Spectrum expects that you will have a rewarding working relationship with your provider and that you will benefit from the treatment process. Spectrum wishes to inform you of the following:
Informed Consent:
You and your provider will be engaged in a cooperative working relationship. Each of you must contribute to make the relationship successful. There is no valid way to predict a specific treatment outcome. You have numerous rights which include:
- The right to be aware of all aspects of the working relationship
- The right to have all of your questions addressed regarding treatment
- The right to participate actively in all aspects of treatment planning
- The right to discontinue treatment at any time
Confidentiality:
All materials which is part of the treatment progress will be held in the strictest confidence by your provider except where state and/or federal law prevails. Information regarding your treatment may be shared among professionals within Spectrum Behavioral Management/Spectrum Psychiatry, PC. Consistent with applicable law, you should understand that confidentiality may be broken in cases where the provider believes that abuse or neglect has been rendered to a minor or vulnerable adult, where your provider believes that you represent an active threat to your well-being or to that of others and/or where the circumstances of state/federal law apply. Additional limits to confidentiality of Protected Health Information through the Health Insurance Portability and Accountability Act (HIPAA).
Appeals and Grievances:
I understand that I have the right to request reconsideration in the case that outpatient care is not authorized. I understand that the request for review can be made to my insurance company and that I risk nothing to exercise this right. I also understand that I have a right to file a complaint (Grievance) and risk nothing to exercise that right. Appeals and Grievances should be submitted in writing to the appropriate departments.
I hereby acknowledge that I have received, read and understand the above information regarding treatment, confidentiality and the Health Insurance Portability and Accountability Act (HIPAA) from Spectrum Behavioral Management/Spectrum Psychiatry, PC. I recognize that I may request a copy of Spectrum's complete privacy practices at any time.