Medication Management in Washington, District of Columbia

Caring Health Services
Consent to Electronic Communications
By using our Telehealth Service, you consent to receiving certain electronic communications from us as further described in our Privacy Policy. Please read our Privacy Policy to learn more about our electronic communications practices. You agree that any notices, agreements, disclosures, or other communications that we send to you electronically will satisfy any legal communication requirements, including that those communications be in writing.

This consent was signed by: ____________________________________________________
(PRINT NAME PLEASE)

Signature: _______________________________________________ Date: ___________________
Witness: _______________________________________________ Date: ___________________

CaringHealth Rights and Responsibilities
Client Rights and Responsibilities
This is a brief outline of both your rights and responsibilities while you receive services at Caring Health Services LLC, Inc. with face to face or telehealth. It will help you better understand the need for cooperation between me your Psychiatric Mental Health Provider, yourself, or other care provider that is in colla boration with your mental health needs. You have certain rights that must be respected. The health care providers also have rights and it is only through a mutual understanding of both sets of needs that you can receive the most effective health care. We promote that understanding through the following information. As a client, you have the right:

1. To receive prompt evaluation, care and treatment regardless of your race, gender, sexual orientation, gender identity, ethnicity, disability, religion, age and to be treated with dignity and respect and addressed in a respectful, age-appropriate manner, and regardless of ability to pay.
2. To have services explained to me in a language and in a I can understand, such as an ASL fluent clinician or an appropriately certified interpreter, if deaf services are needed.
3. To receive information about the qualifications of the staff that provide services to me and to have any change in the professional staff responsible for your care or for any transfer from one caregiver t o another within or outside the facility.
4. To receive psychiatric treatment that is within the accepted standards of medical practice and to an explanation of the risks, effects and benefits of all medications and treatment provided.
5. To refuse specific medications or treatment procedures to the extent permitted by law.
6. To participate in the planning of your and care, including admission or discharge planning and follow up care. This includes active participation of patients over 12 years of age and their parents, relatives or guardians in planning for treatment.
7. To have your records kept confidential to the extent permitted by law and to know where and to whom your records have been disclosed. I understand that Caring Health Services LLC participates in a Health Information Exchange (HIE). HIE is an electronic method used to share medical information about your care with other healthcare providers who have an established treatment relationship with you. We may use or disclose your information through the HIE with these other providers, and we may access your information from other providers through HIE. You may obtain more information about the HIE or begin the opt out process by contacting Caring Health Services LLC vial electronic communication provided to you. Or via telephone 202-204-2212 or 240-755-1924.
8. To have access to and an explanation of your health records, unless deemed therapeutically inadvisable.
9. To receive, at initial visit or admission: a written description of services, costs and rules and a written statement and explanation of patient rights and responsibilities and grievance without fear of recrimination

GAD-7 English

HIPAA-consent
HIPAA Compliance Patient Consent Form

Our Notice of Privacy Practices provides information about how we may use or disclose protected health information.

The notice contains a patient’s rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent.

The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date.

You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations.

By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive.

By signing this form, I understand that:

• Protected health information may be disclosed or used for treatment, payment, or healthcare operations.
• The practice reserves the right to change the privacy policy as allowed by law.
• The practice has the right to restrict the use of the information but the practice does not have to agree to those restrictions.
• The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.
• The practice may condition receipt of treatment upon execution of this consent.

May we phone, email, or send a text to you to confirm appointments? YES NO
May we leave a message on your answering machine at home or on your cell phone? YES NO
May we discuss your medical condition with any member of your family? YES NO
If YES, please name the members allowed:
___________________________________________________________________________________________________
___________________________________________________________________________________________________
This consent was signed by: ____________________________________________________
(PRINT NAME PLEASE)
Signature: ________________________________________________________________ Date: _________________
Witness: _________________________________________________________________ Date: _________________

Patient Health Questionnaire (PHQ-9)

Teltherapy-Informed-Consent-Web 2
Telehealth/Therapy Informed Consent Form:

As a patient of Caring Health, I hereby consent to engage in teletherapy/coaching with the staff, contractors or members of Caring Health if recommended by my treating Clinician. I understand that “teletherapy” includes consultation, treatment, transfer of medical data, emails, telephone conversations and education using interactive audio, video, data and telecommunications. I understand that teletherapy/coaching also involves the communication of my medical/mental information, both orally and visually.

I understand that I have the following rights with respect to telehealth and therapy:

1. I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment.
2. I understand that our teletherapy sessions are governed by the state laws of the District of Columbia. The laws that protect the confidentiality of my medical information also apply to teletherapy. As such, I understand that the information disclosed by me during the course of my therapy or consultation is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, which are regulated by federal HIPPA, the DC Mental Health Procedures Act and other health record provisions.
3. I understand that there are risks and consequences from teletherapy, including, but not limited to, the possibility, despite reasonable efforts on the part of Caring Health, its staff or members that: the transmission of my information could be disrupted or distorted by technical failures; the transmission of my information could be interrupted by unauthorized persons; and/or the electronic storage of my medical information could be accessed by unauthorized persons.
4. I understand that telehealth-based services and care may not be as complete as face- to-face services. I also understand that if my clinician believes I would be better served by face-to-face services, telehealth services will be discontinued or transition to face to face services. Finally, I understand that there are potential risks and benefits associated with any form of telehealth services, and that despite my efforts and the efforts of my clinician, I may not improve and my results cannot be guaranteed or assured and, in some cases, may even get worse.
5. I understand that there is a risk of being overheard by anyone near you if I don’t place myself in a secure and private area. Using a headset device is recommended. I also agree to participate fully and without interruption while in a teletherapy session.
6. I accept that telehealth services do not provide emergency services. During your first session, your Psychiatry Mental Health Nurse Practitioner (PMHNP) and I will discuss an emergency plan. If I am experiencing an emergency situation, I understand that I should call 911 or proceed to the nearest hospital emergency room for help. If I am having suicidal thoughts or making plans to harm myself, I can call the National Suicide Prevention Lifeline at 1.800. 273.TALK (8255) for free 24-hour hotline support. I agree that calling Caring Health, its staff or members and leaving a message on voice mail or email is not the emergency protocol and have been discouraged to do so.
7. I understand that I am responsible for (1) providing the necessary computer, telecommunications equipment and internet access for my telehealth sessions, (2) the information security on my computer, and (3) arranging a location with sufficient lighting and privacy that is free from distractions or intrusions for my telehealth session.
8. I acknowledge that I have received from Caring Health, the “Federal HIPPA Privacy Notice,” “Financial Policy,” “Electronic Communication Agreement,” and the “Patients’ Rights and Responsibilities Policy” have had adequate opportunity to read, review and agree with the documents fully.
9. My signature and/or my parent or guardians’ signature on Page 3 of the Caring Health “New Patient Forms” (Acknowledgement of Receipt) confirms that I have read, agree with and understand the information provided above. I have discussed it with my clinician and all my questions have been answered to my satisfaction.