Common use of Informed consent mismanagement Clause in Contracts

Informed consent mismanagement. Without comprehensive informed consent policies and procedures, patients may not realize the risks or advantages of telemedicine—or even that they might be receiving such care. Neglecting to adequately explain specific telemedicine services and how they might be used for a patient’s treatment, or neglecting to obtain consent for such services, could become a major matter of negligence if not discussed with their patients prior to treatment services. We are not often immediately available by telephone and email. If we are not available by telephone, you may leave a message on our confidential voicemail system or send us a confidential email and your call/email will be returned as soon as possible, but it may take up to three days for non-urgent matters. If, for any number of unseen reasons, you do not hear from us or we are unable to reach you, and you feel you cannot wait for a return call/email or if you feel unable to keep yourself safe: 1. Contact your Community Mental Health Services 2. Go to your local hospital emergency room 3. Call 911 and ask to speak to the mental health worker on call. We will make every attempt to inform you in advance of planned absences and provide you with the name and phone number of the covering mental health professional. STILLPOINT COUNSELING ASSOCIATES may terminate treatment if payment is not timely, if recommendations are not followed (such as seeking consultations from specialists, refraining from dangerous practices, coming to sessions sober and alert, etc.), or if some problem emerges that is not within the scope of practice or competency of the counselor. The usual minimal termination period is 2 weeks. You are urged to consider the risk which major psychological transformation may have on current relationships and the possible need of psychiatric consultations during periods of extreme depression or agitation. Not all people experience improvement from psychotherapy and therapy may be emotionally painful at times. Patients have the right to refuse or to discontinue services at any time. If you are unhappy with what is happening in therapy, we hope you will talk with us so that we can respond to your concerns. Such comments will be taken very seriously and handled with the utmost care and respect. You may also request that we refer you to another therapist within our agency or an external referral to a therapist in your area. You have the right to considerate, safe and respectful care, without discrimination as to race, ethnicity, color, gender, sexual orientation, age, religion, national origin, or source of payment. You have the right to ask questions about any aspect of therapy and about our specific training and experience. You also have the right to expect that we will not have any social or sexual relationships with current patients or with former patients. The Board of Behavioral Sciences receives and responds to complaints regarding services provided by licensed or registered counselors. If you have a complaint and are unsure if your counselor is licensed or registered, please contact the Board of Behavioral Sciences at 000-000-0000 for assistance or utilize the Board’s online license verification feature by visiting xxx.xxx.xx.xxx.

Informed consent mismanagement. Without comprehensive informed consent policies and procedures, patients may not realize the risks or advantages of telemedicine—or even that they might be receiving such care. Neglecting to adequately explain specific telemedicine services and how they might be used for a patient’s treatment, or neglecting to obtain consent for such services, could become a major matter of negligence if not discussed with their patients prior to treatment services. We are not often immediately available by telephone and email. If we are not available by telephone, you may leave a message on our confidential voicemail system or send us a confidential email and your call/email will be returned as soon as possible, but it may take up to three days for non-urgent matters. If, for any number of unseen reasons, you do not hear from us or we are unable to reach you, and you feel you cannot wait for a return call/email or if you feel unable to keep yourself safe: 1. Contact your Community Mental Health Services 2. Go to your local hospital emergency room 3. Call 911 and ask to speak to the mental health worker on call. We will make every attempt to inform you in advance of planned absences and provide you with the name and phone number of the covering mental health professional. STILLPOINT COUNSELING ASSOCIATES may terminate treatment if payment is not timely, if recommendations are not followed (such as seeking consultations from specialists, refraining from dangerous practices, coming to sessions sober and alert, etc.), or if some problem emerges that is not within the scope of practice or competency of the counselor. The usual minimal termination period is 2 weeks. You are urged to consider the risk which major psychological transformation may have on current relationships and the possible need of psychiatric consultations during periods of extreme depression or agitation. Not all people experience improvement from psychotherapy and therapy may be emotionally painful at times. Patients have the right to refuse or to discontinue services at any time. If you are unhappy with what is happening in therapy, we hope you will talk with us so that we can respond to your concerns. Such comments will be taken very seriously and handled with the utmost care and respect. You may also request that we refer you to another therapist within our agency or an external referral to a therapist in your area. You have the right to considerate, safe and respectful care, without discrimination as to race, ethnicity, color, gender, sexual orientation, age, religion, national origin, or source of payment. You have the right to ask questions about any aspect of therapy and about our specific training and experience. You also have the right to expect that we will not have any social or sexual relationships with current patients or with former patients. The Board of Behavioral Sciences receives and responds to complaints regarding services provided by licensed or registered counselorswithin the scope of practice of marriage and family therapy. If you have a complaint and are unsure if your counselor is licensed or registered, please You may contact the Board of Behavioral Sciences board online at xxx.xxx.xx.xxx, or by calling (000) 000-000-0000 for assistance or utilize the Board’s online license verification feature by visiting xxx.xxx.xx.xxx0000.

