Hope and Healing providers and professional staff look forward to working with you. You need to provide the informed general consent for evaluation and treatment for medical and behavioral services for your protection and safety. Feel free to ask questions if you would like a detailed explanation of the Informed Consent Form before signing this document.

1. I consent to receive medical and behavioral assessment and treatment from Hope and Healing providers and professional staff members, to include Telehealth or Telepractice services. See Telepractice policy below for detailed information.
2. I have read and understand that Arizona State Law permits or requires the disclosure of confidential information without my consent under very specific circumstances (see Notice of Privacy Practices below).
3. I am giving my consent to Hope and Healing to use my health information from my record for purposes of providing me treatment and for coordination of my care as defined and explained in more detail in the Notice of Privacy Practices ("Notice"). Hope and Healing's Notice provides more complete information about how protected health information may be used, and a copy of this Notice is available upon request.
4. I authorize the sharing of information among Hope and Healing clinicians/ medical providers, BHTs and other staff members who are involved in my mental and physical health treatment, and who are working in different locations and /or sister facilities owned and operated by Hope and Healing.
5. I may revoke this General Consent Form at any time by notifying Hope and Healing in writing of my intention to revoke.
6. I, hereby grant my permission for any counseling, testing, or diagnostic evaluation that may be deemed necessary by my clinicians/ providers. I understand that treatment is a joint effort between my clinicians, professional staff and myself, the results of which cannot be guaranteed. Progress depends on many factors including motivation, effort, and other life circumstances.
7. I know that I can end treatment at any time and that I can refuse any requests or recommendations made by my clinicians.
8. I also give my authorization and consent to receive behavioral health treatment services from Behavioral Health Provider, Behavioral Health Technicians, Therapists and other clinical staff representing the outpatient and residential behavioral facilities of Hope and Healing Addiction Treatment Centers.
9. I have been given information regarding my rights and responsibilities as a participant.
10. I have been given information regarding the limits of confidentiality of my records.
11. I have been given information regarding the cost of services from: AZ Hope and Healing Addiction Treatment Centers
12. I understand that I may address any concerns or grievances with my BHT or any other representative of the facility at any time.
13. I am freely choosing to enter into treatment, and I understand that I may discontinue treatment at any time. Except for court mandated treatment plans, when voluntary participation is waived, and all clients referred to our facility from the court system are ordered to participate and will not be allowed to discharge voluntarily prior to completion of treatment plan.
14. I have been given information about the advantages and disadvantages of the treatment recommended as well as other alternatives.
15. I give consent to be photographed for marketing purposes and when admitted to a Hope and Healing facility for identification and administrative purposes. I give consent to the release Medical or Financial Records.
16. The client understands that the facility may use monitoring equipment and devices for safety monitoring only. That may include cameras surveillance in common and outside areas. Video recordings are maintained on temporary basis.
17. The client also understands that Hope and Healing has different locations and different level of care facilities, therefore all medical and behavioral health records will be shared on a need to know basis, with pertinent staff members working at all locations and levels of care and who are involved in providing behavioral and medical services to clients
18. I, hereby assign all medical and/or surgical benefits to which I am entitled to, including Medicare, private insurance, auto insurance and any other health plan to Hope and Healing. This agreement will remain in effect until revoked by me in writing. I, hereby authorize said assignee to release all information necessary to secure payment.
19. I also agree to receive email and text communications requesting payment for the patient responsibility of any claim balances.

HIPAA NOTICE OF PRIVACY PRACTICES

We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. We are also required to abide by the terms of the notice currently in effect. If you have any questions regarding this notice, please contact Hope & Healing Outpatient. Our contact information is listed above.

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

This Notice of Privacy Practices is NOT an authorization. This Notice of Privacy Practices describes how we, our Business Associates, and their subcontractors, may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health condition and related health care services.

USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION

Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physicians practice, and any other use required by law.

TREATMENT

We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you. We will abide by the patient’s request not to disclose PHI to a health plan for services which the patient has paid out of pocket and requests the restriction.

PAYMENT

Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.

HEALTHCARE OPERATIONS

We may use or disclose, as needed your protected health information to support the business activities of your physician’s practice. These activities include, but are not limited to, quality assessment, employee review, training of medical students, licensing, and conducting or arranging for other business activities. For example, we may disclose your protected health information to medical school students that see patients at our office. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment, and inform you about treatment alternatives or other health-related benefits and services that may be of interest to you. We may use or disclose your protected health information in the following situations without your authorization. These situations include: as required by law, public health issues as required by law, communicable diseases, health oversight, immunizations to schools, abuse or neglect, food and drug administration requirements, legal proceedings, law enforcement, coroners, funeral directors, organ donation, research, criminal activity, military activity and national security, workers’ compensation, inmates, and other required uses and disclosures. Under the law, we must make disclosures to you upon your request. Under the law, we must also disclose your protected health information when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements under Section 164.500.

USES AND DISCLOSURES THAT REQUIRE YOUR AUTHORIZATION

Other Permitted and Required Uses and Disclosures will be made only with your consent, authorization or opportunity to object unless required by law. The same authorization/restrictions that were used while you are alive will remain in place for up to 50 years after your death. Without your authorization, we are expressly prohibited to use or disclose your protected health information for marketing purposes. We may not sell your protected health information without your authorization. We may not use or disclose most psychotherapy notes contained in your protected health information. We will not use or disclose any of your protected health information that contains genetic information that will be used for underwriting purposes. You may revoke the authorization, at any time, in writing, except to the extent that your physician or the physician’s practice has taken an action in reliance on the use or disclosure indicated in the authorization.

