CONSENT TO TREAT PACKET

Main: 602-358-7073
Text: 602-825-1513
Fax: 888-927-0409
Email: frontdesk@terishealthservices.org
Website: terishealthservices.org
Office: 14040 N. Cave Creek Rd. Suite 104, 205 Phoenix, Az 85022
Office: 7205 S 51st Ave Suite 203 Laveen, Az 85339
Mailing: 6635 W Happy Valley Rd. Suite A104-621 Glendale, Az 85310

Appointment Reminders
We send appointment reminders to your phone/SMS and email. If you opt out of this type of communication please call our office and let us know so we can make sure you do not receive this communication. All forms of our office communication is secure. If you do not call the communication will continue with this consent acting as consent for the communication.

Payment
Payment. Teri's Health Services requires an active insurance be on record even when using EAP or a credit card authorization form. If you are self-pay and will not be using any form of insurance please state N/A to the below insurance questions.

At Teri’s Health Services we value our staff and clients alike. To attempt to reduce and eliminate no shows and late cancellations to occur we require a $60.00 fee to be paid in the event that a client or patient cancels their visit in 24 hours or less to the visit time/date or a no show occurs.

One no show without a call into our office within 24 hours of the missed visit will result in the you being removed from all visits going forward until you call our office to reschedule and pay your balance and/or fees associated with the no show.
Two cancellations in 90 days will also result in removal on the third cancellation for the 90 days from the providers calendar until a commitment to the scheduled timeframes can occur. If you reschedule your visit in the same week as the canceled visit, then you can bypass the late cancellation fee (if the provider’s schedule allows for this to occur). No bypass can happen in the event of a no show. The fee applies to all no shows.

If you are having difficulty getting to the visit or are going to be late please call us right away so we can help. If something last minute comes up and you need to cancel but can reschedule to a different time and/or day then do this also, which again will stop the late cancellation fee from happening. However, if you reschedule to another date/time of the cancellation week and no show or cancel the rescheduled visit a $100 fee applies even if the cancellation of the visit happened outside of 24 hours.

A balance must be paid at time of receipt of the invoice. Copay and balances must be paid before visit occurs. You will be prompted to take care of your copay and/or balance prior to your visit. If you fail to pay your balance or copay your visit will be canceled and all visits on the schedule will be removed. This also will count as a no show or late cancellation, which then a $60 fee will also apply. Once the balance is paid in full you can resume your visits by calling the front desk and rescheduling. You can also email us at frontdesk@terishealthservices.org or secure text at 602-825-1513.

You can pay your balance and copay in your patient portal or before your visit by calling the front desk or at check in for office visits. If you need a payment plan you can register for Care Credit and pay through Care Credit which acts as a payment plan for you. Teri’s Health Services does not offer any type of payment plan internal.
Please note THS will send your unpaid balance to collections if you fail to pay your balance after three attempts by our office to collect. After three attempts to collect a balance through a statement process Teri's Health Services will send your account to a collection agency to then start their collection cycle. This company is called Transunion (TSI).

Care Credit: https://www.carecredit.com/
Payment Link to Healow: https://mycw139.ecwcloud.com/portal19413/jsp/100mp/login_otp.jsp
Download the Healow App on your smart device to easily access your patient portal, join a telehealth visit, see your statements, pay your balance and copays, see upcoming visits, and exchange messages with our office:
https://healow.com/app.html
Apply the Practice Code to set up the app on your smart device:
Practice Code: GJCACD

Social Media, Provider and Client Relationship, & Telehealth Social Media
*Services refers to counseling, psychiatry, case management, psychological services, primary care

* Providers refers to counselors, social workers, psychiatric nurse practitioners, medical personnel, psychologists, or other direct service care staff.

Social media forums are not HIPAA compliant forms of confidential communication between a provider and patient. To protect your confidentiality, we will not “friend” you on Facebook, accept a “friend request,” Tweet, Instagram, LinkedIn, Pinterest, or any other social media means to participate in communication with you.
Patient and Provider Relationship

The patient and provider relationship is a professional relationship that is set up for your treatment and care. Providers are held to very high ethical standards of treatment and are prohibited from engaging in what is called “dual relationships” with patients. This means, providers are not allowed to provide services to persons they have a formed relationship with already that is personal and once services are in progress or ends a relationship that is personal or professional outside of the servicing realm is considered unethical.

