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)
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: