Consent For Treatment



Client Name: _____________________________________ DOB: _______________________

(Last, First Middle)

Primary Insurer ___________________________________ ID#_________________________

Secondary Insurer _________________________________ ID#_________________________

Consent for Treatment

Florida Therapy Services, Inc. (FTS) provides community mental health and targeted case management services to children, adolescents, and adults who voluntarily seek treatment. Individuals may decide to stop services at anytime. FTS is committed to hiring qualified providers. Individuals have the right to know the professional qualifications and training of the assigned treatment team members. Treatment team members are available to answer questions or concerns involving your treatment and care. FTS provides services to consumers without regard to race, color, religion, national origin, sex, or handicap. Your treatment providers are available to support you throughout the treatment process. I understand that with help from my treatment team I am responsible to plan, practice, and maintain my treatment goals and objectives and/or my service plan goals and objectives. My treatment /services will end when I have reached my goals, achieved maximum benefit, voluntarily stop treatment, or I am no longer eligible for services. I further understand FTS may suspend or terminate services if I threaten harm or inflict harm on any FTS provider or employee. The outcome of services provided by FTS is generally positive; however, the level of individual satisfaction is not predictable

Counselor/Therapist – A licensed or master level practitioner that is qualified to provide therapy. A Counselor possesses a minimum of a master’s degree in counseling, psychology, or social work program obtained from an accredited university. The counselor may also be referred to as a therapist.

Targeted Case Manager –These providers will see you in the home at least once a month. During this visit they attempt to help you with resource needs. Case Managers have a minimum of a bachelor’s degree from an accredited university with a major in a qualified degree program and the required experience and Medicaid training

APRN – An Advanced Registered Nurse Practitioner who specializes in behavioral/mental health. ARNP evaluate, diagnose, prescribe medication, and monitor client treatment under the supervision of an onsite or off site psychiatrist as per Florida Statute 458.348.

Psychiatrist – A medical doctor who specializes in behavioral/mental health. Psychiatrists evaluate, diagnose, prescribe medication, and monitor client treatment.

FTS is committed to providing services at the most appropriate and least restrictive level of care necessary. FTS subscribes to evidence based and clinically sound treatment modalities that are medically necessary. Service is individualized and based on need and benefit eligibility. Services will be provided at FTS sites, in homes, in schools, in the community, as well as via telemedicine. Telemedicine is the use of electronic communication and information technologies to provide or support clinical psychiatric care at a distance. You have a choice as to the location and manner of services you are provided based on the availability of providers and reimbursement allowed. I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment. I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine, and that no information obtained in the use of telemedicine, which identifies me, will be disclosed to researchers or other entities without my written consent.

I agree to receiving scheduling information via phone contact and or voice messaging about appointments using the contact information I have provided. I understand that all interactions with FTS including but not limited to, scheduling of or attendance at appointments, information about an assessment or evaluation, and information disclosed within therapy sessions is confidential and may not be disclosed to anyone outside FTS without my written expressed permission. Limitations to confidentiality apply in the following circumstances, where the law requires disclosure:

1. if I present an imminent threat of harm to myself or to others,

2. to report a crime committed on FTS premises or against FTS personnel,

3. when there is a suspicion or indication of abuse, abandonment, or neglect of a child, vulnerable adult, or an elderly adult.

4. to medical personnel in a medical emergency, and

5. by a court order from a judge under specific circumstances.

STATEMENT TO PERMIT PAYMENT OF INSURANCE BENEFITS TO PROVIDER

I request that payment of Medicare, Medicaid, and/or any insurance benefits I may be entitled to, be made on my behalf to Florida Therapy Services, Inc. for any services furnished to me by Florida Therapy Services, Inc.

I authorize the release of any medical other information necessary to determine these benefits or the benefits payable for related services to Florida Therapy Services, the Centers for Medicare and Medicaid, Florida Medicaid, Magellan Health Services, and/or any other insurance company or government entity that is authorized to make payments on my behalf, and its agents. A copy of the authorization will be sent to the Centers for Medicare and Medicaid, Florida Medicaid, Magellan Health Services, and/or any insurance company or government entity that is authorized to make payments on my behalf, and its agents, if requested. The original authorization will be kept on file by Florida Therapy Services, Inc.

