CONSENT FOR TREATMENT & PATIENT RIGHTS
CONSENT FOR TREATMENT & PATIENT RIGHTS
I understand I have the right to confidential medical records and protected health information. I have the right to be treated considerately and respectfully while receiving care. Care will be free from physical or verbal abuse, neglect or by employees and/or contractors, free from corporal punishment or psychological abuse. I have the right to refrain or deny participation in research projects and/or student participation in my treatment.
FREEDOM OF CHOICE GRIEVANCE PROCEDURE
Any client may initiate a complaint, orally, or in writing, not limited to, concerning his/her individual treatment plan, the exercise of ones right or the quality of services at the facility. Every client shall have the right to assistance of an independent person and witness in presenting his/her complaints. Parents of children under 14 years of age, or legal guardians, may exercise this procedure on behalf of the client unable to do so for himself/herself. Person’s not directly involved in circumstances leading to the grievance shall decide resolution.
CIVIL RIGHTS COMPLIANCE AWARENESS
In accordance with applicable federal and state civil rights laws and regulatory requirements, you, as a client of this agency have the right to be provided services at this facility and to be referred to services at other facility without regard to your race, color, religion, creed, handicap, ancestry, national origin, age or sex. You may file a complaint of discrimination if you feel you have been discriminated against on the basis of any of the above listed groups. Bureau of Civil Rights Compliance, Department of Public Welfare 625 Forster St, P.O. Box 2675 Room 225, Health and Welfare Bldg. Harrisburg A 17105-2675
PATIENT RESPONSBILITIES AND FACILITY REGULATIONS
Rules and regulations have been established for the well-functioning of our program and you are expected to comply with them. Your services may be terminated from this facility for failure to comply with your responsibilities and for these reasons: arriving to the clinic under the influence of drugs and/or alcohol, failure to attend three consecutive clinic appointments without cancelation. Exhibiting violent behavior, threatening any staff member, or another patient. Possession of a concealed weapon, sale or attempt to sell illicit or prescription drugs.
You are responsible to provide accurate personal information in order for New Beginnings to render appropriate care. You are responsible to keep your appointments on time and to cancel within 24 hours in advance. You are responsible to be respectful to our staff, participate in the planning and follow-up of your treatment, and to take your prescribed medications as instructed by your psychiatrist.
CONSENT FOR OUTPATIENT TREATMENT
I hereby give New Beginnings permission to provide treatment to me in the Outpatient Program and/or Outpatient Group Program. I understand that I am entitled to the least restrictive treatment appropriate to my needs, including medication. I understand that I may revoke this consent at any time. I am aware of my right to discontinue treatment at any time uses I am court mandated.
I understand that the information released among group members is confidential and is to remain confidential among group members. Should information that is shared be determined to put any known individual at risk I understand New Beginnings has the right to notify the proper authorities and other relevant personnel.
I confirm that I have read, understand and agree to the above statements and policies. Next INSURANCE BENEFITS AND PRIVACY PRACTICES
INSURANCE BENEFITS AND PRIVACY PRACTICES
ASSIGNMENT AND COORDINATION OF INSURANCE BENEFITS
I agree to provide information regarding all group hospitalization, health maintenance organization, Workers' Compensation, automobile, and other health care benefits (“Insurance Plan(s)”) to which I may be entitled. I hereby assign payment(s), if any, from my Insurance Plan(s) to New Beginnings (or its affiliate) and each of the independent contractor physicians and/or professional corporations for services rendered to me. The direct payment hereby assigned and authorized includes any Insurance Plan(s) benefits to which I am otherwise entitled, including any major medical benefits otherwise payable to me under the terms of my policy, but is not to exceed the balance due to New Beginnings (or its affiliate), the independent contractor physicians and/or professional corporations for services rendered to me during the applicable periods of medical care.
UNAUTHORIZED, NON-COVERED, OR OUT OF PLAN SERVICES
I understand if my Insurance Plan(s) does not consider this admission or any service rendered during this admission a covered service or has not authorized this service, they will not pay for this admission or the service rendered during this admission or outpatient visit. I agree to be fully responsible for payment to New Beginnings for this admission or any service if determined by my Insurance Plan(s) to be a non-covered service. I also understand and acknowledge that in the case of Out of Plan/Network services, there may be reduced benefits and I may be required to pay a larger co-payment, co-insurance or other charge in the event my Insurance Plan(s) does not reimburse these services provided to me, I acknowledge I will be responsible for any remaining balance.
FOR MEDICARE/MEDIGAP RECIPIENTS ONLY
I certify the information given by me in applying for payment under Title XVIII of the Social Security Act is correct. I request that payment of authorized Medicare benefits be made on my behalf to the Hospital and/or independent contractors for any services furnished to me by that physician or supplier. I authorize any holder of medical information about me to release to the Centers for Medicare & Medicaid Services and its agents any information needed to determine these benefits or the benefits payable for the related services. In the case of Medicare Part B benefits, I request payment either to myself or to the party who accepts assignment.