For confidential purposes, if you see your counselor outside of the counseling room please note that counselors are not allowed to come up to you but you can come up to them in a community setting. This is for your protection. Therefore, the counselor is not ignoring you when we walk by without saying hello instead we are allowing you to choose whether you want to at that time to engage in a conversation.
Telehealth and Telemedicine

Telehealth or telemedicine are used interchangeable to mean the same thing. This is a type of service via electronic means such as a telephone or video. There are times when your provider may be traveling outside of Arizona and may offer telehealth services while out of town. This is permitted as long as the provider is licensed in the state you are residing in at the time of services. When you travel out of state you must make sure our provider is licensed in the state you travel to. Most of our providers are only licensed in Arizona. This means if you travel outside of Arizona we are not able to provide services to you until you return.

Things to consider when using telehealth:
Benefits: Include the opportunity to explore needs and continued treatment progress with a provider. Benefit of exploring ways to change and feeling better in your life, exploring life changes, and healing from past and current struggles. Benefits also include being able to travel and still do therapy as long as it is in the state the counselor is licensed in.

Limitations: Include when the scope of practice of the therapist does not fit the needs of the client. When this happens we will detail to you as the client the limitations of our scope of practice and offer to help refer you to another provider who is able to provide treatment to fit your needs.

Risks: If you share there is an emergency or concern we are not physically available to help you so will need to inform local authorities such as 911 or police to help you if you are not able to provide a satisfactory response that ensures safety. If you hang up the phone or video and we cannot reach you after you tell us there is an emergency we will have to send police to your residence. We will provide the officers with your name, phone number, address, diagnosis, statements of safety concern and any other information that is pertinent to help you to be safe. Group counseling can pose a risk if you as the client share things in group with members who are not held to confidentiality. Risks in treatment include also stopping therapy before completion of the goals which can reduce the chances of fully improving. Sometimes during the start of treatment or in treatment clients can feel worse before feeling better. This happens as the issues being brought up are surfaced. Other risks may include lack of improvement, feeling temporary relief but not long term, relationships can be impacted as you change and others stay the same, difficulty stopping treatment when it is time because of the relationship built with the therapist.
Alternative means of services: While absent, another provider can be scheduled with you if you choose.

Platform: The clinician assigned to you will send out an email to you provided by you with the link for the video online telehealth forum for counseling. Please follow the link. We also use a video format called Healow. You can download Healow on any smart device or access with a company. If using another video format, our office uses HIPAA compliant Zoom and Google Meets platforms. To make follow up appointment call or email: 602-358-7073 or frontdesk@terishealthservices.org.

In an emergency: You are to contact 911 or local police department, not your provider or the front desk. If you are at a facility or group home please go to your staff first. If you have a crisis please dial 988.

Confidentiality: When using telephone communication or video format please make sure you are in a private location. This will ensure your confidentiality. In terms of your provider, when we meet with you we will be in a private setting that is not around other people or in public.

Technology failure: If the phone or video goes dead or bad service results we will contact you again or at a later time, if when failure results and you have shared with us a crisis situation we will contact police for a wellness check or crisis. 
Anticipated response time: If you contact the front office they will get back to you within 24 hours or by next business day. You can also text securely to 602-825-1513.
Time zones: When we are out of town I will ensure you are aware of time zone changes.

Verification of Client: When using video for session we verify the client by drivers license and picture in the video of the client. If using telephone as the means of session (audio only) we will ask the client to identify their name and date of birth and address on record.

Body language and nonverbals: Please note that telehealth communication restricts the provider’s ability to recognize your nonverbal reactions and needs (we cannot see tearfulness, difficulty with controlling emotion, or physical ailments), therefore, we may ask about presentation throughout the session. This may also mean that we may ask directly about your feelings and behaviors. Most insurance health plans require telehealth be a video format to cover the expense. If you are using insurance you agree to use video and show your face.

License to practice: Most of our direct care staff (i.e., providers) are licensed in the state of Arizona or practicing in the state of Arizona. We hire independently licensed and associate level licensed professionals. We hire non licensed staff as well. All non-Independently licensed professionals are provided the opportunity for Clinical Supervision.

Email, Text, Phone Calls During Working Week – If you have questions or need to schedule or cancel please call the front office directly. You and your provider will set up follow up an appointment after each visit. If you need to cancel please do so within 24 hours of the appointment date as this helps the provider to schedule another person in that time spot. It also reduces the chance you will be required to pay a cancellation fee.

Email: You can email front desk team at frontdesk@terishealthservices.org. This is a fully secured email and staff will respond within 24 hours or next business day. You can also email leadership@terishealthservices.org if you having problems getting through.

