TrueCare24 Informed Consent for Outpatient Services contract

DISCLOSURE STATEMENT
This statement is being provided to you by Truecare24 and its business associates, so that you are aware of your rights as a patient. This document contains important information about Truecare24 and its business associates' policies as well as counseling sessions. Please read this and discuss any questions or concerns you have with your healthcare professional. Your provider's license, qualifications, and contact information are listed at the end of this document.

For more information regarding communication practices and State board information please visit: www.truecare24.com/patient-rights/

YOUR RIGHTS AS A PATIENT
Except in an emergency situation, or where psychotherapy is being administered pursuant to a court order, every Licensed Psychotherapist, Licensed Social Worker, Licensed Mental Health Counselor, Unlicensed Psychotherapist, or Psychologist shall provide the information below in writing to each client at the initiation of therapy.

Please see the link above for state specific general responsibility of regulating the practice of licensed psychologists, licensed social workers, licensed professional counselors, licensed marriage and family therapists, licensed school psychologists practicing outside the school setting and unlicensed individuals who practice psychotherapy.

Importantly, you have the right to receive evidenced based medical care and professional services from your counselor. Your counselor aims to provide services in a professional and ethical manner within accepted legal standards. If you are ever dissatisfied with your therapy, please directly discuss these concerns with your counselor. If they are not able to resolve these issues you may report complaints to the [email protected]

You are entitled to receive information about methods of therapy, the techniques used, the duration of your therapy (if it can be determined), and fee structure. You may seek a second opinion from another therapist and you can terminate services at any time. Your therapist may refer you to another provider if the issues brought up in therapy are outside of the scope of practice, or beyond their training, experience and/or competence.

CONFIDENTIALITY
What you discuss in sessions is kept confidential between you and your therapist. No content of the sessions may be shared with another party without your written consent or the written consent of the parent/legal guardian of a minor. However, there are times when counselors are required, by law and professional ethics, to break confidentiality and file a report. Those exceptions are:
- When a professional counselors learn of, or strongly suspect, physical or sexual abuse or neglect of any person under 18 years of age.
- When a professional counselors learn of, or strongly suspect, physical or sexual abuse or neglect of an elderly person.
- If there is evidence of clear and imminent danger of harm to self and/or others.
- Parents or legal guardians of non-emancipated minor clients have the right to access clients' records.
- Counselors may be ordered by the court to disclose information.
- If you or your child is involved in legal action/proceedings, your records may be subject to subpoena or lawful directive from a court.
- You or your child discloses sexual contact with another mental health professional who has or is providing health care services to you or your child.

Your therapist may occasionally find it helpful to consult other professionals about a case. During a consultation, your therapist will make every effort to avoid revealing the identifying information. The consultant is also legally bound to keep the information confidential. Ordinarily,your therapist will not tell you about these consultations unless it is important to your work together.

COPAY ACKNOWLEDGEMENT
I authorize Truecare24,its business associates, and associated mental healthcare providers to bill my insurance for medical services provided to me. I also authorize Truecare24,its business associates, and associated mental health care providers to bill my credit/debit or checking account on file to cover the cost of any copay related to the medical services I receive. I authorize Truecare24, its business associates and my assigned therapist to bill my insurance company.

CONSENT AND AGREEMENTS
Please sign a copy of this form and keep a copy for yourself. Your signature will indicate that you have read this form, that you have your copy, that you understand your rights and you have received HIPAA information. By signing this form, you give your consent for treatment and share required HIPAA protected information with TrueCare and its business associates.

By signing this form, you give consent for another licensed mental health professional employed by Truecare24 and its business associates to conduct your treatment and to take possession of your clinical records in the event that your primary assigned therapist needs replacement or upon your request for another therapist.

Your signature also allows Truecare24, its business associates and your therapist to release information necessary to process insurance claims and authorize payment (including Medicare) directly to Truecare24 and its business associates for services provided.

Your signature below indicates that you have read the information in this document and agree to abide by its terms during our professional relationship.

AUTHORIZATION FOR RELEASE/DISCLOSURE OF INFORMATION
I hereby authorize the release/request of copies and/or discussion of the information including medical/psychological history, medications and current symptoms for coordination of care.

I may revoke this authorization in writing at any time by sending an email to [email protected]. If not revoked prior to the end of treatment with Truecare24 this consent will automatically expire 30 days after termination of services, unless otherwise specified.

I confirm that I understand that in the event that information has already been shared by the time authorization is revoked, it may be too late to cancel permission to share the health data, that I do not need to give any further permission for the information detailed above to be shared with the person(s) or organization(s) listed, and that the failure to sign/submit the authorization of the cancellation of this authorization will not prevent the reception of treatment or benefits the client is entitled to receive, provided this information is not required to determine eligibility to receive those treatments or benefits or to pay for the services I receive.

CREDIT / DEBIT CARD PAYMENT INFORMATION & CONSENT
I Authorize TrueCare24 Physicians Group, S.C. to charge my credit/debit/health account card for professional services 24 hours before our scheduled appointment. TrueCare24 will charge you for only your Co-Pay prior to sessions, and co-insurance after sessions (If Applicable) TrueCare24, will also not charge for Late Cancels, as many of our clients are elderly and within Assisted Living Communities.

I verify that my credit card information, provided here, is accurate to the best of my knowledge. If this information is incorrect or fraudulent or if my payment is declined, I understand that I am responsible for the entire amount owed and any interest or additional costs incurred if denied. I also understand by signing and initialing this form, that if no payment has been made by me, my balance will go to collections if another alternative payment is not made within thirty days.