone. Although MTC will do its best to uphold confidentiality standards, we are aware that there are inherent risks associated with using technology as a means of service.
-SOCIAL MEDIA: Though telehealth is an internet-based modality, using telehealth does not imply an open digital relationship with your clinician. To maintain confidentiality and professional boundaries, your clinician will not interact with you on any social media or other internet platforms.
-MEDICAL INFORMATION & RECORDS: All existing laws regarding your access to medical information and copies of your medical records apply to in-person office visits and telehealth visits. Records associated with in-person office visits and telehealth visits will become a part of your medical record.
-RIGHTS: You may withhold or withdraw consent to telehealth visits in writing at any time without affecting your right to future care or treatment.
-ALTERNATIVE SERVICES: If an in-person office visit is not possible at MTC and you cannot access or choose to not access telehealth sessions, MTC will provide you with appropriate referrals to equivalent mental health services.
-PURPOSE: The purpose of this form is to obtain your consent to receive treatment at the Mood Treatment Center and to participate in a telehealth visit using secure HIPAA-compliant systems.
-FINANCIAL: I will pay for in-person office visits at the time of service. I agree to have my credit card on file run the day of any telehealth appointment as detailed in the Billing and Scheduling Section below. If I miss or cancel an office or telehealth appointment with less than 24 hours notice, even for a good reason, I agree to have my credit card on file run for the late cancellation or missed appointment fee as detailed in the Billing and Scheduling Section below.
By signing below you agree that this agreement and any other documents to be delivered in connection herewith may be electronically signed, and that any electronic signatures appearing on this agreement or such other documents are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
Patient Signature*
Today's Date*
Month
Day
Year
If patient is under 18, we must receive a parent/guardian signature
Today's Date
Month
Day
Year
**The following section is REQUIRED to be completed by ALL patients.***
PSYCHOTROPHIC MEDICATIONS: Patient Agreement I understand that if I am currently a patient, I am bound by this signed and dated agreement for any future medication appointments with a medication clinician at Mood Treatment Center. I understand and voluntarily agree that (initial each statement after reviewing):
- I will keep the medicine safe, secure, and out of the reach of children.
- I will take my medication as instructed and not change the way I take it on my own.
- I will not sell this medicine or share it with others.
- I understand that I have been given prescription(s) for enough medication until my next office visit (including necessary refills). If I need additional medication due to a missed appointment, I will need to call for an urgent appointment.
- I will make sure I have an appointment for refills. If I am having trouble making an appointment, I will tell a member of the treatment team immediately.
- I will keep (and be on time for) all my scheduled appointments with the provider and other members of the treatment team.
- I will always treat the staff at the office respectfully.
- I will sign a release form to allow the provider to speak to other providers that I see.
- I will tell the provider all other medicines that I take and let them know right away if I have a prescription for a new medicine.
- I will not accept or obtain prescriptions for benzodiazepines (Klonopin, Xanax, Ativan, Valium, etc.) or stimulants (Ritalin, Adderall, etc.) from other providers. If I am prescribed pain medication that contains opioids, I will promptly notify my provider of the prescription.
- I will promptly notify my provider if I take medications that are not prescribed for me including amphetamines, cocaine, opioids, fentanyl, benzodiazepines, and cannabis products.
- I will make timely payments for co-pays and deductibles and tell a member of the treatment team immediately if I lose my insurance or cannot pay for treatment.
- If I am capable of becoming pregnant - I recognize there may be serious potential risks of taking psychotropic medications on a fetus and growing baby. I will discuss my plans to get pregnant with my provider and notify my provider promptly if I become pregnant.
- I understand that I may lose my privilege to be treated in this office if I break any part of this agreement.
Signature*
Date*
MM slash DD slash YYYY
Privacy Notice (HIPAA)

Authorization for the Disclosure of Protected Health Information for Treatment, or Healthcare Operations (164.508(a))

As part of a client’s care, the client should understand that the Mood Treatment Center originates and maintains health records describing the client’s health history, symptoms, examination, and test results, diagnosis, treatment, and any future care or treatment. This information serves as:

A. a basis for planning the client’s care and treatment;

B. a means of communication among the health professionals who may contribute to the client’s health care;

C. a source of information for applying the client’s diagnosis and medical information;

D. a means by which a third-party payer can verify that services billed were provided;

E. a tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals.

I have been provided with a copy of the notice of privacy practices that provides a more complete description of the information and uses and disclosures.

I understand that as part of my care and treatment, it may be necessary to provide my protected health information to another covered entity. I have the right to review Mood Treatment Center's notice before signing this authorization. I authorize the disclosure of my protected health information as specified below for the purposes and to the parties designated by me.

Consent to the use and disclosure of protected health information for treatment, payment, or healthcare operations (164.506(a))

I understand that:

1. I have the right to review Mood Treatment Center's Privacy Practices prior to signing this consent;

2. That Mood Treatment Center reserves the right to change their Privacy Practices at any time and, if requested, will mail a copy of any notice to the address I’ve provided;

3. I have the right to object to the use of my health information for directory purposes;

4. I have the right to request restrictions as to how the client’s protected health information may be used or disclosed to carry out treatment, payment, or healthcare operations, and Mood Treatment Center is not required by law to agree to the restrictions requested;

5. I may revoke their consent in writing at any time, except to the extent that the Mood Treatment Center has already taken action in reliance thereon.
- I consent.
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DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.