Informed consent mismanagement. Without comprehensive informed consent policies and procedures, patients may not realize the risks or advantages of telemedicine—or even that they might be receiving such care. Neglecting to adequately explain specific telemedicine services and how they might be used for a patient’s treatment, or neglecting to obtain consent for such services, could become a major matter of negligence if not discussed with their patients prior to treatment services. We are not often immediately available by telephone and emailtelephone. If we are not available by telephone, you may leave a message on our confidential voicemail system or send us a confidential email and your call/email call will be returned as soon as possible, but it may take up to three days for non-urgent matters. If, for any number of unseen reasons, you do not hear from us or we are unable to reach you, and you feel you cannot wait for a return call/email call or if you feel unable to keep yourself safe: 1. Contact your Community Mental Health Services 2. Go to your local hospital emergency room 3. Call 911 and ask to speak to the mental health worker on call. We will make every attempt to inform you in advance of planned absences and provide you with the name and phone number of the covering mental health professional. STILLPOINT COUNSELING ASSOCIATES may terminate treatment if payment is not timely, if recommendations are not followed (such as seeking consultations from specialists, refraining from dangerous practices, coming to sessions sober and alert, etc.), or if some problem emerges that is not within the scope of practice or competency of the counselor. The usual minimal termination period is 2 weeks. You are urged to consider the risk which major psychological transformation may have on current relationships and the possible need of psychiatric consultations during periods of extreme depression or agitation. Not all people experience improvement from psychotherapy and therapy may be emotionally painful at times. Patients have the right to refuse or to discontinue services at any time. If you are unhappy with what is happening in therapy, we hope you will talk with us so that we can respond to your concerns. Such comments will be taken very seriously and handled with the utmost care and respect. You may also request that we refer you to another therapist within our agency or an external referral to a therapist in your area. You have the right to considerate, safe and respectful care, without discrimination as to race, ethnicity, color, gender, sexual orientation, age, religion, national origin, or source of payment. You have the right to ask questions about any aspect of therapy and about our specific training and experience. You also have the right to expect that we will not have any social or sexual relationships with current patients or with former patients. The Board Patient acknowledges that they have read, discussed, understands, and agrees to the above terms of Behavioral Sciences receives this Informed Consent Agreement, as well as the Exhibits to this Agreement (including Exhibit A, Exhibit B, Exhibit C, Exhibit D, and responds the attachments thereto), and that Patient has been able to complaints ask STILLPOINT COUNSELING ASSOCIATES and their physician, psychologist or other healthcare professional any questions regarding the therapy and services to be provided by licensed STILLPOINT COUNSELING ASSOCIATES. Signature: Patient/Guardian Name: Date: Signature: Patient/Guardian Name: Date: Authorized STILLPOINT COUNSELING ASSOCIATES Representative (name, title) Executed this day of , 20 , in the State of California. Primary Insurance Holder Birth Date: Relationship to patient: Name of Insurance Carrier: Carrier Address: Covered Dependents: Policy Number: Policy Effective Date: □ The above-named Patient has the following up to date insurance coverage: PRIMARY INSURANCE (copy of insurance cards are required for all insurance coverage) SECONDARY INSURANCE □ Not Applicable Secondary Insurance Holder Name: Secondary Insurance Holder Birth Date: Relationship to patient: Name of Insurance Carrier: Carrier Address: Covered Dependents: Policy Number: Policy Effective Date: □ The above-name patient already has correct insurance information already on file. Signature: Secondary Insurance Holder Name: Signature: □ The above-name patient DOES NOT have insurance coverage. Signature of Patient or registered counselorsLegal Guardian: Patient Name: Date of Birth: (month) / (date) / (year) I, THE UNDERSIGNED, AUTHORIZE PAYMENT BY THE PROVIDED INSURANCE COMPANY BE MADE DIRECTLY TO STILLPOINT COUNSELING ASSOCIATES AND ANY REPRESENTATVIE FOR ALL BENEFITS, IF ANY, OTHERWISE PAYABLE TO ME FOR