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Behavioral Health Consent

Last Updated: October 31, 2023

CONSENT TO TREAT: I, the patient or the parent or legal guardian of the patient presenting for treatment (the “Patient”), consent for the Patient to receive behavioral health services at PM Pediatric Care (the “Practice”) in-person or through the Practice’s telemedicine platform. Such behavioral health services shall include any diagnostic, treatment, or consultation services and/or tests that the physician(s), licensed clinical social worker(s), psychologist(s), nurse practitioner(s), and/or registered dietician(s) (each, a “Provider) determine to be necessary and advisable, with the support of a behavioral health care manager or sleep/parent coach. This consent shall remain valid until revoked. I understand that I may revoke this consent at any time by providing written notice of my intent to revoke such consent to, and that such revocation will not affect my right to future treatment at the Practice. I acknowledge that the Provider will protect the confidentiality of information obtained from the Patient during the provision of behavioral health services, except in certain cases where disclosure is permitted or required by law. This may include cases of Patient disclosure of intent to harm self or others, instances of past or present child neglect or abuse, and/or other situations where disclosure and/or mandated reporting may result, in accordance with applicable local, state or federal law and/or the Practice’s policies and practices.

I understand that the Patient will receive behavioral health services from a Provider either in person or through teletherapy consultations conducted via the telemedicine platform. I understand that I will be provided with the name, license, title, and, if applicable, specialty and board certifications of the Provider who will be providing the behavioral health services. In order to receive behavioral health services, I understand that a Provider or behavioral health care manager will first conduct an assessment to determine if the Patient is an appropriate candidate for behavioral health services. During this initial consultation and any subsequent behavioral health visit, the Provider or behavioral health care manager (as applicable) will ask the Patient questions, document clinical information shared by the Patient, document the service(s) provided, and ensure that documentation is included in the Patient’s clinical record for future reference.

If consultations are conducted via teletherapy, I understand that telehealth technology will be used to connect the Patient with a Provider, and that such consultations will be conducted by interactive, real-time, two-way videoconferencing that allows the Patient and Provider to see one another during the teletherapy consultation. Teletherapy services generally require the Patient to have access to a computer with a webcam and microphone or a smartphone that is connected to high speed internet or wireless data service. The Provider may also use asynchronous store-and-forward technology to allow for the electronic transmission of images; diagnostics (including test results and interpretation); data; and medical and psychological information to facilitate the provision of behavioral health services to the Patient. If the Provider determines that he or she can meet the standard of care for behavioral health services without using the video component, the Provider may use interactive, real-time, two-way audio in combination with the asynchronous store-and-forward technology described above to provide behavioral health services to the Patient.

I understand that teletherapy services provide many benefits, including improved access to care, efficient evaluation and management, and convenient care scheduling and logistics. However, in choosing to participate in a teletherapy consultation, I understand that the use of telehealth technology for diagnosing or treating behavioral health conditions presents certain risks, including but not limited to the following, which may occur in rare instances:

If proceeding with a teletherapy consultation or assessment, I acknowledge that I have been advised and understand all the potential risks, benefits and alternatives to teletherapy and choose to proceed with behavioral health services via teletherapy. I release and hold harmless the Practice from any loss of data or information due to technical failures.

If teletherapy services are provided, the Provider will obtain the Patient’s contact information in case of a technological or equipment failure, in which case the Provider will call the Patient back as soon as possible to continue the consultation. I understand that if the Patient is a minor, the Patient’s parent or legal guardian should be present at the onset of each teletherapy consultation, unless an alternative is discussed and agreed upon by the Provider, Patient, and the Patient’s parent or legal guardian. I understand that both the Patient and Provider must state whether anyone else is present in the room during the teletherapy consultation and all parties agree to refrain from recording any audio or video footage of the teletherapy consultation. It is the Patient’s responsibility to ensure privacy of their immediate environment. The Provider cannot guarantee the confidentiality of teletherapy consultations where the Patient chooses to proceed with a consultation in a non-private or public setting.

I understand that the Provider may terminate the teletherapy consultation if he or she feels that teletherapy services are inappropriate under the circumstances and may advise the Patient of the need to obtain an additional in-person medical or psychological evaluation reasonably able to meet the Patient’s needs. I understand that I have the right to terminate the teletherapy consultation at any time, without affecting the Patient’s right to future care or treatment.

If the Patient is participating in a group behavioral health session, whether in-person or via teletherapy, the services will be provided in a group setting with other individuals present. It is important to note that other individuals participating in a group session are not subject to the same confidentiality laws and restrictions as the Providers. Accordingly, by choosing to participate in group therapy sessions, I expressly waive any guarantee that the information shared by the Patient during these sessions will remain confidential.

