Consent Form

These notifications will be used to send appointment reminders. They will never be used for marketing or spam. Note: By providing the above information, you allow us to contact you at these telephone numbers and addresses. 

 

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Authorizations & Rights

Authorization for Medical Treatment: I authorize the physician(s), psychologist(s), therapists(s), their assistants and/or designees in charge of my medical care to administer any treatment as may be necessary or advisable in my diagnosis and treatment at Alivation Health, L.L.C., ("Facility). This authorization includes, but is not limited to, routine diagnostic procedures, rehabilitation therapy, laboratory tests, and the use of prescription medication. I am aware that the practice of medicine is not an exact science and I acknowledge that no guarantees have been made to me as to results of examination and treatment received at this Facility. I acknowledge that my care is under the direction of my treating physician(s) and the Facility will follow the instructions of my physician(s) in the provision of said care.

Statement of Responsibility: I understand that I am financially responsible to the Facility(s) as the patient, parent, guardian, conservator or insured for all charges not covered by the above assignments. Charges may include medical insurance deductibles, co­ insurance, or out-of- pocket expenses.

Notice of Privacy Practices: I have been given the opportunity to review the Facility's Notice of Privacy Practices for Protected Health Information. I understand that the Facility has the right to change the Notice of Privacy Practices at any time, and that I may obtain a current copy at the Facility's office during normal business hours.

Patient Rights & Responsibilities: I have been given the opportunity to review the Facility's Patient Rights & Responsibilities. I understand that the Facility has the right to change the Patient Rights & Responsibilities at any time, and that I may obtain a current copy at the Facility's office during normal business hours.

Magellan Member Rights & Responsibilities: I have been given the opportunity to review the Magellan Member Rights & Responsibilities and I understand that I may obtain a current copy at the Facility's office during normal business hours.

 

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Payment & Insurance

I authorize Alivation Health, L.L.C. to release to the Insurance carrier(s) provided any medical information needed for authorization or payment of this or a related claim. I also authorize payments directly to this office for the health benefits. I understand that I am responsible for all pre-authorizations required by my insurance. Furthermore, I understand that I am financially responsible for all charges.

For the benefit of our patients, Alivation Health is contracted with most insurance companies. We accept cash, checks and credit cards (Visa, Discover, and MasterCard). Some services we offer, such as school physicals and weight management services, may not be covered by insurance. Insurance coverage varies based on each patient's individual insurance plan.

Monthly Billing Statements: Every month our office sends out a monthly billing statement to every patient. The balance due is the remainder owed after your insurance has paid.

Copayments: Copays are due at the time of service, if you are unable to pay at the time of service you may need to reschedule your visit. If your visit will not take place in the clinic, you may be asked to pay your Copay at time of scheduling.

Insurance Cards: Insurance cards are requested at every visit. If you have not provided our office with the correct insurance information, you may be responsible for any balance due.

Self-Pay Patients: If you do not have insurance, your balance is due at the time of your office visit. If you are unable to pay at time of service, you may be asked to reschedule.

Screening Labs: If a screening lab is done, charges from the lab may be applied to your deductible. Please speak with the provider if you would like a limited lab draw instead of the recommended full screening lab.

Late Arrival: If you arrive late, your appointment may not transpire as scheduled. We may need to cancel your appointment & reschedule or we may ask that you wait until the next open spot in the schedule while we continue to see the patients who arrived on time.

No-Show Fees: I have been advised that this office requires a 24-hour prior notice on all appointment changes. I have been advised that there may be a no-show fee for appointments that are changed with less than 24-hours' notice. This fee is not covered by any insurance plan. Fee varies based on appointment type missed and are updated from time to time.

Collections: If your account balance is unpaid and overdue after three attempts to contact you, and you have not responded to any of our attempts to contact you, your account may be referred to a collection agency. Once your account is in collections, you will be dismissed from our practice, which includes refill requests and appointments.

Pre-Authorization for Health Services: Most insurance companies require pre-authorization for health services, prescription medications, and certain medical treatments. We strongly encourage you to contact your insurance to inquire about any pre-authorization requirements. You may also want to obtain information regarding your health benefits. Most often, health insurance benefits for mental health are different from the benefits for general healthcare. Please contact our billing office should you have any questions regarding the information from your insurance.

Dismissal: You may be dismissed from the clinic due to, but not limited to, non-compliance, behavior, no-shows and or nonpayment.

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Appointments

We see patients by appointment and offer same-day appointments for patients with acute needs. If you call our office outside of regular business hours with a medical concern, you will be prompted to leave a message for the on-call provider who will triage those calls.

Providers: To ensure you receive the best care, your provider may change during treatment. Reasons for this may include, but are not limited to, insurance changes, provider specialty, or provider availability.

