This is to help you understand your rights and responsibilities and the level of cooperation that we need from you in order to help you realize the highest level of mental and emotional health of which you are uniquely capable. Our desire is to form a partnership with you regarding your mental health. Your assistance is crucial and the interest and commitment that you bring to this partnership are essential to attaining significant improvement or resolution to your mental health concerns.
You are assured the following rights:
-The right to be treated with dignity and respect
-The right to treatment including access to medical care and habilitation, regardless of your race, religion, gender, ethnicity, age, or sexual orientation.
-The right to have your treatment and other patient information kept private.
-The right to know about all your treatment choices, regardless of the cost of those treatment choices, and to participate in the choice of treatment.
-The right to consent or to refuse treatment,consent can be withdrawn at any time.
-The right to obtain a copy of your treatment plan by completing a release form.
-The right to contact Disability Rights of North Carolina at 919-856-2195.
In order to provide you with the best care, your commitment to your treatment and recover is essential. We require that patients’ understand their role and responsibilities in their care:
-You have the responsibility to give your provider the information needed so that we can delver the best possible care.
-You have the responsibility to let your treating provider know if or when the treatment plan no longer works for you.
-You have the responsibility to follow your medication plan. You must tell your treating provider about any medication changes, including medications prescribed for you by other healthcare professionals.
-You have the responsibility to keep your scheduled appointments.
-You have the responsibility to ask your treating provider any questions you may have about your care, so that you can better understand your care and the role you play in your care.
-You have the responsibility to follow your treatment plan and instructions for your care, once that care has been agreed upon by you and your treating provider.
By signing below, you acknowledge that you fully understand your rights and responsibilities, and that you consent for care and treatment by Carolina Complete Psychiatry, PLLC.
I have read and fully understand my rights and responsibilities in my partnership with Carolina Complete Psychiatry, PLLC in providing for my care, and agree to adhere to them, and acknowledge that I have received a copy of this statement. Further, I hereby consent to outpatient treatment and give permission for the clinician to provide the services deemed necessary or advisable in the diagnosis and treatment of the patient. I am aware that the practice of medicine is not an exact science and I acknowledge that no guarantees have been made as to the result of treatment received by Carolina Complete Psychiatry, PLLC. I understand that the patient has the right to without consent to any medical service that is deemed necessary or advisable by the clinician. My signature below indicates my understanding and approval of the above.
This notice describes how medical information about you may be used and disclosed and your access to it. Protected health information about you is obtained as a record of your visits or contacts with Carolina Complete Psychiatry, PLLC for healthcare services. Specifically, PROTECTED HEALTH INFORMATION is information about you, including demographic information (name, address, age, etc.) that may identify you and may relate to your past, present and/or future physical or mental health condition(s) and related healthcare services. Carolina Complete Psychiatry, PLLC is required to follow specific rules for maintaining the confidentiality of your protected health information, the use of your information and how providers disclose or share this information to/with other healthcare professionals involved in your care and treatment. All employees, interns, students may have access to your records, while working with Carolina Complete Psychiatry. This Policy describes your rights to access and control your protected health information. It also describes how we follow those rules in the use and disclosure of your protected health information for the purposes of providing treatment, obtaining payment for the services you receive, managing our healthcare operations and for other purposes permitted/required by law. YOUR RIGHTS UNDER THE PRIVACY RULE: The following is a statement of your rights under the Privacy Rule in reference to your protected health information. Please feel free to discuss any questions/concerns with the staff. YOUR RIGHTS TO A COPY OF PRIVACY POLICIES We are required to follow the terms of this notice. We reserve the right to change the terms of our notice at any time. If needed, new versions of this notice will be effective for all protected health information that we maintain. Upon request, you will be provided with a revised Notice of Privacy Policies. YOUR RIGHTS TO AUTHORIZE OTHER USE AND DISCLOSURE This means that you have the right to authorize or deny authorization for any other use/disclosure of protected health information not specified in this notice. You may revoke an authorization at any time except to the extent that Carolina Complete Psychiatry, PLCC has taken an