Consent for Telepsych Services

What are Telepsychiatric Services?

Telepsychiatric services are used when the psychiatrist cannot be physically present with you to evaluate your mental health needs and, if appropriate, provide medications. The psychiatrist may be present at another location, to serve you through newly available technology. Telepsychiatric services use video and audio technology to send both voice and visual images between you and the designated psychiatrist. The combination of visual and audio make it possible for your psychiatrist to make a better evaluation of your needs.

How do Telepsychiatric services work?

You will be in a private room by yourself, or with a family member. The room will have a computer screen with a video camera. The Psychiatrist will also be in a private room at another location with similar equipment. When the session is ready to begin program staff will start the computer and camera so you and your Psychiatrist can see each other and talk together. When the session is over you can exit the room and inform the program staff that your session is completed.

What happens if I choose not to consent to Telepsychiatric Services?

If you choose not to consent to Telepsychiatric services, you will be provided with an onsite psychiatrist to provide you face-to-face psychiatric care.

Telemedicine privileges shall include consulting, prescribing, rendering a diagnosis or otherwise providing clinical treatment to patients through the use of visual & audio technology.

Introduction

Telepsychiatry is the delivery of psychiatric services using interactive audio and visual electronic systems where the psychiatrist and the patient are not in the same physical location.

The interactive electronic systems used in telepsychiatry incorporate network and software security protocols to protect the confidentiality of patient information and audio and visual data. These protocols include measures to safeguard the data and to aid in protecting against intentional or unintentional corruption.

My Rights

I understand that the laws that protect the privacy and confidentiality of medical information also apply to telepsychiatry.
I understand that the technology used is encrypted to prevent the unauthorized access to my private medical information.
I have the right to withhold or withdraw my consent to the use of telepsychiatry during the course of my care at any time. I understand that my withdrawal of consent will not affect any future care or treatment.
I understand that the Psychiatrist has the right to withhold or withdraw his consent for the use of telepsychiatry during the course of my care at any time.
I understand that the all rules and regulations which apply to the practice of medicine in the state of California also apply to telepsychiatry.
I understand I may not have any face to face contact with my psychiatrist, except for my telepsychiatry visits.

My Responsibilities

Telepsychiatry sessions will not be recorded without written consent. I understand that the psychiatrist will not record any of our telepsychiatry sessions without my written consent.

The psychiatrist will I will inform you if any other person can hear or see any part of our session before the session begins.

- I consent to Telepsychiatric services and I have read and understand the information provided above regarding telepsychiatry. I have had the opportunity to ask questions about this information and questions have been answered to my satisfaction. I hereby give my informed consent for the use of telepsychiatry in my psychiatric care and authorize to use telemedicine in the course of my diagnosis and treatment.
Signature of Patient (or person authorized to sign for Patient)
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If authorized signer, relationship to Patient
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Acknowledgement of Receipt of Notice of Privacy Practices

By signing this document, I acknowledge that I have received a copy of Palo Verde Behavioral Health's Notice of Privacy Practices and the Consumer Health Assistance Pamphlet.
Patient Name
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Patient Personal Representative
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Patient Medical Record Number or Social Security Number
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Conditions of Admission