Staff: Our staff will treat all patients with the upmost respect and professional attitude. In return, we expect our patients to be courteous in our office.

Appointment Norms: Due to healthcare regulations and time constraints, please prioritize your concerns each visit.

Lab, Tests, and Procedure Norms: Please schedule a follow up appointment each time a test is performed, or a lab test is ordered. Results are usually received 7-10 days after the test is completed. We may not be able to provide you with the results of labs, x-rays, MRI etc. without an appointment.

Physicals, Well Child Checks, Pre-Ops, and other Preventative / Screening Visits: Providers are unable to discuss new problems at Preventative and Screening Visit types. You may be asked to address new issues at a different visit or reschedule your current visit if your other need is urgent. Due to insurance regulations, we are only able to see you for one type of visit per business day.

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Prescriptions

Please check your medication supply prior to your visit so we can order refills at the time of your appointment. We process refill requests during appointments.

Prescription Refill Requests: Medications will only be filled during an appointment. It is important that we closely monitor your medication. If you need a refill prior to your next scheduled appointment, we require that you schedule a sooner appointment prior to receiving a prescription refill. If a refill is provided, it will only cover the days until your regularly scheduled appointment. If you miss your appointment, no refills will be given, until you are seen.

Medication Lists: Please bring all current and new medications, as well as any medication changes, with you to all appointments. This allows our providers to not only review the medications that our office is prescribing, but also to review medications taken over the counter on a regular basis and medications prescribed by other providers.

Note: Alivation has a policy against prescribing chronic narcotic medications for chronic pain. If you have a chronic pain condition, we will refer you to a pain management specialist.

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Medical Records

Your medical records are strictly confidential. We are prohibited from releasing any information from your records without your express written permission unless court ordered. By law we must respond to a request within 30 days. Be advised that some forms and letters may require an office visit or have a pre-paid fee to complete them.

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Controlled Substance Agreement

Alivation Health providers utilize controlled substance medications in our patient care.  To be compliant with state and federal laws, and for the protection of the practice and patient, we require all patients to sign this controlled substance policy.  If you are uncomfortable being prescribed a controlled substance you may inform your provider you wish to receive alternative options, however you must still sign this policy.

 

The following agreement relates to my use of controlled substances including but not limited to benzodiazepines, stimulants, sleep aides, and buprenorphine. In signing this agreement, I confirm that I understand and agree to the following:

 

1.       I understand that, depending on the drug and dose, I can become physically dependent on the medication and can develop withdrawal symptoms if medication is stopped suddenly, or the dose is reduced rapidly. There is a chance of developing an addiction to controlled substances. Controlled substances can cause sedation, confusion, or other changes in mental state and thinking abilities. I understand that the decision to drive while I am taking controlled substances is my own decision and I agree not to be involved in any activity that may be dangerous to me or someone else such as driving or operating any dangerous equipment, working in unprotected heights or being responsible for another individual who unable to care for his/herself if I am in any way sedated, feel drowsy or I am not thinking clearly.

 

2.       I will not abuse any illegal controlled substances.

 

3.      I will not drive while intoxicated or impaired.

 

4.      The office policy regarding the dispensing of controlled substances requires that I be seen regularly, and I agree to make and keep my appointments. I will advise the practice of all other medications and treatments that I am receiving. I consent to lab tests, urine tests, remote patient monitoring, substance abuse evaluation, and other routine monitoring or services as recommended by the practice.

 

5.      If the medications require adjustment, an appointment must be made. No adjustments will be made over the telephone. My careful planning is required. I understand that medication refills and adjustments are only done during appointments except under unusual circumstances. I must stay with the prescribed dosing so that I do not run out of medication early.

 

6.      I understand that the practice policy is not to prescribe medications early.  I understand this this applies to all reasons for running out of my medications early, including if they are lost or stolen.  I understand that if I run out of my medication, I may experience withdrawal symptoms and should contact the practice to inform them of my symptoms. 

 

7.      Because of the risk of certain medications to unborn children, I will inform the practice immediately if I become pregnant or decide to try to become pregnant. I am aware that should I carry a baby to delivery while taking these medications, the baby may be physically dependent on these medications. I am aware that there is a risk of birth defects while on these medications. However, birth defects can occur whether or not the mother is on medication and there is always the possibility that my child will have a birth defect.

 

8.      I understand that in general I may be weaned off my medication or my drug therapy may be terminated at the discretion of the practice if any of the following occur:

·         It is the opinion of the practice that controlled substances are not very effective as a treatment,

·         I misuse the medication,

·         I develop a rapid tolerance or loss of effectiveness from my treatment,

·         I develop side effects that are significant and detrimental to me,

·         I no longer require the medication for treatment

·         I obtain controlled substances from sources other than Alivation without informing the practice,

·         I am arrested and/or convicted for a controlled or illicit drug violation including but not limited to drunk driving or driving while under the influence of a controlled substance,

·         Any other concern by the practice that you are not in compliance with your treatment protocol,

·         Any concerns resulting from a review of my Prescription Drug Monitoring Program (PDMP),

·         Any concerns regarding verbal/written/digital forgery or impersonation of our practice,

·         Any violation of this agreement.