DISCLOSURES THAT DO NOT REQUIRE YOUR CONSENT ARE: DANGER TO SELF, DANGER TO OTHERS, DUTY TO WARN, SUSPECTED CHILD OR ELDER ABUSE, MEDICAL EMERGENCIES

YOUR RIGHTS

The following are statements of your rights with respect to your protected health information:

You have the right to inspect and have a copy of your protected health information (fees may apply). Pursuant to your written request you have the right to inspect or have a copy your protected health information whether in paper or electronic format. The records will be provided within 30 days of request. Under federal law, however, you may not inspect or copy the following records: Psychotherapy notes, information compiled in reasonable anticipation of, or used in, a civil, criminal, or administrative action or proceeding, protected health information restricted by law, information that is related to medical research in which you have agreed to participate, information whose disclosure may result in harm or injury to you or to another person, or information that was obtained under a promise of confidentiality.

Patient Requesting Medical Record Copies. There may be fees associated with requesting copies of medical records, such as copy fees, and/or shipping and handling fees.

You have the right to request a restriction of your protected health information – You may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. You have the right to request to receive confidential communications

You may ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.

You have the right to request an amendment to your protected health information – You may ask us to correct health information about you that you think is incorrect or incomplete. We may say “no” to your request, but we will tell you why in writing within 60 days.

You have the right to receive an accounting of certain disclosures — You have the right to receive an accounting of disclosures, paper or electronic, except for disclosures: pursuant to an authorization, for purposes of treatment, payment, healthcare operations; required by law for up to six years prior to the date of the request.

You have the right to receive notice of a breach - We will notify you if your unsecured protected health information has been breached.

You have the right to obtain a paper copy of this notice from us even if you have agreed to receive the notice electronically. We reserve the right to change the terms of this notice and we will notify you of such changes on the following appointment. We will also make available copies of our new notice if you wish to obtain one.

Client Consent for Telepractice

Telemedicine / Telehealth / TelePractice

Hope and Healing utilizes HH online application platform for telepractice. This platform is HIPAA compliant.

Client reviewed and accepted the limitations, risks, and benefits of technology within a therapeutic setting. This includes email, phone, text and video.

The provider will ultimately determine if telepractice could meet the client’s needs.

Benefits:

The benefits to technology are:

1. Reduces the stigma of obtaining mental health services
2. More convenient for clients to get the help they need
3. Reduces the overall costs due to not having to drive to and from office.
4. Reduces the wait time for scheduling office appointments.
5. Increases availability of services to people who are unable to leave the home or have difficulties with transportation

Limitations:

It is important to note that there are limitations to technology that can affect the quality of the session(s).

These limitations include but are not limited to the following:

1. Because sessions are not in person, the provider has limitations to reading client body language, or client non-verbal reactions to what is being discussed.
2. Due to technology limitations the provider may not hear all of what the client are saying
3. Technology may fail before or during the session.
4. Although every effort is made to reduce confidentiality breeches, even when we are using HIPAA COMPLIANCE technology platforms, the provider does not have any control over whether the protection of confidentiality used by the platform has been compromised.
5. The provider will inform client of which technology platforms they are using and it is client responsibility to read, understand, and agree to that platforms rules and limitations.

Logistics:

When the provider is using technology, they will be in private location to ensure client privacy. It is the client’s responsibility to be in a location that is safe and confidential to protect their privacy. If the client chooses a place where others can hear the client, the provider cannot be responsible for protecting client confidentiality Every effort MUST be made on the client’s part to protect their own confidentiality.

Connection Lost:

If connection is lost during a video or phone session, the provider will call client to try and troubleshoot the reason for the lost connection. If the reason the connection is lost occurs on the client’s part

i.e. battery dying, bad reception, etc. the client could still be charged for the entire session. If the loss for connection is a result of something caused by the provider, the provider will do everything possible to troubleshoot the problem and may offer other options such as completing the session using other technology or rescheduling the session.

Recording of Sessions:

Please note the recording of audio/video, photographing, screenshots, streaming, etc of any kind is NOT permitted and are grounds for termination of the client-therapist relationship.

Client Location:

The provider can only practice in the state(s) they are licensed in. That means client must reside in and be participating from the state the provider is licensed. AT THE BEGINNING OF A VIDEO SESSION, THE PROVIDER WILL ASK THE CLIENT FOR THEIR PHYSICAL LOCATION AT THAT TIME. The client must also ensure they are located in a safe and secure environment prior to the start of the session.

In Case of Emergencies:

Before each session begins the provider will request the address for which client are currently located and will use this information to give to authorities in case of a crisis or emergency. If for some reason client and provider get disconnected and client are in crisis/emergency, client agrees to call 911, go to their local emergency room immediately or contact the National Suicide Hotline 800-273-TALK (8255). If the provider has concerns about client safety including client being a danger to themselves or others at ANYTIME during a session, the provider will call 911.

HOPE AND HEALING is required to keep an emergency contact for client. This contact can/will be used during a crisis/emergency.