ALL SERVICES RENDERED. If you have I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR ALL CHARGES NOT COVERED BY SAID INSURANCE OR OTHER FUNDING SOURCES, INCLUDING DEDUCTIBLES AND COPAYMENTS. I HEREBY AUTHORIZE THE RELEASE OF ALL INFORMATION NECESSARY TO SECURE PAYMENT OF SAID BENEFITS. I FURTHER AGREE IN THE EVENT OF NONPAYMENT OF ANY AMOUNTS DUE BY ME, TO BEAR THE COST OF COLLECTION, AND OR/COURT COST AND REASONABLE LEGAL FEES SHOULD THIS BE REQUIRED. Copy of Primary Insurance Stillpoint Counseling Associates On File: □ Yes □ No □ N/A Copy of Secondary Insurance Stillpoint Counseling Associates On File: □ Yes □ No □ N/A HIPAA Form 3.601 🙝 I hereby consent to, request, and authorize STILLPOINT COUNSELING ASSOCIATES and their representatives. to receive any or all funding-related, medical, social, psychological, or educational information regarding the above- named participant/patient from (Funding Agency and/or Individual) with the understanding that all such information becomes part of the CENTER FOR AUSTISM AND RELATED DISORDERS, INC. records and will be utilized for planning services for the above-named participant/patient. 🙝 I hereby consent to, request, and authorize the STILLPOINT COUNSELING ASSOCIATES and their representatives to release any or all funding-related, medical, social, psychological, or educational information regarding the above-named participant/patient to (Funding Agency or Individual) . Effective date for this authorization: From To 1. Revoke this Authorization by sending written notice to this office, except to the extent that: (1) STILLPOINT COUNSELING ASSOCIATES has taken action in reliance on my prior authorization; or, (2) if the authorization was obtained as a complaint condition of obtaining insurance coverage, other law provides the insurer with the right to contest a claim under the policy or the policy itself. 2. Knowledge of any remuneration involved due to any marketing activity as allowed by this authorization, and are unsure if your counselor as a result of this authorization. 3. Inspect a copy of Participant Health Information being used or disclosed under federal law. 4. Restrict what is licensed or registered, please contact the Board of Behavioral Sciences at 000-000-0000 for assistance or utilize the Board’s online license verification feature by visiting xxx.xxx.xx.xxxdisclosed with this authorization.

Informed consent mismanagement. Without comprehensive informed consent policies and procedures, patients may not realize the risks or advantages of telemedicine—or even that they might be receiving such care. Neglecting to adequately explain specific telemedicine services and how they might be used for a patient’s treatment, or neglecting to obtain consent for such services, could become a major matter of negligence if not discussed with their patients prior to treatment services. We are not often immediately available by telephone and emailtelephone. If we are not available by telephone, you may leave a message on our confidential voicemail system or send us a confidential email and your call/email call will be returned as soon as possible, but it may take up to three days for non-urgent matters. If, for any number of unseen reasons, you do not hear from us or we are unable to reach you, and you feel you cannot wait for a return call/email call or if you feel unable to keep yourself safe: 1. Contact your Community Mental Health Services 2. Go to your local hospital emergency room 3. Call 911 and ask to speak to the mental health worker on call. We will make every attempt to inform you in advance of planned absences and provide you with the name and phone number of the covering mental health professional. STILLPOINT COUNSELING ASSOCIATES may terminate treatment if payment is not timely, if recommendations are not followed (such as seeking consultations from specialists, refraining from dangerous practices, coming to sessions sober and alert, etc.), or if some problem emerges that is not within the scope of practice or competency of the counselor. The usual minimal termination period is 2 weeks. You are urged to consider the risk which major psychological transformation may have on current relationships and the possible need of psychiatric consultations during periods of extreme depression or agitation. Not all people experience improvement from psychotherapy and therapy may be emotionally painful at times. Patients have the right to refuse or to discontinue services at any time. If you are unhappy with what is happening in therapy, we hope you will talk with us so that we can respond to your concerns. Such comments will be taken very seriously and handled with the utmost care and respect. You may also request that we refer