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Telehealth

I hereby consent to telehealth services (“Telehealth”) with Alivation Health, LLC (“Alivation”). Telehealth may include health evaluations and assessments, consultations, treatment planning, education, and therapy. Telehealth will occur primarily through interactive audio, video, telephone, or other data communications.
 

Insurance: I am responsible for contacting my insurance company, if applicable, to determine what my out-of-pockets costs may be. I authorize insurance benefits to be paid directly to Alivation that Alivation may release any information to my insurance provider required for processing my claims.

 

Self-Pay clients: I am aware of the fees associated with Telehealth appointments and agree to pay at the time of my appointment. I understand that I am responsible for cancelled Telehealth appointments in accordance with the Alivation cancellation policy.  In addition, I understand that:

·         I must be in compliance with the Alivation provider's treatment plan.

·         To receive telehealth services, I must be at an “originating site” acceptable to Alivation. 

·         Telehealth will not be allowed for opioid recovery and treatment.

·         If access for Telehealth is from my computer or mobile device, I may need to download an application or software to use Telehealth and a broadband Internet computer or mobile device with a good cellular connection.  

·         Alivation has self-pay options if my insurance does not cover the telehealth visit.

·         All other Alivation policies are applicable to Telehealth Visits.

 

Expectations:

·         Patients are instructed to verify all equipment prior and log-on to the most up-to-date clinic Telehealth application at least 15 minutes prior to their appointment time.

·         The patient understands and agrees to that any issues arising in utilizing the Telehealth platform, including but not limited to technical issues, connection issues, and usage issues in any capacity may result in the appointment not transpiring at the scheduled time and needing to be rescheduled, including to another date and time.

·         Any appointment that is not able to be successfully completed to clinic standards is subject to all other clinic policies, including but not limited to, no-show fees, dismissal and loss of Telehealth privileges.

·         Alivation continues to prefer and recommend all visits be completed in-person due to the factors cited above.

Disclosures.  I understand I have the following rights:

1)      I have the right to withhold or remove consent to Telehealth at any time without affecting my right to future care or treatment, nor endangering the loss or withdrawal of any program benefits to which I would otherwise be eligible.

2)      The HIPAA laws that protect the confidentiality of my personal information also apply to Telehealth. The information released by me during the course of my sessions is generally confidential, but there are both mandatory and permissive exceptions to HIPAA confidentiality including but not limited to reporting child and vulnerable adult abuse, expressed imminent harm to oneself or others, or as a part of legal proceedings where information is requested by a court of law.  Alivation has provided to me, including online disclosure, its Notice of Privacy Practices.

3)      I understand that there are risks and consequences from Telehealth including the possibility, despite reasonable efforts on the part of Alivation that the transmission of my personal information could be disrupted or distorted by technical failures.

4)      I understand that Telehealth based care may not be as complete as in-person services. I understand that if my therapist believes I would be bettered served by other interventions I will be referred to a mental health professional who can provide those services in person

5)      I understand that the use of Telehealth services is not 100% secure and may have issues with Wi-Fi and network connectivity.

6)      All reasonable attempts to keep information confidential while using Telehealth will be made but a guarantee of 100% confidentiality cannot be made with any inherent service.

7)      By signing this document, I agree that certain situations, including emergencies and crises, are inappropriate for audio/video/computer-based psychotherapy services. If I am in crisis or in an emergency, I should immediately call 911 or go to the nearest hospital or crisis facility. By signing this document, I understand that emergency situations may include thoughts about hurting or harming myself or others, having uncontrolled psychotic symptoms, if I am in a life threating or emergency situation, and/or if I am abusing drugs or alcohol and are not safe. By signing this document, I acknowledge I have been told that if I feel suicidal I can to call 911, local county crisis agencies, or the National Suicide Hotline at 1-800-784-2433.

8)      Others may also be present during the consultation other than my counselor in order to operate the video equipment. The above-mentioned people will all maintain confidentiality of the information obtained. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history that are personally sensitive to me, (2) ask non-clinical personnel to leave the Telehealth room, and/or (3) terminate the consultation at any time.

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8550 Cuthills Circle Lincoln, NE 68526 | alivation.com | info@alivation.com

Behavioral Health | Phone: 402.476.6060 | Fax: 402.476.6809

Primary Care | Phone: 402.466.3355 | Fax: 402.466.3410