1. MEDICAL/PSYCHIATRIC: The patient is under care of his/her attending physician/provider. The undersigned consents to any x-ray examination, laboratory procedures, anesthesia, psychiatric, medical or hospital services rendered the patient under the general and special instructions of the physician. The undersigned realizes that all doctors of medicine furnishing services to the patient including the radiologist, pathologist, anesthesiologist and the like may be independent contractors and not employees or agents of Palo Verde Behavioral Health. The undersigned understands that a physician/provider is not staffed on the premises 24-hours a day, but a physician/provider is on-call and may be reached 24-hours a day by Palo Verde Behavioral Health staff.
2. PERSONAL VALUABLES: Palo Verde Behavioral Health shall not be liable for the loss or damage to money, clothing, jewelry, dentures, or any other articles of value on or within Palo Verde Behavioral Health property. Palo Verde Behavioral Health shall not be liable for loss or damage to any other personal property.
3. CONTRABAND ITEMS: The undersigned agrees and understands that drugs, alcohol, weapons, or other articles specified as contraband by Palo Verde Behavioral Health may not be brought onto the premises, and that failure to abide by this rule could result in immediate discharge from Palo Verde Behavioral Health.
4. PHOTOGRAPHS: The undersigned hereby consents to the taking of a photograph for the purpose of identification. The photograph may be permanently retained in the patient's medical records. I understand that a patient identification wrist band may be used in lieu of a photograph. I understand the photograph will be used only for the purpose described, and will not be otherwise released without my express permission. Further, the undersigned acknowledges and is hereby informed that Palo Verde Behavioral Health uses real-time video surveillance and recording equipment on its premises. This equipment is uses solely for monitoring the t areas for safety.
5. VIOLENCE - ZERO TOLERANCE POLICY: I understand that Palo Verde Behavioral Health enforces a Zero-Tolerance policy regarding violence (verbal or physical), and that Palo Verde Behavioral Health has the right to pursue legal action against any person who engages in violence, either verbal or physical, against staff members, patients, visitors, or others while on the premises.
6. DISCHARGE AGAINST MEDICAL ADVICE: This is to certify that the patient assumes full responsibility for being discharged against the advice of the attending physician/provider and Palo Verde Behavioral Health administration, and hereby releases the attending physician, providers, therapist and Palo Verde Behavioral Health from all responsibility for any ill effects which may result from this action.
7. PROPERTY DAMAGE: Any damage to Palo Verde Behavioral Health property, caused by the patient, will be billed to the patient's account for the cost of repair or replacement, and must be paid in full on or before discharge.
8. ASSIGNMENT OF BENEFITS AND AUTHORIZATION TO RELEASE INFORMATION: In consideration of the services rendered, I hereby transfer and assign Palo Verde Behavioral Health all rights, titles, and interest in any payment due me for said services as provided by any and all policies of the insurance or other health care covered contract in which the patient is covered beneficiary. I further assign all right to payment due to medical services under said policies to the patient's attending practitioner and all consulting practitioners. I do hereby assign and transfer any and all Medicare/Medicaid benefits payable for outpatient services and practitioner services relating to this outpatient admission to Palo Verde Behavioral Health and the patient's attending consulting practitioners, therapist and hereby authorize Palo Verde Behavioral Health and said practitioners or practitioner organizations to submit claimers directly to Medicare/Medicaid for payment on behalf of the undersigned patient. I hereby authorize authorize Palo Verde Behavioral Health to release any information requested by said insurance company(s), its representatives, third party payers, or agencies as may be necessary to verify or process any and all claims for insurance coverage or third party reimbursement. I understand that such disclosures may contain information which could result in limitation or denial of insurance benefits or third party reimbursement. Nevertheless, each of the undersigned do hereby release and hold Palo Verde Behavioral Health, all agents and treating practitioners harmless of and from any and all costs, loss, damage or liability resulting from any such disclosure(s).
9. FINANCIAL AGREEMENT: The undersigned understands and agrees that Palo Verde Behavioral Health is not responsible for collecting insurance, or for resolving any disputed insurance or other third party payer claim, and promises unconditionally to pay Palo Verde Behavioral Health all costs and charges incurred in connection with the patient's hospitalization pursuant to this admission. It is agreed that if full payment is not made by insurance or other third party payers within thirty (30) days, the undersigned shall make payment in full. The undersigned acknowledged that failure to the outpatient services account may result in referral of said account to a commercial collection agency and/or credit bureau. Should the account be referred to any agency or attorney for collection, the undersigned shall pay reasonable attorney's fees and collection expenses.
10. PHYSICIAN/PROFESSIONAL SERVICES: Physicians/Providers will bill separately for their services. You may incur bill for specialized services provided by physicians/providers in the outpatient program other than your attending physician/provider. Acceptable payment arrangements must be made with their business office. Physician/Providers offices encourage communication so that you will have a clear understanding of their billing and collection policies.
10. PHYSICIAN/PROFESSIONAL SERVICES: Physicians/Providers will bill separately for their services. You may incur bill for specialized services provided by physicians/providers in the outpatient program other than your attending physician/provider. Acceptable payment arrangements must be made with their business office. Physician/Providers offices encourage communication so that you will have a clear understanding of their billing and collection policies.
ANY QUESTIONS OR CONCERNS REGARDING BILLING, INSURANCE, OR PAYMENT ARRANGEMENTS SHOULD BE DISCUSSED WITH OUR PATIENT ACCOUNT REPRESENTATIVES IN THE BUSINESS OFFICE AT (844)-884-CARE
The undersigned certifies that he/she has read the foregoing, received a copy thereof, and is the patient or parent/legal guardian if the patient is a minor, or is duly authorized by the patient as the patient's general agent to execute its terms.
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Print Name of Guardian
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Consent for Treatment