I understand that Florida Therapy Services, Inc. reserves the right to review all agreements on an individual basis to determine the continued acceptance of assignment for Medicare, Medicaid, Magellan Health Services, and/or any other insurance companies or government entities.

I agree to assume responsibility for payment for services and/or products furnished to me by Florida Therapy Services, Inc. which are not paid to Florida Therapy Services, Inc. for any reason by Medicare, Medicaid, Magellan Health Services, and /or any other insurance or government entity unless precluded by law or agreement between Florida Therapy Services, Inc. and the insurer or government entity.

I understand that in certain circumstances, insurance companies may send a check for services provided by Florida Therapy Services, Inc., directly to me. If that should occur, I agree to endorse the check and mail or hand carry it directly to Florida Therapy Services, Inc. to the address shown below. If I deposit the check, I understand that I am responsible to pay Florida Therapy Services, Inc. the equivalent amount.

Clients Rights and Responsibilities

You have the right to:

• know and understand your rights and responsibilities.

• a written copy of your rights and responsibilities.

• be treated with courtesy, respect and dignity, regardless of ethnicity, gender, sexuality, religion, financial status, and/or handicaps.

• confidentiality regarding your treatment and treatment documentation within the scope of state and federal laws.

• know who makes up your treatment team and their professional qualifications.

• participate in the development of your treatment plan and discharge plan.

• be notified in advance of any changes in the care you are receiving.

• ask questions regarding your treatment and receive prompt and fair answers to those questions.

• know the availability of treatment support services.

• terminate and/or refuse treatment, unless the law says care must be given.

• know what other care may be available regarding your treatment.

• know what the potential risks and outcomes there are to treatment.

• information regarding the cost of treatment and what cost you are responsible for, if applicable.

• know what treatment expenses are covered or not covered by Medicare, Medicaid, and/or third party insurance companies, as applicable.

• inform Florida Therapy Services, Inc. and/or your payor source, if applicable, of any questions, concerns, or complaints, regarding your treatment.

• if applicable, receive a bill that is easy to understand.

• help with any emergency problem that will get worse if help is not given.

• know when treatment is for experimental research and that you have the choice to say “yes” or “no.”

• an interpreter, if applicable.

• know that Florida Therapy Services, Inc. does not use any type of seclusion and/or restraint.

You are responsible for:

• telling your provider, to the best of your ability, all information related to your behavioral health problem.

• answering questions your provider asks you for the purpose of diagnosis and treatment of your behavioral health problem.

• informing your provider about any changes in the way you feel.

• informing your provider of any physical illnesses/challenges that may impact your treatment.

• participating in your treatment to the best of your ability.

• attending scheduled appointments and calling if you can’t make an appointment.

• the possible consequences should you refuse treatment or fail to follow your treatment plan.

• your decisions and conduct.

Participation Agreement

As a client of Florida Therapy Services, I agree to the following:

_____ I will notify my therapist, case manager, other provider or office staff at least 24 hours ahead of my appointment if I can’t keep a scheduled appointment.

_____ I understand that missing three scheduled appointments in a row may result in my discharge from Florida Therapy Services and referral to another provider.

_____ I will notify my therapist, case manager, other provider or office staff of any changes to my address or phone number.

_____ I agree to make sure that a safe, private and confidential space will be available for scheduled meetings in my home, FTS office or telemedcine by not having access to weapons.

_____ I agree to insure that any medications I bring to an FTS location are appropriately secured and maintained by me to prevent other’s access to them.

_____ I understand that, if I, a family member or friend, acts in a violent or threatening manner toward any FTS staff member, my services with Florida Therapy Services could be ended and I would be transferred to another provider.