action in reliance on the use or disclosure indicated in the authorization. Any revocation of authorization to use or disclose protected health information must be presented in writing. YOUR RIGHTS TO DESIGNATE A PERSONAL REPRESENTATIVE This means that you may designate a person who then has the delegated authority to consent to or authorize the use or disclosure of your protected health information. Any notice of revocation of authorization/designation of a previously named personal representative must be presented in writing. YOUR RIGHTS TO YOUR PROTECTED HEALTH INFORMATION This means that you may inspect and obtain a copy of protected health information about you that is contained in your patient record. Under certain circumstances, we may deny your request or redact information. Any requests for copies of your protected health information must be made in writing. YOUR RIGHTS TO REQUEST A RESTRICTION OF YOUR PROTECTED HEALTH INFORMATION This means that you may request, in writing, that we not disclose any part of your protected health information for the purposes of treatment, payment for service you have received, or healthcare operations. You may also request that any part of your protected health information be restricted from disclosure to others who may be involved in your care or for notification purposes as described in this Notice of Privacy Policies. Under certain circumstances, we may deny your request for restriction. All requests for restriction of your protected health information must be made in writing. YOUR RIGHTS TO REQUEST YOUR PROTECTED HEALTH INFORMATION AMENDED This means that you may request an amendment of your protected health information for as long as we maintain the information. Under certain circumstances, we may deny your request for an amendment. All requests for amendment to your protected health information must be made in writing.
Carolina Complete Psychiatry, PLLC may contact me at the following phone numbers or email address regarding my appointments, treatment, and information about my health. Messages may be left unless otherwise noted.
By providing my email address below and signing, I understand that I give Carolina Complete Psychiatry permission SMS (text message), call or e-mail me on the account given. Furthermore, I understand that e-mail and text messages is not a HIPAA compliant form of communication, nor is information protected in any way other than basic passwords. I waive any and all liability for Carolina Complete Psychiatry, PLLC in the event of information disclosure that resulted from the use of e-mail, voicemail and/or text messages.
Lastly, you are invited to use Patient Fusion, an electronic communication portal that is encrypted and HIPAA complaint. This will allow you to communicate with your provider, as well as see upcoming appointments, medications, and recent lab work results. Please ask the office for an invitation code if you do not want an invitation to be sent to you via email.
Credit Card Number: Number*
Expiration Date: MM/YY*
CVV: 3 Digit cide* Zip code: Number*
WE DO NOT CARRY PATIENT BALANCES. ALL FEES ARE DUE AT THE TIME OF SERVICE. A VALID CREDIT CARD OR DEBIT CARD IS REQUIRED BY ALL PATIENTS.
Please note: You must inform the office if there have been ANY changes to your credit card information. Failure to inform the office of such changes or a declined credit card transaction will result in a $25.00 charge to your account.
By signing below, you agree to, approve, and understand all of the following:
Carolina Complete Psychiatry, PLLC, reserves the right to charge the credit card on file, at any time for service provided by the company. If your account at Carolina Complete Psychiatry, PLLC carries an outstanding balance for more than 30 days, we may charge the card for the outstanding amount without giving prior notice.
You have the right to request an invoice/statement at any time.
Carolina Complete Psychiatry, LLPC. will not be held liable for any fraudulent charges made to the credit card account.
If you are not the cardholder of the credit card, you agree to take full responsibility for any charges made by Carolina Complete Psychiatry to the card you have provided.
Please feel free to request a copy of this document for your own records if needed. Thank you. The undersigned acknowledges reading and understanding the policies for Carolina Complete Psychiatry, PLLC.
I understand this authorization remains in effect until the date of expiration. I understand this authorization may be withdrawn any time in writing (except to the extent that action has already been taken). Further release shall cease (except as allowed by law) upon Carolina Complete Psychiatry receipt of the written revocation.
NOTICE TO RECIPIENT OF PROTECTED HEALTH INFORMATION Prohibition Against Re-Disclosure: This information has been disclosed to you from records protected by federal confidentiality rules. The federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 C.F.R., Part 2. A general authorization for the release of medical or other information is not sufficient for this purpose. The federal rules restrict any use of information to criminally investigate or prosecute any alcohol or drug abuse client. Drug abuse patient records are also protected under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 C.F.R. parts 160 and 164. These conditions apply to every page disclosed and a copy of this authorization will accompany every disclosure.