Treatment Agreement Form

Treatment Agreement

We try to keep policies to the minimum, but have a few that we want to make sure you understand before starting treatment.

Payments, Cancellations, and Missed Appointments

I will pay for office visits at the time of service. If I miss or cancel an appointment with less than 24-hours notice, even for a good reason, I will pay missed appointment fee (equal to half the cost of service missed)

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 has not been met, I will pay the full amount at my visit. I authorize payment of medical benefits to the Mood Treatment Center and the release of any diagnostic, medical, psychiatric, and/or substance abuse information to my insurer that is needed to process my claims.

Privacy Notice

I have received the Privacy Notice (at bottom of page).
Sign your agreement to those three terms, and your consent to treatment at the Mood Treatment Center, by typing your name below
MM slash DD slash YYYY
MM slash DD slash YYYY
In typing your name, you agree that your electronic signature is the legal equivalent of your manual signature.

Telehealth Agreement

We offer visits in the office or through telehealth (video visits through a secure Zoom-like app). Telehealth is optional and there for your convenience unless mandated by law (ie, "lockdown").

While telehealth is a great way to maintain care, it also has some downsides to be aware of. You may experience technical difficulties (freezing of video, delays in sound, etc). Sometimes video technology fails and we will need to pick up by phone. Although we utilize encrypted software, no encryption can guarantee against all possible data breaches.

Clients who use our telehealth services pay for services in advance through a credit card that we keep securely on file. If you would like to use telehealth, we'll need your signature expressing agreement to these terms and a specific card that you'd like us to charge. To ensure security, only provide the last four digits of the card here:
Sign below if you would like to use telehealth (this is optional)
MM slash DD slash YYYY
MM slash DD slash YYYY

Privacy Notice (HIPAA)

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

I understand that as part of my care, Mood Treatment Center originates and maintains health records describing my health history, symptoms, examination, and test results, diagnosis, treatment, and any future care or treatment. I understand that this information serves as:

A. a basis for planning my care and treatment;
B. a means of communication among the health professionals who may contribute to my health care;
C. a source of information for applying my diagnosis and surgical information;
D. a means by which a third party payer can verify that services billed were actually provided;
E. a tool for routine health care operations such as assessing quality and reviewing the competence of health care professionals.

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

I understand that as part of 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 prior to 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 my protected health information may be used or disclosed to carry out treatment, payment, or healthcare operations, and that Mood Treatment Center is not required by law to agree to the restrictions requested;
5. I may revoke this consent in writing at any time, except to the extent that Mood Treatment Center has already taken action in reliance thereon.