you to another therapist within our agency or an external referral to a therapist in your area. You have the right to considerate, safe and respectful care, without discrimination as to race, ethnicity, color, gender, sexual orientation, age, religion, national origin, or source of payment. You have the right to ask questions about any aspect of therapy and about our specific training and experience. You also have the right to expect that we will not have any social or sexual relationships with current patients or with former patients. The Board Patient acknowledges that they have read, discussed, understands, and agrees to the above terms of Behavioral Sciences receives this Informed Consent Agreement, as well as the Exhibits to this Agreement (including Exhibit A, Exhibit B, Exhibit C, Exhibit D, and responds the attachments thereto), and that Patient has been able to complaints ask STILLPOINT COUNSELING ASSOCIATES and their physician, psychologist or other healthcare professional any questions regarding the therapy and services to be provided by licensed STILLPOINT COUNSELING ASSOCIATES. Signature: Patient/Guardian Name: Date: Signature: Patient/Guardian Name: Date: Authorized STILLPOINT COUNSELING ASSOCIATES Representative (name, title) Executed this day of , 20 , in the State of California. Primary Insurance Holder Birth Date: Relationship to patient: Name of Insurance Carrier: Carrier Address: Covered Dependents: Policy Number: Policy Effective Date:  The above-named Patient has the following up to date insurance coverage: PRIMARY INSURANCE (copy of insurance cards are required for all insurance coverage) SECONDARY INSURANCE  Not Applicable Secondary Insurance Holder Name: Secondary Insurance Holder Birth Date: Relationship to patient: Name of Insurance Carrier: Carrier Address: Covered Dependents: Policy Number: Policy Effective Date:  The above-name patient already has correct insurance information already on file. Signature: Secondary Insurance Holder Name: Signature:  The above-name patient DOES NOT have insurance coverage. Signature of Patient or registered counselorsLegal Guardian: Patient Name: Date of Birth: (month) / (date) / (year) I, THE UNDERSIGNED, AUTHORIZE PAYMENT BY THE PROVIDED INSURANCE COMPANY BE MADE DIRECTLY TO STILLPOINT COUNSELING ASSOCIATES AND ANY REPRESENTATIVE FOR ALL BENEFITS, IF ANY, OTHERWISE PAYABLE TO ME FOR ALL SERVICES RENDERED. If you have I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR ALL CHARGES NOT COVERED BY SAID INSURANCE OR OTHER FUNDING SOURCES, INCLUDING DEDUCTIBLES AND COPAYMENTS. I HEREBY AUTHORIZE THE RELEASE OF ALL INFORMATION NECESSARY TO SECURE PAYMENT OF SAID BENEFITS. I FURTHER AGREE IN THE EVENT OF NONPAYMENT OF ANY AMOUNTS DUE BY ME, TO BEAR THE COST OF COLLECTION, AND OR/COURT COST AND REASONABLE LEGAL FEES SHOULD THIS BE REQUIRED. Copy of Primary Insurance Stillpoint Counseling Associates On File:  Yes  No  N/A Copy of Secondary Insurance Stillpoint Counseling Associates On File:  Yes  No  N/A HIPAA Form 3.601  I hereby consent to, request, and authorize STILLPOINT COUNSELING ASSOCIATES and their representatives. to receive any or all funding-related, medical, social, psychological, or educational information regarding the above- named participant/patient from (Funding Agency and/or Individual) with the understanding that all such information becomes part of the STILLPOINT COUNSELING ASSOCIATES records and will be utilized for planning services for the above-named participant/patient.  I hereby consent to, request, and authorize the STILLPOINT COUNSELING ASSOCIATES and their representatives to release any or all funding-related, medical, social, psychological, or educational information regarding the above-named participant/patient to (Funding Agency or Individual) . Effective date for this authorization: From To 1. Revoke this Authorization by sending written notice to this office, except to the extent that: (1) STILLPOINT COUNSELING ASSOCIATES has taken action in reliance on my prior authorization; or, (2) if the authorization was obtained as a complaint condition of obtaining insurance coverage, other law provides the insurer with the right to contest a claim under the policy or the policy itself. 2. Knowledge of any remuneration involved due to any marketing activity as allowed by this authorization, and are unsure if your counselor as a result of this authorization. 3. Inspect a copy of Participant Health Information being used or disclosed under federal law. 4. Restrict what is licensed or registered, please contact the Board of Behavioral Sciences at 000-000-0000 for assistance or utilize the Board’s online license verification feature by visiting xxx.xxx.xx.xxxdisclosed with this authorization.