TMS / Spravato New Patient Enrollment Form

Consent to Treatment
Full Name*

First NameLast Name
By submitting this form via this web portal, you acknowledge and accept that risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "Yes, I want to submit this form" you agree to hold Journey Healthcare LLC harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means.**

Yes

Family Consent and Authorization for the release of information

Famiy Consent
I First Name Last Name Consent for the release and authorization the disclosure and use of my protected health information by Journey Healthcare, in accordance with federal and/or state law, whichever is more protective of the client's confidentiality, by written copies, facsimile or verbal communication to:
Family Member Name:

First NameLast Name
Relationship:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
In accordance with Federal Register Vol. 65, Part II, SubPart E 164.508, I authorize Journey Healthcare to disclose my protected health information for the purpose of:

Family involvement in TreatmentTreatment Progress ReportsEmergency Contact
The health information to be released is limited to the following:

General progress updatesFamily Thearpy Sessions.
I also understand:
1. That regulation 164.508 ensures my right to treatment, payment or enrollment in a health program regardless of whether I sign this authorization, and that I may refuse to sign.
2. That when either federal or state laws afford me more a stringent level of privacy protection than those regulated by 164.508, Journey Healthcare will always abide by the more stringent law.
3. Journey Healthcare will only disclose my health information gathered through treatment by our internal healthcare clinicians, and will not re-disclose my PHI received from any other external healthcare provider.
4. That although Federal Law (42 CFR Part 2) prohibits re-disclosure of your PHI, recipients of your information could potentially disregard these and other laws.
5. That this authorization expires 30 days after discharge from treatment episode.
I have been offered a copy of this authorization and:

Accepted itRejected it
Signature

Clear
Date

MonthDayYear
Date
I understand that I may revoke all or part of this authorization verbally or in writing.
Please contact the office if you wish to revoke this consent.

This Consent/Authorization complies with the Privacy Regulations contained within Federal Register Vol. 65, Part II, Part 164; SubPart E 164.508.

PROHIBITION OF REDISCLOSURE: This information has been disclosed to you from records whose confidentiality is protected by Federal Law. Federal regulations prohibit you from making any further disclosures of this information except with the specific written consent of the person to whom it pertains or as otherwise permitted by such regulations. A general release of medical or other information is NOT sufficient for this purpose.
Should be Empty:

Consent to Treatment

PCP/Family Doctor Consent

Family Consent and Authorization for the release of information