In-person Informed Consent

Columbus Behavioral Health
An Association of Independent Practitioners
614.360.2600
Westerville | New Albany

This document contains important information about in-person services in light of COVID-19. Please read this information 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)

Risks
There is an inherent risk of exposure to COVID-19 in any public place where people are present, particularly where there may be close contact with others. COVID-19 is an extremely contagious disease that can lead to severe illness and death. Although CBH has implemented preventative measures to reduce the spread of COVID-19, we cannot guarantee that you will not be exposed to or infected with COVID-19. This risk may increase if you travel by public transportation, cab, or ridesharing service.

Telehealth services are available to you. You understand that by coming in to the office, you are assuming the risk of exposure to the coronavirus (or other public health risk) and agree to indemnify and hold harmless your provider, CBH, their officers, employees, agents, contractors, and representatives, from any and all liabilities, claims, actions, damages, costs, losses of any kind (including attorney fees and costs through appeal) arising from or out of or related to exposure to or infection with COVID-19 or any other illness, injury, including death, related in any way to your participation in services provided at CBH.

Your responsibility to minimize exposure
To receive services in person, you agree to take certain precautions to 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.

Initial each to indicate that you understand and agree to these actions:

You will be vaccinated (at least one COVID-19 shot) prior to being seen in-person. Unvaccinated patients will need to use telehealth services we have available.*

You will only keep your in-person appointment if you are symptom free. 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 if it is elevated (100 Fahrenheit or more), you agree to cancel the appointment or proceed using telehealth.*

You will wait in your car or outside until no earlier than 5 minutes before your appointment time. *

You will wear a surgical or N95 mask covering your nose and mouth the entire time you are in the building. (No cloth/homemade masks.) *

You will keep a distance of at least 6 feet and have no physical contact (e.g. no shaking hands) with anyone in the office. *

You will not bring children with you (unless they are the patient) and will not bring extra people with you to your session. Only those individuals who are part of the session will attend. *

If you have been in close contact with someone who has tested positive for the infection in the last 10 days, immediately contact our office to reschedule your appointment.*

Failure to comply with these requirements will result in termination of in-person visits and a return to telehealth, as appropriate.

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.

Illness
If your or your provider are sick, the in-person appointment will need to be cancelled or converted to a telehealth appointment, as appropriate.

Confidentiality
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.

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.

Informed Consent and Waiver of Liability
This agreement supplements the general informed consent that you agreed to at the start of your work with your provider.

By signing below, you attest that you have read, understand and agree to the terms and conditions as outlined; accept any/all risks associated with in-person appointments; release your provider, CBH and its contractors, employees and representatives from any and all liability for exposure or infection; and agree to comply with the responsibilities to minimize risk and exposure. You agree that failure to comply with these requirements will result in termination of in-person visits and a return to telehealth, as appropriate.

Patient's Name*

First NameLast Name

Patient's Date of Birth*

Date

Parent/Guardian Name (if patient is a minor)

First NameLast Name

Patient Signature (or parent/guardian, if patient is a minor)*

Clear

Today's Date*

Date