_____I agree to make sure that family and children who are scheduled for services will be available at scheduled times.

_____ I agree to turn off TV, radio, cell phone, and other distractions during my sessions and actively participate in each session with my therapist, case manager, or other provider.

_____ I agree to arrange for child care so that I can be involved in each session with my therapist, case manager or other provider without interruption.

_____I agree to follow all recommendations for therapy, case management, medication management and others services. If I choose not to follow these recommendations, my services with Florida Therapy Services could be ended and I would be transferred to another provider.

_____ I understand that, if FTS makes arrangements to provide auxiliary services: interpreter services, other contracted services, I will be responsible for reimbursing FTS should I miss or break the appointment without proper notice.

_____ I understand that, if I break this agreement, my services with Florida Therapy Services could be ended and I would be transferred to another provider.

CONSENT OR AUTHORIZATION FOR REQUEST OR RELEASE OF

PROTECTED HEALTH INFORMATION WITH THIRD PARTIES

AHCA

I authorize Florida Therapy Services, Inc. to

Agency for Health Care Administration

N/A Receive information from: 2727 Mahan Drive

Tallahassee, FL 32308-5407

N/A Release Information to: Phone: 1-888-419-3456

Florida Therapy Services, Inc. will request my protected health information consisting of: enrollee eligibility and authorization information, demographic information, pharmacological history, behavioral health service benefit history and availability, and PCP information for the purpose of treatment authorization and continuity of care.

Florida Therapy Services, Inc. will release my protected health information consisting of: psychological testing and assessments, psychiatric evaluations and medication management, psychosocial evaluations, treatment plan goals and interventions, treatment updates, progress notes, and demographic information for the purpose of assisting with treatment authorization and continuity of care.

Communication between your behavioral health provider(s) and your primary care physician (PCP) is important to make sure all care is complete, comprehensive, and well-coordinated. This form allows your PCP and behavioral health provider to share valuable information. No information will be released without your signed authorization.

Primary Care Physician

I authorize Florida Therapy Services, Inc. to Name of Physician:________________________________

Address:_________________________________________

N/A Receive information from: Phone _________________________________________

N/A Release Information to Fax _________________________________________

Florida Therapy Services, Inc. will request my protected health information consisting of: diagnosis, treatment, prognosis, medication(s), known allergies, substance abuse medical treatment, and pertinent health information, as necessary to ensure quality and coordination of care.

Florida Therapy Services, Inc. will release my protected health information consisting of: psychological testing and assessments, psychiatric evaluations and medication management, psychosocial evaluations, treatment plan goals and interventions, treatment updates, and demographic information for the purpose of assisting with treatment authorization and continuity of care.

Pharmacy

I authorize Florida Therapy Services, Inc. to Name of Pharmacy:________________________________

Address:_________________________________________

N/A Receive information from: Phone _________________________________________

N/A Release Information to Fax _________________________________________

Florida Therapy Services, Inc. will request my protected health information consisting of: medication(s) and pertinent health information, as necessary to ensure quality and coordination of care.

Florida Therapy Services, Inc. will release my protected health information consisting of: medication(s) and pertinent health information, as necessary to ensure quality and coordination of care.

Emergency Contact

I authorize Florida Therapy Services, Inc. to Name of Emergency

Contact:_________________________________________

Address:_________________________________________

N/A Receive information from: Phone _________________________________________

N/A Release Information to

Florida Therapy Services, Inc. will request my protected health information consisting of: emergency related information to include current prescription and over the counter medications, location, demographic information, family contact information and ___________________________________________________________________________________________________________.