Text: We have a secure text you may use for questions that is the office text line at: 602-825-1513. This line is available 24/7. 

Client:

• Understands that telemental health/medical services are completely voluntary and that you can withdraw this consent at any time.
• Understands that none of the telemental/telemedicine health sessions will be recorded or photographed.
• Understands not to make or allow audio or video recordings of any portion of the sessions.
• Understands that the laws that protect privacy and the confidentiality of client information also apply to telemental health/telemedicine, and that no information obtained in the use of telemental health/telemedicine that identifies you will be disclosed to other entities without your consent.
• Understands that telemental health/telemedicine is performed over a secure communication system.
• Understands that any internet based communication is not 100 % guaranteed to be secure.
• Understands that the provider/therapist and Company (THS) will not be held responsible if any outside party gains access to your personal information by bypassing the security measures of the communication system.
• Understands there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties.
• Understands that you or your provider/therapist may discontinue the telemental/telemedicine sessions at any time if it is felt that the video technology is not adequate for the situation.
• Understands that if there is an emergency during a telemental health/telemedicine session, then my therapist/provider may call emergency services and/ or my emergency contact.
• Understands that this form is signed in addition to the Notice of Privacy Practices and Consent to Treatment and that all office policies and procedures apply to telemental health/telemedicine services.
• Understands that if the video conferencing connection drops while you are in a session, my therapist/provider will contact me back. During the evaluation process at times your therapist/provider will complete an evaluation over the phone. All therapists/providers who call from Teri's Health Services are held to the same practice procedures as in office providers/therapists. All providers/therapists over telemental health/telemedicine services are mandated reporters by law. If your the client reports they might harm themselves or someone else or hang up the phone during session and you have stated risk of harm your therapists/providers is permitted by Arizona law to break confidentiality to get you help or someone else in foreseeable harms way. In addition, if you as the client/patient are in crisis and you hang up the phone and your therapist/provider is unable to contact again 911 or the nonemergency line will be contacted to respond for help.

Purpose of Counseling
Counseling is an opportunity to explore changes you want to make with a qualified health care professional. At Teri’s Health Services clinicians are licensed or license eligible. Teri’s Health Services also employs masters level interns who are under the direct supervision of an independently licensed professional. All clinicians whether licensed or interns are trained in several various trauma informed care approaches including CBT, EMDR, Sand Tray Therapy, SFT, Brain Spotting, Family Systems approaches, among other types of approaches. All or some of these approaches may be used with clients who seek therapy services from Teri’s Health Services. At intake, a qualified clinician will complete an initial assessment and treatment plan to identify those goals you want to meet and what approaches will be used to get you there. We provide individual, couples and marriage, family, and group counseling.

Purpose of Psychiatry
The purpose of psychiatry is to assess a patient for a mental health diagnosis and any issues that can be treated safely and soundly with medication. Our providers are licensed in their field to provide psychiatry services and will discuss your goals, symptoms, and if medication will be helpful in your treatment journey.
Purpose of Medical Services

The purpose of physical health services is to promote the well-being of individuals and to evaluate prior to treatment to reduce the risk of disease by finding the issues early so treatment can be more successful. Physical health coupled with behavioral health services is an integrated approach to health care that has been found to be successful in providing services to patients.

Payment, Cost and Copay
We accept most major health insurances. Visit our website to view our active plans we accept. If using insurance, we require your deductible and copay to be paid prior to your appointment. We do not set up payment plans to pay balances. However, you can sign up for Care Credit and use Care Credit to pay your invoices for services. We also have self-pay options.

Counseling and Psychiatry: $150 new patient, $110 follow up
Medical: $150 new patient, $125 follow up

Please review our copay and balance process and late fee and cancellation process located on our website under the “consents and forms” tab.
You can choose to leave a credit card on file with our office and we will charge the card for the balance and copay collections. If you are self-pay or using EAP we require a credit card or primary active insurance to be held on record with our office. If your credit card is on file for this reason you authorize Teri’s Health Services to charge your card when there is a balance or payment required. If you want to have your credit cared on file please call our office and we will send our authorization form over to you to complete.

Fees and Refund Policy
PURPOSE:
To provide a policy for explanation of Teri’s Health Services (THS) fees and defines a process for resolving credit balances and overpayments.
II. POLICY:
THS will make available, upon request, the fee schedule to clients. Information on how to obtain this information will be posted in the main lobby of all outpatient treatment center facilities. FEES: It is the billing departments staff’s responsibility to explain to each client the fees associated with care, treatment, or services with THS’ programs and services. REFUNDS: Client accounts with credit balances or overpayments must be researched and analyzed promptly. If the payment discrepancy is confirmed as an overpayment, timely refunds must be made. Refunds will be made in the form of a check or credit card refund.

