Consent for Services:
I consent to such medical, psychiatric and / or other service as the staff may recommend, including diagnostic tests and counseling. I agree to cooperate in the implementation of the services including follow through with terms and conditions of services recommended by staff. I have been informed that statistical information concerning my treatment will be submitted to the Georgia Department of Behavioral Health and Developmental Disabilities for compilation of statistical information statewide. I knowingly and freely agree to assume all such risks and responsibility for any injuries or damages that I may suffer that arise from my participation.
I understand that my healthcare provider will access prescription databases to gather information on current or previously prescribed medications for the purpose of enhancing quality of care. Prescribed databases include those, which monitor prescribed controlled substances. The information gained from prescription databases provides an accurate history of prescribed medications and may reduce the misuse of these medications.
Consent for Contact:
There may be times when we need to contact you regarding your services at our agency. LMCS may contact via telephone, text, or email. By signing this document you are giving permission to be contacted by the methods indicated above. You have the right to change the preferred method of contact and may do so by informing a support staff representative at this agency. You are responsible for informing the agency of changes in address and/or phone number.
Financial Acknowledgments and Consent:
I affirm that the information provided regarding insurance coverage for myself and/or dependents is true and accurately reflects my current circumstances. I understand and agree that I am responsible for payment for services provided to myself and/or dependents. I understand that the organization may ask me for additional information to assist in making a final determination of my ability to pay.
Controlled Substances Agreement:
Controlled substances will be taken as prescribed. I will not increase dosage of my controlled medication unless authorized by my physician. I will exercise caution when performing activities such as driving or operating heavy machinery.