BIPP Telehealth Consent

I have been asked to participate in a TELEHEALTH SESSION that is under the direction of the STAR Council on Substance Abuse (STAR Council) BIPP Program. The purpose of this telehealth session is to provide BIPP Services through a two-way interactive audio/video connection between the STAR Council BIPP Facilitator and myself. My services during this temporary period may include Intake Assessments, Orientation, Groups, as well as other program aspects as deemed necessary.

I understand the following:

I will receive BIPP services by a STAR Council BIPP Facilitator.
I may request that the session be discontinued at any time.
The information gathered during Intake Assessment and Orientation will be strictly confidential and only shared with individuals that I have given written consent to release information to.
There will be a documented confidential record of each session provided by the STAR Council BIPP Facilitator and myself reflected on the program roster.
These Telehealth sessions will be provided on a temporary based during the COVID-19 pandemic.
Every effort will be made to structure the sessions so there will be effective follow-up care, and I will have the opportunity to express any concerns I may have.
There are potential problems with the use of this new technology. These include, but are not limited to: Interruption or disconnection of the audio/video link; an unclear picture or image; electronic tampering.
If any of the above problems occur, the visit might need to be stopped.
The telehealth process and evaluation has been explained to me.
I know the visit may not be equal to a face-to-face visit with a sessions.
If I have any questions before, during, or after the visit, I may contact my BIPP Facilitator by phone at the direct contact number provided below, the local office number or at our Toll Free number: 800-375-1395.
I understand that I will have to sign my consents virtually via a link that is provided, i.e. Orientation Paperwork.
I verify that I will be the only person present at my location during all telehealth sessions as to maintain strict confidentiality.
I will be provided a random 6 digit code at the Intake Assessment session that will be my verification code while receiving Telehealth services. I understand that I am to provide this code at the beginning of every session to verify my presence.

I certify this form has been fully explained to me. I have read it or had it read to me, and I understand its contents. I agree to participate in the telehealth session offered on this temporary bases and I consent to receive substance abuse evaluation, treatment, and/or education via telehealth.

Choose the STAR Council location that you are interested in. *

Todays Date*

Date

First Name*

Last Name*

Email*

example@example.com

Photo ID Required*

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Date of Birth*

Date

Signature*

First and Last Name*

By entering into the BIPP program participants are choosing to abide by the following information:

Rescheduled appointments require 24 hours advanced notice.
A $20 No-show fee will be required, for missing any session, without 24-hour notice.
Intake Assessment Fee is $50.
Orientation Fee is $30.
2 Individual Sessions during the duration of the program
- $30 each (Mid-Point and Exit)
Groups Session Fee is $30.
- Group session fees are due by 5 pm the Thursday prior to group.
- STAR Council will refuse admittance without payment, which could result in participant being counted absent.
Form of payment allowed:
- Credit Card only, by contacting the main office, dial #8 once the recording starts.
Fees are non-refundable.
Participants have the option to make a onetime, non-refundable, payment of $860, less any amounts already paid. This payment covers the cost of the Intake Assessment, Orientation, and 24 weekly group sessions. No-show fees are additional. Programs longer than 24 weeks will require additional payment.
STAR Council BIPP Program offers Financial Assistance to participants who qualify. I understand that I must complete an Application for Financial Assistance. If my application is approved, I will be advised of the details of the reduced payment structure. Application link can be found on the STAR Council’s BIPP webpage.

Date*

Date

By providing my Signature I am agreeing to the above requirements.*

Telehealth Consent

Appointment Notice