RELEASE OF INFORMATION: I understand that I may request access to a copy of the records relating to the behavioral health services provided to the Patient. To obtain copies of such records, please visit or call (516) 869-0650. I understand that the Provider may withhold certain information contained in the Patient’s record if, in the reasonable exercise of the Provider’s professional judgment, the Provider determines that the release of such information would adversely affect the Patient’s health or welfare. If I am the parent or legal guardian of an adolescent Patient, I also understand that the Patient may have the right to consent or object to my receipt of the Patient’s health information depending on applicable federal, state or local law and regulation.

I consent to the use and disclosure of the Patient’s behavioral health information for purposes of treatment, payment and health care operations as described in the Notice of Privacy Practices. I authorize and direct the Practice to release to government agencies, insurance carriers, managed care companies, or other entities who are or may be financially liable for the Patient’s care (and to authorized agents of such entities) all information needed to substantiate payment for the behavioral health care and to permit representatives thereof to examine and request copies of records related to the Patient’s case and treatment. I further authorize the Practice to release billing information to any healthcare provider involved in the Patient’s care. I authorize the Practice to use and disclose my protected health information (“PHI”) as permitted under the Health Insurance Portability and Accountability Act (“HIPAA”), other applicable law, and by the Practice’s Notice of Privacy Practices. I consent to the Practice accessing, storing and sharing my medical information electronically through one or more health information exchanges (“HIEs”) pursuant to applicable state and federal law. I understand that other healthcare providers within the HIE network will have access to my health information for purposes of treatment, payment and healthcare operations and that I may choose to direct the Practice not to share my health information with the HIE network by submitting to the Practice a signed copy of the Health Information Exchange Opt-Out form (available upon request). I understand that the Practice typically shares medical records and other visit notes with the Patient’s primary care provider for purposes of continuity of care. I further understand that the Practice may share my contact information with community organizations to which I am referred, with my prior verbal consent.

I understand that the Practice has implemented security measures sufficient to protect the Patient’s electronic health information. Electronic health information is stored in a secure data center in encrypted format to prevent unauthorized individuals from viewing or accessing such data. The Practice also utilizes password and authentication protections as additional safeguards where appropriate.

ASSIGNMENT: I assign, transfer and set over to the Practice sufficient monies and/or benefits to which I am or may be entitled from government agencies, insurance carriers, or others who may be financially responsible for the Patient’s care to cover costs of the care and treatment rendered.

PATIENT GUARANTEE OF PAYMENT: I accept that I am financially responsible for the cost of the behavioral health services provided. I accept personal responsibility for all co-payments, deductibles, and non-covered services, as dictated by my or the Patient’s insurance coverage (hereinafter, the “insurance plan”), plus any collection costs for amounts personally owed by me. I acknowledge that services provided by the Practice may not be covered by the insurance plan for one or more reasons, including but not limited to exclusions under the insurance plan, exhaustion of benefits, the insurance plan’s designation of the Practice as an out-of-network provider, and/or my failure to provide the insurance card. I understand that if I do not fulfill the requirements of the insurance plan, do not receive the requisite prior approval, if the authorization is denied or if the insurance plan refuses to pay the cost of the services for any other reason, I understand and agree that I am financially responsible for the cost of these services. I understand that I may independently contact my insurance company to determine if my insurance plan covers the Patient’s behavioral health services, and that, upon request, the Practice will provide me with information that I can submit to my insurance plan for reimbursement. I understand that the Practice will not submit a claim to the Patient’s insurance plan seeking payment for services rendered if the Practice does not participate with the Patient’s insurance plan or if I inform the Practice that I will not be seeking insurance coverage for the cost of the behavioral health services.

I allow the Practice to keep my credit card information on file, and I authorize the Practice to charge my credit card for the cost of the services for which I am financially responsible. If the insurance plan sends me or the Patient money that is designated to pay for the services provided by the Practice, I agree to immediately send the check or an amount equal to the amount received by the insurance plan to the Practice. I understand that all bills are to be paid immediately upon receipt. I also understand that in the event my account is transferred to a collection agency due to my failure to pay for the services, that I will be responsible for any reasonable attorney’s fees and collection fees incurred by the Practice in collecting payment, in addition to the amount of the bill.

COMMUNICATIONS: I understand that the Practice may need to contact me regarding the behavioral health services provided to the Patient. I authorize the Practice to call the phone number I have provided and to leave voicemail messages with respect to the Patient’s care, to facilitate treatment, payment and health care operations, and for quality improvement or educational purposes. I consent to the Practice mailing materials incident to treatment, payment and health care operations to the address I have provided, such as billing statements and/or other materials containing PHI. I consent to receive text messages and/or emails (generated through an automated system or otherwise) from or on behalf of the Practice for purposes of treatment, payment and health care operations, including, without limitation, quality improvement and patient satisfaction activities. I understand that the Practice cannot guarantee the privacy, security or confidentiality of text messages or email communications sent or received. I understand that I may opt-out of receiving automated emails or text messages at any time.

AFFIRMATION: I affirm that I have read and fully understand this Consent to Treat and Guarantee of Payment form and have been given the opportunity to ask questions and that all my questions have been answered to my satisfaction.