INFORMED CONSENT/HIPAA
I hereby request to be provided psychological services by a therapist at MSM Counseling.
I have received a copy of the "Patients Bills of Rights" including the grievance procedure.
I have received a copy of the "Notice of Privacy Practices" as required by HIPAA.
I have been informed of the following by clinic staff and in writing.
The type and manner of treatment to be provided has been discussed with me.
The probable benefits and possible consequences of the proposed treatment, including side effects or risks of side effects from medications have been discussed with me. Also, the possible consequences of not receiving proper treatment and services have been explained.
The importance of coordinating psychology clinic services with physician medical services has been discussed.
The fees for services provided, any co-pay that may be incurred, and payment considerations involving these fees for missing an appointment if notice was not sufficient.
Our clinic policy is 24-hour notice for an appointment change or cancellation. You may be billed a late fee for missing an appointment if notice was not sufficient.
Multiple missed appointments without notification may result in the discontinuation of your service at MSM Counseling.
The time period for which the informed consent is effective shall be no longer than 13 months from the time the consent is given.
The right to withdraw informed consent at any time in writing has been discussed with me.
Patient Name:
Date of Birth:
Patient Signature:
Date:
Responsible Person for Minor or Incompetent:
Date:
Provider Signature:
Date:
Legal Disclaimer:
This authorization is valid for current academic year. I understand that I may revoke authorization at any time by submitting written notice of the withdrawal of my consent and that written revocation must be given to the above agency. I authorize to release information. I recognize that health records once received by electronic email, may not be protected by HIPPA privacy act and may become clinical records and those of Family educational Rights and Privacy Act (FERPA) with additional protection afforded by Wisconsin statutes 118.25 (2M)(a)(b) and 146.83. I also understand that if I refuse to sign, such refusal will not interfere with my child's ability to obtain interagency mental health services.