III. PROCEDURE:

FEES:

1. THS’ billing department and or front office staff will obtain accurate, complete, and timely demographic and financial information from every client.
2. The billing department or front office staff will obtain eligibility and benefit information from any third-party payer and information provided by the client.
4. Upon request, the Billing department will discuss with every client any applicable third-party payor contribution towards their bill, as well as client’s financial responsibility after insurance payment has been received, including out-of-pocket or deductible obligation(s).

Refunds:
1. Client accounts with credit balances are to be researched to determine the reason for the account balance. These reasons may include an overpayment by an insurance carrier and/or another responsible party, duplicate payment/contractual entries, misapplied charges/credits, and incorrect client account adjustments, etc.
2. Once confirmed, all bona fide overpayments must be promptly refunded to the appropriate client, guarantor, or third-party payer.
Incident to Billing
When your provider is an LMSW/LAC we will bill under their clinically licensed supervisor who reviews their clinical work and signs off. Incident to billing or supervisor billing scenarios are permitted by most major health plans except TriCare for Life and Magellan. For these plans we will ensure you are matched with an independently licensed provider who is credentialed under these plans directly. At Teri’s Health Services Incident-to-Billing is only used for behavioral health services.
Eligibility: Once you complete the consent packet we will verify your insurance and eligibility and publish a summary of the eligibility to your patient portal with an e-message that comes in the form of an email to open up the secure message. If you have questions about the summary of eligibility please call our office directly and select the option for billing. Any copay or deductible cost to you, you will be informed of this. You have a right to understand your billing at all times and can request copies of statements and overview of billing at any time. Our office will review eligibility ongoing and if your insurance changes you are required to provide that information to our office prior to or at your next visit. Any time your eligibility changes we will publish it to your patient portal.

Emergency
If an emergency, please call 911 or EMPACT-SPC crisis line at 480-784-1500. This crisis line is available 24-hours a day, 7 days a week.

Client Records
All of your information is stored within a HIPAA compliant electronic medical records forum. Teri’s Health Services will save your chart for up to 7 years following the closure of chart for services. At any time, you have a right to your records. If you are requesting your records, please allow up to 14 days from the medical records department. You may complete a record request by contacting our office and requesting one be sent to you to complete.

Records Sharing
Your record is only shared with those you provide a release of information for. In some cases, there are court orders that require sharing of records. If one or both of these scenarios are not present then your records are not shared with anyone outside of Teri’s Health Services practice. You are also authorizing the release of information about your care to your insurance company. The information often required by insurance companies may include, but is not limited to, diagnosis, prognosis, and treatment goals. It is important for you to understand that your insurance company has the right to your records for the purpose of verifying the billed services. As a treatment team, all of Teri’s Health Services employees have access to your record. We also will frequently speak specifically about the care of clients in a treatment team setting. You have a right to ask what if anything was shared about you in these settings. We only share that information that is pertinent to client care.

Guardian Expectation
For guardians completing this form with or for your minor child or adult dependent. You agree that you will allow treatment to take place for your dependent with some privacy. As guardian, you have full access to request records from Teri’s Health Services at any time by signing a release of information for how you choose to have them released to you. In counseling it is important even for dependents to feel they have privacy in the session to share. Sharing is very important to the outcome of treatment. For this reason, we ask that guardians allow privacy. Clinicians at Teri’s Health Services agrees that if a high-risk situation or emergency presents in session clinician will bring guardians into session to address with them. If clinician does not speak to guardians outside of the set timeframes, then it is to be realized that no crisis or high-risk situations have been shared. Further, it is expected that guardians will take an active role in the healing process their dependents are enrolled in for counseling. This means that engagement at intake and treatment plan updates at minimum is expected. As a client you have a right to participate in treatment decisions and in the development and periodic review and revision of the client's treatment plan.

Confidentiality
By law, a clinician is considered and titled a "Mandated Reporter." In the state of Arizona mandated reporters include doctors, teachers, nurses, social workers, and counselors. What this means is that if you report to a clinician or healthcare worker at Teri’s Health Services anything that suggests serious and foreseeable harm to yourself or someone else we are required to break confidentiality and get you help and/or warn someone about your plans to harm them. If we are court ordered to release records, we are also required to break confidentiality. If you are court ordered to treatment the courts have a right to your record. If you are a minor (17 or younger) your parents or guardian have a right to your record and this consent will go to them to sign as well. Also, guardians will be provided s to sign as they are updated at minimum every 90 days.