RESIDENTS, INTERNS OR MEDICAL STUDENTS
I understand residents, interns, medical students and other health care professional students may participate, under the supervision of an attending psychiatrist or clinician or other health care professional, in my care as part of the New Beginnings education programs.
CONSENT TO DISLOSE HEALTH INFORMATION
I understand and agree that /new Beginnings may use and disclose protected health information for treatment, payment, or health care operations. I understand I must consent to this use and disclosure in order to receive services through New Beginnings. I understand I have the right to review the privacy notice prior to signing this form. I understand that I have the right to request that New Beginnings restrict how protected health information is used or disclosed to carry out treatment, payment, or health care operation.
I hereby authorize New Beginnings to release to my insurer, governmental agencies, or any other entity financially responsible for my medical care, all information, including diagnosis and the records of any treatment or examination rendered to ne needed to substantiate payment for such medical or psychiatric services as well as information required for precertification, authorization or referral to other providers.
NOTICE OF PRIVACY ACT (HIPPA)
Health insurance portability and accountability act of 1996 (HIPPA) privacy regulations grant patients six right in connection with protected health information. Patients have the right to request limits on uses and disclosures of their protected health information, the right to choose how health information is sent, the right to see and obtain copies o f their protected health information, receive a list of disclosures a facility has made with their protected health information, the right to request corrections and updates, an receive the notice of privacy by email, if they choose.
NOTICE OF PRIVACY PRACTICES
I certify that I have been made aware of New Beginnings Notice of Privacy Practices and that I have a right to receive a copy upon request. This Notice describes the type of uses and disclosures of my protected health information that might occur during my treatment, to facilitate the payment of my bills or in the performance of New Beginnings operations. The Notice also describes my rights and New Beginnings duties with respect to my protected health information. I understand that copies of the Notice of Privacy Practices are available in the registration areas of each facility and on New Beginnings website at www.newbeginningsservices.com. New Beginnings reserves the right to change the privacy practices that are described in the Notice of Privacy Practices.
I certify I have read and understand the foregoing, have had the opportunity to ask questions and have them answered and accept the above conditions and terms and I agree to pay all charges for which I may be legally responsible including, but not limited to health insurance deductibles, co-payments, and non-covered. I also agree in the event my account must be placed with an attorney or collection agency to obtain payment, I will pay the reasonable attorneys' fees and other collection costs incurred by New Beginnings. I understand and agree this document will remain in effect for all future outpatient or mental health office visits to New Beginnings, unless specifically rescinded in writing by me.
I confirm that I have read, understand and agree to the above statements and policies. TELE-PSYCHIATRY CONSENT FORM
TELE-PSYCHIATRY CONSENT FORM
Telepsychiatry provides psychiatric services using interactive video conferencing tools, such as Telespark, in which the psychiatrist and the patient are not at the same location. Telepsychiatry will allow the patient to receive medical care without the need to visit the office and travel long distance. Alternative to telepsychiatry include traditional face to face sessions.
I understand that the laws that protect the privacy and confidentiality of medical information also apply to telepsychiatry
I understand that the Telespark is known to incorporate network and software security protocols to protect the confidentiality of information and audio/visual data. These protocols include measures to safeguard the data and to aid in protecting against intentional or unintentional corruption.
I have the right to withdraw my consent to the use of telepsychiatry during the course of my care at any time.
I understand that New Beginnings has the right to withhold or withdraw consent for the use of telepsychiatry during the course of my care at any time.
I understand that all rules and regulations which apply to the practice of medicine in the State of Pennsylvania also apply to telepsychiatry.
I will not record any telepsychiatry sessions without the prior written consent of New Beginnings and I understand that New Beginnings will not record telepsychiatry sessions without my consent.
I will inform New Beginnings if any other person can hear or see any part of our session before the session begins. Likewise, New Beginnings will inform me if any other person can hear or see any part of the session before the session begins.
I understand that I must be a resident of Pennsylvania to be eligible for telepsychiatry services from New Beginnings.
I understand that my initial consultation will not be done by telepsychiatry except in special circumstances under which I will be required to verify my identity to New Beginnings satisfaction before the evaluation.
Potential risks include, but may not be limited to: information transmitted may not be sufficient (poor resolution of video); delays in medical evaluation and treatment due to deficiencies or failures of the equipment; security protocols can fail, causing a breach of privacy; and a lack of access to all the information available in a face to face visit may result in errors in medical judgment. I confirm that I have read, understand and agree to the above statements and policies. REGISTER FORM
HEALTH HISTORY FORM
HEALTH HISTORY FORM
PERSONAL INFORMATION MEDICAL INFORMATION Please list any MEDICATIONS you are currently taking, prescribed or over the counter If you have or had any of the following, please check Please list any SURGERIES you have had and include the month/year TOBACCO USE AND HISTORY ALCOHOL AND DRUG USE AND HISTORY DIET AND PHYSCIAL ACTIVITY BEHAVIORAL HISTORY