Martin & Muir Counseling Online Medical Consent Form

Name

First NameLast Name

Age

Date of Birth

Date

Gender

Email

example@example.com

Phone Number

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Health Insurance Name

Insurance Policy ID

Contact Person Name

First NameLast Name

Primary Phone Number

Secondary Phone Number

I agree to participate in evaluation and treatment provided by Martin and Muir Counseling, Inc and its staff. I agree and understand that I may withdraw from treatment at any time.As the parent/guardian/self, I understand that the choice of my providers is my responsibility and right as a parent/guardian/client. I further understand that I have the right to contact the providers prior to selection that I may determine the best provider for myself/child. I also understand that I may at any time choose another provider for this services by notifying my current provider.I agree and acknowledge the issues that are discussed in treatment are important are legal protected as both "confidential" and "privileged". However, there's are limits to privilege of confidentiality. These situations include: 'Suspected abuse or neglect of a child, elderly person, or disabled person, 2) When I believe you are in danger of harming yourself or another person or are unable to care for yourself, 3) IF you report that you intend to physically injure someone, the law requires MMC to inform that person as well as the legal authorities, 4) If I am ordered by a court to release information as part of a legal involvement in company litigation, etc. 5) When your insurance company is involved, for example, by filing a claim, insurance audits, case review, or appeals, etc. , 6) In natural disasters whereby protected records may become exposed or 7) when otherwise required by law. You may be asked to sign a Release of Information so that MMC may speak with other mental health professionals or to family members.I agree to participate in a telemedicine evaluation and/or ongoing treatment performed by an independent contracted provider who assumes sole responsibility and liability for treatment. By signing this agreement, I authorize the electronic transmission of my medical information and/or video conference session so that it can be viewed by a doctor and other persons involved in my medical or mental health care. Note: The likelihood of this transmission being intercepted by persons other than those at the consulting site is extremely small. I understand that I can withdraw my permission at anytime and that I can not have to answer any questions that I consider to be inappropriate or am unwilling to have heard by other persons. I understand that if I do not choose to participate in a telemedicine session, no action will be taken against me that will cause a delay in any care and that I may still pursue face to face consultation. I understand that as with any technology, telemedicine does have its limitations. There is no guarantee, therefore, that this telemedicine session will eliminate the need for me to see a specialist in person. I understand that medical records of telemedicine services will be kept at Martin and Muir Counseling , PLLC.I reviewed for the purpose of evaluation ( date collection, analysis , and presentation in verbal or written during supervision meetings). I understand that medical records of telemedicine services will be kept at Martin and Muir Counseling, INC. I agree to have my telemedicine medical records reviewed for the purpose of evaluation (supervision meetings/evaluations) . I understand that any discussion will not identify me by name or other identifiable markers.Member Consent to Release Confidential Information to PCP. I give permission to contact my Primary Care Physician to share information about my/my Childs diagnosis and/or treatment related to substance abuse, mental health, or medical history, NOT Including the results of a blood test for antibodies to the human immunodeficiency virus (HIV). I understand the purpose is for collaboration and sharing to help me receive better care. This consent to my PCP will expire in 1 year.Due to COVID-19, I understand that I may have to give verbal consent for documents where I am unable to sign in person due to COVID-19. I understand these documents will be discussed with me over telehealth treatment sessions with an MMC provider. I understand that I will have opportunity to decline my signature at any time. If I agree, I give permission for MMC staff to sign on behalf and document that verbal permission was given due to COVID-19.I agree to participate in a telemedicine evaluation and/or ongoing treatment performed by an independently contracted provider who assumes sole responsibility and liability for treatment. By signing this agreement, I authorize the electronic transmission of my medical information and/or video conference session so that it can be viewed by a doctor and other persons involved in my medical or mental health care. [Note: The likelihood of this transmission being intercepted by persons other than those at the consulting site is extremely small]. I understand that I can withdraw my permission at anytime and that I do not have to answer any questions that I consider to be inappropriate or am unwilling to have heard by other persons. I understand that if I do not choose to participate in a telemedicine session, no action will betaken against me that will cause a delay in my care and that I may still pursue face-to-face consultation. I understand that as with any technology, telemedicine does have its limitations. There is no guarantee, therefore, that this telemedicine session will eliminate the need for me to see a specialist in person. I understand that medical records of telemedicine services will be kept at Martin & Muir Counseling INC. I agree to have my telemedicine medical records reviewed for the purposes of evaluation (data collection, analysis and presentation in verbal or written format during supervision meetings). I understand that any discussion will not identify me by name or other identifiable markers.

Statement for Verbal Consent Authorization: We kindly request your verbal authorization to sign the consent on your behalf. By providing your verbal consent, you acknowledge and agree that Martin & Muir Counseling may act as your authorized representative for the purpose of signing the consent document. Your verbal consent will be duly noted and documented by our team. Please proceed by affirming your consent verbally. Patient/Parent/Guardian Signature

Date Signed

Date

I have read and agreed to the following statements regarding copay deductibles regarding my insurance policy. By signing below, I understand that I am responsible for all fees and costs related to my insurance plan.

