Online Medical Consent Form

Online Medical Consent
Client Information
Name

First NameLast Name
Age
Date of Birth

MonthDayYear
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
Parent/Guardian or Emergency Contact Details
Contact Person Name

First NameLast Name
Primary Phone Number
Secondary Phone Number
Acknowledgment, Authorization and Waiver
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 responsibilty 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 exampple, 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 withdrwaw my persmission 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 amy care and that I may still pursue face to face consultaion. 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 (supervison 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.
Patient/Parent/Guardian Signature

Clear
Date Signed

MonthDayYear
Date

I have read and agreed to the following statements regarding copays, 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 prior

to 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 DEDUCTIBLE MAY CHANGE AS ADDITIONAL CLAIMS ARE PROCESSED.

While we take every effort to provide accurate information to you it is your responsibility to

know and understand your insurance policy and fees associated with it prior to 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/deductible 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 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 certain 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 in-network providers as well as a financial disincentive to use out-of-network providers.

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 unilaterally waive patient deductibles and copays, 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—and that puts the provider at risk of being sued for damages.
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Online Medical Consent

Client Information

Parent/Guardian or Emergency Contact Details

Acknowledgment, Authorization and Waiver