This document contains important information about the decision you and your provider have made to resume in-person services in light of the COVID-19 public health crisis. Please read this carefully and let your provider know if you have any questions. When you sign this document, it will be an official agreement between you, your provider and Columbus Behavioral Health (CBH)
Decision to Meet Face-to-Face
You and your provider have agreed to meet in person for some or all future sessions. You understand, however, that if there is a resurgence of the pandemic, if other health concerns arise, or your provider deems it necessary, we may require you to rturn to telehealth for everyone's well-being. If you have concerns about meeting through telehealth, talk with your provider and s/he will try to address any issues.
If you decide at any time that you would feel safer returning to telehealth services, your provider will respect that decision, as long as it is feasible and clinically appropriate. Reimbursement for telehealth services, however, is also determined by the insurance companies and applicable law, so that is an issue you may also need to discuss with your provider.
Risks of Opting for In-Person Services
You understand that by coming to the office, you are assuming the risk of exposure to the coronavirus (or other public health risk). This risk may increase if you travel by public transportation, cab, or ridesharing service.
Your Responsibility to Minimize Exposure
To obtain services in person, you agree to take certain precautions which will help keep everyone safer from exposure, sickness and possible death. If you do not adhere to these safeguards, it may result in starting/returning to a telehealth arrangement.
By signing this document you indicate that you understand and agree to these actions:
You will only keep your in-person appointment if you are symptom free and agree to complete a symptom checklist upon arrival. If you have symptoms of the coronavirus, you agree to cancel the appointment or proceed using telehealth.
You will take your temperature before coming to each appointment and agree to have it checked upon arrival. If it is elevated (100 Fahrenheit or more), you agree to cancel the appointment or proceed using telehealth.
You will wait in your car for your appointment.
You will wear a mask covering your nose and mouth the entire time you are in the building.
You will use provided alcohol-based hand sanitizer when you enter the building.
You will adhere to safe distancing precautions. For example, you won’t move chairs or sit where we have signs asking you not to sit.
You will keep a distance of 6 feet and there will be no physical contact (e.g. no shaking hands) with anyone in the office.
You will try not to touch your face or eyes with your hands. If you do, you will immediately sanitize your hands.
You will not bring children with you (unless they are the patient).
You will not bring extra people with you to your session ; only those individuals who are part of the session will attend.
You will take steps between appointments to minimize your exposure to COVID.
If you have a job that exposes you to other people who are infected, you will immediately let your provider know.
If your commute or other responsibilities or activities put you in close contact with others (beyond your family), you will let your provider know.
If a resident of your home tests positive for the infection, you will immediately let your provider know and will begin/resume treatment via telehealth.
We may change the above precautions if additional local, state or federal orders or guidelines are published. If that happens, your provider will talk with you about any necessary changes.
Our Commitment to Minimize Exposure
CBH has taken steps to reduce the risk of spreading the coronavirus within the office and we have posted our efforts on our website and in the office. Please let your provider know if you have questions about these efforts.
If You or Your Provider Are Sick
CBH and your provider are committed to keeping everyone as safe as possible from the spread of this virus.
You will be asked a series of health screening questions when you arrive for an in-person appointment. If you, or anyone in your household, has had a fever or other symptoms in the last 14 days, or your provider believes you have been exposed, s/he will require you to leave the office and you will not be able to have an in-person appointment at this time. You can follow up with services by telehealth, as appropriate.
If your provider is sick, s/he will notify you that the in-person appointment will need to be cancelled or converted to a telehealth appointment, as appropriate.
If you or a resident in your home tests positive for coronovirus, you will notify CBH and/or your provider immediately so we can take appropriate precautions.
If your provider tests positive for the coronavirus, they will notify you so that you can take appropriate precautions.
Your Confidentiality in the Case of Infection
If you have tested positive for the coronavirus, your provider and/or CBH may be required to notify local health authorities that you have been in the office. If they/we have to report this, they/we will only provide the minimum information necessary for their data collection and will not go into any details about the reason(s) for your visits. By signing this form, you are agreeing that your provider and/or CBH may do so without an additional signed release.
This agreement supplements the general informed consent that you agreed to at the start of your work with your provider.
Your signature below shows that you have read, understand and agree to these terms and conditions.