Florida Therapy Services, Inc. will release my protected health information consisting of: appointment information and _________

___________________________________________________________________________________________________________.

OTHER RELEASES

I authorize Florida Therapy Services, Inc. to

| | |Agency/School: | |

| |Receive information from | | |

| | |Address: | |

| | |Phone: | |

| |Release Information to: | | |

| | |Fax: | |

I authorize Florida Therapy Services, Inc. to

| | |Agency/School: | |

| |Receive information from | | |

| | |Address: | |

| | |Phone: | |

| |Release Information to: | | |

| | |Fax: | |

I authorize Florida Therapy Services, Inc. to

| | |Agency/School: | |

| |Receive information from | | |

| | |Address: | |

| | |Phone: | |

| |Release Information to: | | |

| | |Fax: | |

CONSENT AUTHORIZATION FOR PRESCRIPTION PICK-UP

________________________________________________________________ ____________________________

Print Client Name - Last, First, Middle Date of Birth

In order to protect the privacy of clients, FTS will only release prescriptions to persons identified on this document based on your direct consent. If you plan to have someone pick up your prescription, please indicate the persons in this consent.

I give my permission to the following person(s) to pick up my prescription from FTS due to my unavailability:

____________________________________________________________________________ ____________________________________________

Print Name Relationship

____________________________________________________________________________ ____________________________________________

Print Name Relationship

____________________________________________________________________________ ____________________________________________

Print Name Relationship

Print Name Relationship

Please note: This consent only authorizes the release of prescriptions to another individual. If you wish for medical information to be released, please request an “AUTHORIZATION FORM FOR RELEASE OF HEALTH INFORMATION”.

I permit any HIV/AIDS identifying information that is within the above specified information to be released. (Initial) _________

I permit any Substance Abuse identifying information that is within the above-specified information to be released. (Initial) _________

This consent or authorization for release of information shall be effective the date of signature and at the time services are concluded, or if I request.

Special Accommodations

Please let us know of any special needs, accommodations, services, or other items we can provide to better support your opportunity for success.

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Receipt of required information and Client/Guardian signatures.

_____I have been provided access to a copy of this orientation packet through the patient portal which includes my Client Rights and Responsibilities. I have been afforded the opportunity to discuss my rights and responsibilities and I fully understand this information. Additionally, I have been provided a copy of my rights.

_____I acknowledge that I have received a consumer handbook that reviews client rights, confidentiality and its limitations, access to records, state rules governing mandated reporting regulations, emergency contacts, and grievance procedures. I have had the opportunity to discuss any questions I have about this information. Additionally I have been provided general information about the provider's infection .

Note: If the client is underage, physically or mentally unable to sign, a legal guardian or representative may sign on the client’s behalf. If you are signing on behalf of the client, please include the appropriate documentation, such as a power of attorney. In addition, the representative’s signature, date signed, representative’s name (print), address, relationship to the beneficiary and reason why the client cannot sign must be listed below.

I have read and understand this Orientation Packet and have voluntarily signed it.

__________________________________________________________ __________________

Printed Name of Client (Last, First Middle) DOB

__________________________________________________________ __________________

Signature of Client Date

__________________________________________________________ __________________

Signature of Legal Guardian Date

__________________________________________________________ __________________

Signature of FTS Representative Date

Reason a Guardian or Representative is necessary: ________________________________________________

(Must attach legal documentation)

Signature: _________________________________________________ Date: __________________________

Notice to Recipient of Information: This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR part 2). The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the 42 CFR part 2. A general authorization for the release of medical or other information is not sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient [52 FR 21809, June 9, 1987; 52 FR 41997, Nov. 2, 1987]

Effective Period: This consent or authorization for release of information shall be effective the date of signature and shall expire at the time services are concluded or at the request of the client

Revocation: I also understand that I may, in writing, revoke this consent or authorization at any time. Revocation has no effect on action previously taken.

Office Locations:

______ Panama City, 459 Grace Ave, FL 32401 Phone: 850-769-6001 Fax: 850-769-6003

______ Marianna, 2944 Penn Avenue, Suite L, FL 32448 Phone: 850-526-5500 Fax: 850-526-5536

______ Tallahassee, 1713 Mahan Dr, FL 32308 Phone: 850-681-6001 Fax: 850-681-6003

______ Pensacola, 6425 Pensacola Blvd , Unit 38, FL 32505 Phone: 850-471-0017 Fax: 850-471-0009

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FLORIDA

Therapy Services, Inc.

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