Notice of privacy practices: I acknowledge receipt of Palo Verde Behavioral Health's Notice of Privacy Practices.
Medicare patients only: I acknowledge receipt of the written material entitled, "Important message from Medicare."
Acknowledge receipt of patient rights, important phone numbers, patient handbook, and dress code: I acknowledge that I have received these documents. My patient rights and the admission documents have been explained to me and I understand my rights and the admission documents.
Consent for treatment: I authorize Palo Verde Behavioral Health, its staff, and attending physicians to render to the patient all customary care, therapy, treatment, tests, and procedures considered advisable, including emergency treatment and transportation to another facility if necessary. Further consent is also given for any diagnostic procedures, medical treatment, x-ray treatment, recreational activities and therapy, and other treatment ordered by Hospital and/or attending physicians including but not limited to services provided by other Healthcare Professionals to the patient.
I affirm I have retained no medications on person and agree that all medications must be administered by a pharmacist or by a licensed nurse while a patient at the Hospital.
I understand the Hospital will not be responsible for the safety or care of the patient if the patient leaves the premises and will indemnify the Hospital for any loss or injury which may occur as a result of leaving against medical advice.
I understand that the use of reasonable restraint and/or confinement in accordance with, or as permitted by, applicable state law may be necessary, if severity of symptoms or behaviors warrants, in order to protect the patient from harming himself or others, or destroying property of the Hospital. Should such restraint and/or confinement become necessary during the patients' admission, I understand and agree to hold harmless the Hospital, its staff, physician, or other mental health professional, from any claim resulting from any loss due to injury that may occur as a result of such restraint and/or confinement.
I authorize the staff to notify my family of any seclusion or restraining episode
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- NO
Guardian/significant other
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I acknowledge that the patient is under the control of an attending physician(s) and the Hospital is not liable for any act or omission in following the instructions of said physicians. The undersigned recognizes that certain healthcare professionals furnishing services to the patient, including, but not limited to, radiologists, pathologists, psychologists, physical therapists and/or licensed social workers may be independent contractors and may not be employees or agents of the Hospital. The undersigned further recognizes that the patient may be billed separately by their attending physicians and/or other healthcare professionals for their services provided.
Consents for admissions: I acknowledge that no guarantee or assurance has been made, as to the results of any services provided including, but not limited to, therapy, treatment, tests or procedures, while admitted to the Hospital. I further understand that, unless otherwise disclosed the Hospital does not employ physicians and that the patients admitting physician and any other physician who may consult or provide services to the patient during this admission are not employed by and are not agents of the Hospital, but are independent physicians who exercise their judgement in the services they render.
I acknowledge that Palo Verde Behavioral Health is a teaching facility and that professional students may have patient contact and access to the patient's medical record information. Students providing direct patient care are subject to the Hospital's orientation and training requirements. These students are supervised by a licensed professional and are required to meet the hospital confidentiality standards.
I authorize the Hospital to search the personal belongings when it is reasonably believed that there may be or is in possession of an item or items which may be dangerous to his/her health or to the health of others. If any are found, it is understood that they will be maintained in a secure place and returned to the patient at discharge unless otherwise therapeutically indicated by the attending physician.
I consent to the taking of photograph(s) for the purpose of identification. This photograph(s) may be permanently retained in the medical record.
I release the Hospital from any liability for the loss or damage of personal property and money. Any property left behind at the time of discharge will be disposed of after 15 days. The hospital assumes no liability for loss or damage to vehicles parked on hospital premises. Patients are encouraged NOT to leave personal vehicles on premises.
Consent to acknowledge your presence: I acknowledge that Palo Verde Behavioral Health will not release my patient health information unless the Hospital has a release or authorization to do so or as authorized under federal or state law. I will be given a confidential Identification Number to be used for acknowledgement. I hereby give my permission to accept mail without the ID Number. Furthermore, I consent to allow Palo Verde Behavioral Health to inform the patient's attending physician and/or referral sources of the admission to and progress at Palo Verde Behavioral Health.
Telemedicine Services: Telemedicine involves the use of electronic communications to enable health care providers at different locations to share individual patient medical information for the purpose of improving patient care. The information may be used for diagnosis, therapy, follow-up and/or education.
Network and software security protocols will be implemented to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.
Expected Benefits: • Improved access to medical care by enabling a patient to remain in the hospital while the provider provides service from another location • More efficient medical evaluation and management • Obtaining expertise of a distant specialist
Possible Risks: As with any medical procedure, there are potential risks associated with the use of telemedicine. These risks include, but may not be limited to: • In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision making by the provider; • Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment; • In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information, or • In rare cases, a lack of access to complete medical records may result in adverse drug reactions.
Responsibility for destruction of property: I understand that I am responsible for any damage to or destruction of Hospital property, or property belonging to others which may be located at the Hospital. I agree to accept liability for, and reimburse the Hospital or other owner of property, I may damage or destroy.
