Consent to Evaluate/Treat: I voluntarily consent that I will participate in a mental health (e.g. psychological or psychiatric) evaluation and/or treatment by staff from Cornerstone Psychiatric Services, Inc. I understand that following the evaluation and/or treatment, complete and accurate information will be provided concerning each of the following areas:
- The benefits of the proposed treatment
- Alternative treatment modes and services
- Expected side effects from the treatment and/or the risks of side effects from medications (when applicable)
The evaluation or treatment will be conducted by one or more of the following provider types: a psychotherapist, a psychologist, a psychiatric nurse practitioner (APRN/ARNP), a psychiatrist, a licensed clinical social worker, a licensed therapist or an individual supervised by any of the professionals listed. I understand that clinicians David Fawks, and Smitha Ajesh are APRN’s. Benefits to Evaluation/Treatment: Evaluation and treatment may be administered with psychological interviews, psychological assessment or testing, psychotherapy, medication management, as well as expectations regarding the length and frequency of treatment. It may be beneficial to me, as well as the referring professional, to understand the nature and cause of any difficulties affecting my daily functioning, so that appropriate recommendations and treatments may be offered. Uses of this evaluation include diagnosis, evaluation of recovery or treatment, estimating prognosis, and education and rehabilitation planning. Clients should be aware that the process of psychotherapy may bring about unpleasant memories, feelings, and sensations such as guilt, anxiety, anger, or sadness, especially in its initial phases. It is not uncommon for these feelings to have an impact on current relationships you may have. If this occurs, it is very important to address these issues in session. Usually these unpleasant sensations are short lived. Possible benefits to treatment include improved cognitive or academic/job performance, health status, quality of life, and awareness of strengths and limitations.
* This consent is knowingly and freely given. This consent will expire 7 years after my last encounter visit at Cornerstone Psychiatric.
* I hereby give my consent for Cornerstone Psychiatric Services and their Business Associate’s (such as, but not limited to, medical billing company, EHR vendor, collection agency, automated appointment reminder vendor, dictation service, Prescription Drug Monitoring Program database, and electronic prescription vendor) to use and disclose protected health information (PHI) about me to carry out treatment, payment and health care operations (TPO You can ask for a copy or download a copy from our website www.cornerstonepsychiatric.com of the Notice of Privacy Practices provided by Cornerstone Psychiatric Services which describes such uses and disclosure in detail. To the extent permitted by law, I authorize any holder of medical or other information about me to release to the Center of Medicare and Medicaid services, my Medigap insurer, and their agents any information needed to determine these benefits for related services.
* I have the right to review the Notice of Privacy Practices prior to signing this consent. Cornerstone Psychiatric Services reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to Privacy Officer at 1790 E Venice Ave. Ste 204, Venice, FL 34292. You can also pick up a copy in our office.
* With this consent, Cornerstone Psychiatric Services may communicate to me in reference to any items that assist the practice in carrying out TPO, such as, but not limited to, appointment reminders, billing statements, insurance issues and any messages pertaining to my clinical care, including laboratory test results, among others by use of phone calls to my home, mobile or other alternative location and speak or leave a message; SMS/Text message, Email, postal delivery and/or by the Patient Portal.
* It is further understood that all information given by the patient or family member to a treating clinician is confidential and will not be released, except under special circumstances, without patient consent or consent of legal guardian as described in details in the Notice of Privacy Practices. You can authorize us to release information relating to your treatment to another person, provider or company by signing a Release of Information (ROI) form provided by our office.
By signing this form, I am consenting to allow Cornerstone Psychiatric Services to use and disclose my PHI to carry out TPO. I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, Cornerstone Psychiatric Services may decline to provide treatment to me. I understand and agree with all the preceding information unless otherwise indicated in writing. I acknowledge that I have received or been offered to review a copy of the following documents: Cornerstone “Welcome Letter”, “Patient Rights and Responsibilities” , “Notice of Privacy Practices”, “Office Policies”, and “Patient Portal Policy and Procedures”. I agree and accept the terms of all these documents. Copies of these documents are available at your request in our office or by downloading from our website.