IDD Virtual Consents

Today's Date:

Date

Name of individual enrolled: *

First Name Last Name

Date of Birth of individual enrolled: *

Date

Name of Legal Guardian: *

Legal Guardian Address *

Street Address

Street Address Line 2

City State

Legal Guardian Contact Phone #: *

Legal Guardian Email Address (Optional):

example@example.com

Consent for Services:

I consent to such medical, psychiatric, and/or other services as the staff may recommend, including diagnostic tests and counseling. I agree to cooperate in the implementation of the services including following through with the 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 the 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 the 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.

I agree to the Consent for Services on behalf of the enrolled individual listed above: *

Yes No

Consent for Contact:

There may be times when we need to contact you regarding your services at our agency. A representative from this agency may contact you 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.

I agree to the Consent for Contact on behalf of the enrolled individual listed above: *

Yes No

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.

I agree to the Financial Consent on behalf of the enrolled individual listed above: *

Yes No

Controlled Substances Agreement:

Controlled substances will be taken as prescribed. I will not increase the dosage of my controlled medication unless authorized by my physician. I will exercise caution when performing activities such as driving or operating heavy machinery.

I agree to the Controlled Substances Agreement on behalf of the enrolled individual listed above: *

Yes No

Consent for Photographs, Film, or Other Recording:

I authorize Lookout Mountain Community Services dba Bridge Health to use the enrolled individual's photograph, video, quote, story, or artwork for marketing, public relations, and external communications.

I understand I am consenting to multiple uses of such items for promotional, celebratory, advocacy, educational and informational purposes to local, state, and national government officials; reporters for local, state, and national media publications, including newspapers, magazines, and online media; and to reporters for local, state and national television broadcast stations, or as otherwise specifically described.

I agree to the Consent for Photographs, Film, or Other Recording on behalf of the enrolled individual listed above: *

Yes No

Telehealth/Telemedicine Consent:

The purpose of this form is to obtain your consent to participate in a telemedicine consultation in connection with the care provided to the person to which you are the guardian.

During the telemedicine consultation, medical history, examinations, x-rays, and tests will be discussed with other health professionals through the use of interactive video, audio, and telecommunication technology. A physical examination may take place. A non-medical technician may be present in the telemedicine studio to aid in the video transmission. Video, audio, and/or photo recordings may be taken of you during the procedure(s) or service(s)

All existing laws regarding access to medical information and copies of medical records apply to this telemedicine consultation. Please note, that not all telecommunications are recorded and stored. Additionally, dissemination of any patient-identifiable images or information for this telemedicine interaction to researchers or other entities shall not occur without your consent.

Reasonable and appropriate efforts have been made to eliminate any confidentiality risks associated with the telemedicine consultation, and all existing confidentiality protections under federal and Georgia state law apply to information disclosed during this telemedicine consultation.

You may withhold or withdraw consent to the telemedicine consultation at any time without affecting the right to future care or treatment, or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled

You agree that any dispute arriving from the telemedicine consult will be resolved in Georgia and that Georgia law shall apply to all disputes.

You have been advised of all the potential risks, consequences, and benefits of telemedicine. The health care practitioner has discussed with you the information provided above. You have the opportunity to ask questions about the information presented on this form and the telemedicine consultation. All questions have been answered, and you understand the written information provided above.

I agree to the Telehealth/Telemedicine Consent on behalf of the enrolled individual listed above: *

Yes No

LMCS Privacy Practices (please download a copy for your records)

LMCS Orientation Handbook (please download a copy for your records)

I have received/reviewed the Consumer Orientation Handbook and the Notice of Privacy Practices. These documents contain important information regarding my rights and grievance procedures as a consumer here. These documents also contain important information about services at this agency and my legal rights regarding protected health information. I have received orientation to the facility's premises and emergency routes/exits, emergency equipment and emergency codes. I understand that if I have questions or complaints, I should ask to speak to the Program Manager or Privacy Officer. *

Yes No

YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ AND UNDERSTAND THE INFORMATION PROVIDED. *

IDD Consents

Notice of HIPAA Privacy and Orientation Handbook