The Center for Cognitive and Behavioral Therapy, Inc., (CCBT) through one of its providers or affiliates (please consult the CCBT Patient Services Agreement you will receive), will be providing some or all of my/my child(ren)’s behavioral healthcare within my primary care physicians office at Beckett Ridge Family Medicine.
I understand that services from CCBT are a part of a more integrated approach to my care. The staff at Beckett Ridge Family Medicine will include information from my behavioral healthcare into their charts to co-ordinate the care of me/my child(ren) when I/my child(ren) see a provider or affiliate of CCBT in the Beckett Ridge Family Medicine offices.
I understand that the CCBT providers or affiliates are not employees or affiliates of Beckett Ridge Family Medicine, and the staff of Beckett Ridge Family Medicine are not employees or affiliates of CCBT. CCBT and Beckett Ridge Family Medicine are separate organizations, working together for the common good of my child(ren)’s health.
To receive services from CCBT’s providers or affiliates, that are co-located in Beckett Ridge Family Medicine’ offices, I agree to complete assessment forms from CCBT. I understand that these forms will be shared with Beckett Ridge Family Medicine, based on my signing this form. Also, I give permission for Beckett Ridge Family Medicine’ staff to share and exchange protected health information with the staff and affiliates of CCBT, including the business office of CCBT.
I agree that the conditions in this form may add or change the content in my Patient Services Agreement from CCBT; and I agree to the conditions in this form.