Acknowledge receipt of patient advocacy policy: I acknowledge that a copy of the Patient & Family Grievances/The Role of the Patient Advocate policy has been given to me. The policy has been explained and I understand this policy.
Discharge policy information: I understand that it is the policy of the Hospital to attempt to provide a structured therapy regimen with effective quality treatment. If the treatment regimen is not completed prior to the exhausting of health insurance benefits; I agree to be liable for any charges incurred which are not paid by insurance in addition to the deductible and/or co-payment liability. It is NOT Hospital policy to discharge or transfer patients or end treatment regimens simply because insurance benefits have been exhausted.
Release of Information: On the Palo Verde Behavioral Health Consent To Release Information form, I authorize the Hospital to release any information or records contained in hospital patient records related to alcohol or substance abuse diagnosis or treatment, mental health treatment, or any communicable disease, including HIV/AIDS to (a) any of my treating practitioners, (b) my insurance company or health plan, (c) any other person or entity that is responsible for paying or processing for payment my hospital bill, (d) any other health care provider to which I am transferred for care, (e) entities using this information for quality management and peer review, and (f) any other writing, of my desire to revoke it or according to the date or condition of expiration specified on the Palo Verde Behavioral Health Consent to Release Information form.
Clinical Staff: Clinical Staff may be provided clinical supervision while performing their duties. As part of this supervision, the clinical supervisor has the same access to the patient charts as the Clinical Staff, will be reviewing patient charts with the clinical staff, and will be sitting in on patient activities. The clinical supervisor is bound by the same State and Federal laws of confidentiality as the Clinical Staff at Palo Verde. If you wish to know the name of or speak to the clinical supervisor, please contact the Patient Advocate at 520-322-2867.
Inpatient Hospital Charges: $2150.00 IP per day includes room, board, nursing care, family, group, multifamily, activity, recreation and use of all the facilities. Outpatient Charges: $1250.00 PHP per day, $750.00 per day. Professional component is billed separately.
Resolution of overpayment: If a payment results in a credit balance (overpayment) and is an improper or excessive payment made, the credit balance will be researched and if appropriate, a refund will be issued by check within 30 days to the appropriate party. In the case of Medicare overpayments, these shall be entered on the quarterly credit balance sheet.
Guarantee of payment: I guarantee the payment of the bill for services rendered by Palo Verde Behavioral Health. I agree whether signing as guarantor or as patient, that in consideration of the services to be rendered to the patient, to be hereby jointly and individually obligated to pay the account(s) of the Hospital in accordance with the regular rates and terms of the Hospital. I understand I am responsible for all health insurance co-payments and deductibles. Should the account be referred for collection by an attorney or collection agency, the undersigned agree(s) to pay all attorney's fees and other reasonable collection costs and charges that are necessary for the collection of any amount(s) not paid when due. I give permission to run a credit report on the guarantor or insured party if payment arrangements are requested on any accounts with Palo Verde Behavioral Health.
Assignment of insurance benefits: In consideration of hospital and medical services rendered or to be rendered by Palo Verde Behavioral Health, to the extent permitted by law, I hereby (I) irrevocably assign, transfer and set over to Palo Verde Behavioral Health (II) all of my rights, title and interest to medical reimbursement, including, but not limited to, (III) the right to designate a beneficiary, add dependent eligibility and (IV) to have an individual policy continued or issued in accordance with the terms and benefits under any insurance policy, subscription certificate or other health benefit indemnification agreement otherwise payable to me for those services rendered by Palo Verde Behavioral Health during the pendency of the claim for this admission. Such irrevocable assignment and transfer shall be for the recovery on said policy or policies of insurance, but shall not be construed to be an obligation of Palo Verde Behavioral Health to purse any such right of recovery. I hereby authorize the insurance company or companies, or third party payor(s) to pay directly to Palo Verde Behavioral Health all benefits due for services rendered. Under this assignment, Hospital shall have the right to appeal any denied or delayed claims on behalf of the insured or beneficiary.
Insufficient insurance coverage: I understand if my insurance or other third party coverage rejects the claim or pays only part of the claim, then I will be responsible for payment of the balance due, as determined by the Hospital or other Healthcare Professional.
Primary/Secondary Insurance coverage: I understand it is my responsibility to furnish the Hospital with all of my insurance policies in order to authorize my care. I understand if I did not provide all insurance information at the time of admission, I will be responsible for any amounts not paid by either carrier, including but not limited to denied days due to no pre authorizations.
Insured employer: On the Palo Verde Behavioral Health Consent to Release Information form, I authorize Palo Verde Behavioral Health to release and to obtain information from the Insured and/or Insured's Employer of the policy, regarding employment, verification of insurance coverage, benefits or any other information necessary to process the insurance claim.
I acknowledge that the above information has been read and understood.
Patient's Name
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Admission Time

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Signature of Insured/Guarantor
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Signature of Legal Guardian - Next of Kin
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Signature of Insured/Co-Guarantor
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Signature of Hospital Staff
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Consent for Telepsych Services

TB Health Questionnaire

HEALTH QUESTIONNAIRE

Acknowledgement of Receipt of Notice of Privacy Practices

Conditions of Admission

Advance Directive

Consent for Treatment

Insurance Information

Acknowledgement

Patient Authorization for disclosure of PHI

Patient Information

Patient Information

Parent/Spouse/Guardian Information

Insurance Information

Acknowledgement

Release of Information