Every effort is given to provide accurate information regarding copays and/or deductibles before your visit. We provide the information given to us by your health plan and are notified of the below disclosure each time.

Benefit Disclaimer

UNLESS OTHERWISE REQUIRED BY STATE LAW, THIS NOTICE IS NOT A GUARANTEE OF PAYMENT. BENEFITS ARE SUBJECT TO ALL CONTRACT LIMITS AND THE MEMBER'S STATUS ON THE DATE OF SERVICE. ACCUMULATED AMOUNTS, SUCH AS DEDUCTIBLES, MAY CHANGE AS ADDITIONAL CLAIMS ARE PROCESSED.
While we make every effort to provide accurate information to you, it is your responsibility to know and understand your insurance policy and its associated fees before your visit. As claims are processed, if additional patient responsibility is listed, you will receive an invoice from our office, as well as an explanation of benefits from your insurance company.

Routine Copay/Deductible Waiver Violates The Law

It is not illegal to write off a patient’s copay/deductible balance if the provider makes a good-faith attempt to collect. However, when a provider has a policy of not attempting to collect copays/deductibles that becomes illegal. Health and Human Services, Office of Inspector General, identified several suspect behaviors that indicate illegal routine copay/deductible waiver:

Advertisements that state that Medicare will be accepted as payment in full.
Advertisements that promise discounts to Medicare beneficiaries.
Routine use of financial hardship forms without attempt to determine patient’s financial situation. Collection of copayments only where the patient has supplemental insurance that pays for copays. Charging more to Medicare beneficiaries to offset the waiver of coinsurance. Sham insurance programs that offer to cover copays but have insignificant premiums.

In a recent federal court case, a provider sued Cigna for failing to pay out-of-network claims. Cigna then countersued the provider for potential injunctive relief under specific ERISA laws, and the court found there was merit for the countersuit, so Cigna was able to attempt to obtain damages for unjust enrichment and intentional tortious interference with contractual relations.

The Employee Retirement Income Security Act (ERISA) is a broad set of federal laws that govern health insurance (among other things). The injunction would be filed to stop the provider from discounting the services based on the “in” vs. “out” of network rates.

Commercial insurance providers have contracts (i.e., legally binding agreements) to provide health insurance to employers and employees—and now, under the Affordable Care Act, to individuals as well. Commercial insurance providers charge a premium for that health insurance. The employer, employee, and/or individual pays that premium. The health insurance contract establishes mutually agreed-upon deductible and copayment amounts for both in-network and out-of-network providers. Typically, the contract also establishes a financial incentive for beneficiaries to use out-of-network providers and a financial disincentive. Because this is a contract—which, again, is a legally binding agreement with an employer or individual—if a provider comes along and decides to waive patient deductibles and copays unilaterally, then the provider is reducing the covered person’s contractual financial obligation. So, by waiving deductibles and copays, the provider is interfering with the employer’s and/or individual’s contract with the insurance carrier, which puts the provider at risk of being sued for damages.

Statement for Verbal Consent Authorization: We kindly request your verbal authorization to sign the consent on your behalf. By providing your verbal consent, you acknowledge and agree that Martin & Muir Counseling may act as your authorized representative for the purpose of signing the consent document. Your verbal consent will be duly noted and documented by our team. Please proceed by affirming your consent verbally.

Date

Primary Care Physician

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Primary Care Physician Phone

Please enter a valid phone number.

Please check one of the following:

NO, I DO NOT give consent to release information to my Primary Care Physician.YES, I DO give consent to release information to the Primary Care Physician (PCP)named below (If you check yes, the therapist will communicate with the named physician and/or send treatment plan and/or progress notes of therapy as agreed upon by the patient and Therapist.)

I hereby give my informed consent for Martin and Muir Counseling to:

Talk with my PCPRelease written documentation regarding my treatment to my PCP.

Patient Authorization: I understand this authorization may be revoked at any time by submitting a written request. Disclosure(s) made prior to receipt of revocation are authorized under the prior authorization. My refusal to release records will not affect my ability to obtain treatment. If a person or facility receiving the above stated information is not a healthcare or insurance provider covered by HIPAA Privacy Regulations this information could be redisclosed.

Name

First NameLast Name

Statement for Verbal Consent Authorization: We kindly request your verbal authorization to sign the consent on your behalf. By providing your verbal consent, you acknowledge and agree that Martin & Muir Counseling may act as your authorized representative for the purpose of signing the consent document. Your verbal consent will be duly noted and documented by our team. Please proceed by affirming your consent verbally.

Relationship to Patient

Date

Online Medical Consent

Client Information

Parent/Guardian or Emergency Contact Details

Acknowledgment, Authorization and Waiver

PCP CONSENT FORM