Complaints
Complaints can go directly to a Clinical Supervisor listed below which you can email directly to leadership@terishealthservices.org. If you feel the complaint is not answered or attended to, you can also make complaints to AZBBHE, 1740 West Adams St. #3600 Phoenix, Az 85007, 602-542-1882. You can also make complaints to AZDHS medical licensing division. To find out who your clinician is being supervised by please see "Team" page at terishealthservices.org, your clinician’s picture, and next to their name will be listed their direct supervisor.
Teri’s Health Services takes all complaints, grievances and concerns very seriously. It is our goal to ensure your compliant, grievance, or concern is addressed and resolved as quickly as possible. If you have concerns regarding your care by you clinical team (this is where you enter the information you current have one the form).
If you have concerns regarding any other care, services, or treatment render by THS, please go to our website and complete the complaint form. You may also email our Chief Strategy and Compliance Officer, Trevor Cooke, at Trevor.cooke@terishealthservices.org. If you feel your complaint, grievance, or concern was not handled or addressed appropriately, you may file a complaint with the Arizona Department of Health Services. A written complaint can be mailed to them at:
Arizona Department of Health Services
Medical Licensing Department
150 N 18th Ave, Suite 450
Phoenix, Az 85007

Clinical Supervisors and Supervisees - How to Contact

Supervisors at Teri’s Health Services

Each of the Clinical Supervisors are listed below: Toni Watson, Teri Hourihan, and Audre Medlock. The therapists assigned under them for Clinical supervision is listed beside their name in parentheses.
Office line for supervisors: 602-358-7073 (with extensions)
Teri Hourihan PHD, LPC, NCC, teri@terishealthservices.org; ext 121
Audre Medlock PHD, LPC audre@terishealthservices.org; ext. 121: (Terrence Culver LAC, Monica Reed LMSW, Monica Lowe LMSW, Rachel Respess LAC, Carolyn Fraleigh LMSW, Tara Jones LAC, Hellen Lacefield LAC, Anamaris Medina LMSW)
Toni Watson LCSW toni@terishealthservices.org; ext. 118: (Terra Barry LMSW, Ashley McCann LAC, Anne Reynolds LMSW)
How to Contact Clinical Supervisors
When a counselor/social worker are associate licensed (LMSW/LAC) or license eligible (MSW, MA, MS, Clinical intern) they are clinically supervised by one of the three above clinical supervisors. If your insurance plan is contracted with a supervisor, certain insurance plans do allow for supervisor or incident to billing per CMS guidelines. Counselors and social workers will go over with you in session who their clinical supervisor is and how to contact their supervisor if needed to. Supervisors can all be contacted by calling also our front desk line at 602-358-7073 or emailing frontdesk@terishealthservices.org. If you are not sure who supervises your counselor social worker and would like to have that information also feel free to call or email and we will follow up with you. You can also find their above contact information to email them and contact office directly to speak to them.

Things to consider when in counseling:

Benefits: Include the opportunity to explore needs and continued treatment progress with a provider. Benefit of exploring ways to change and feeling better in your life, exploring life changes, and healing from past and current struggles. Other benefits include improved mood, increased self-esteem, increased relationship satisfaction, increased ability to set goals, increased ability to trust, improved decision making ability.

Limitations: Include when the scope of practice of the therapist does not fit the needs of the client. When this happens we will detail to you as the client the limitations of our scope of practice and offer to help refer you to another provider who is able to provide treatment to fit your needs.
Risks: Group counseling can pose a risk if you as the client share things in group with members who are not held to confidentiality. Risks in treatment include also stopping therapy before completion of the goals which can reduce the chances of fully improving. Sometimes during the start of treatment or in treatment clients can feel worse before feeling better. This happens as the issues being brought up are surfaced. Other risks may include lack of improvement, feeling temporary relief but not long term, relationships can be impacted as you change and others stay the same, difficulty stopping treatment when it is time because of the relationship built with the therapist.

No Call No Show Policy
Please cancel within 24 hours of your appointment time/date. If you need to reschedule or cancel please call 602-358-7073. Please refer to our cancelation and no show policy. Please refer to our no show and cancellation policy.

Right to Treatment
At any time, you have the right to end counseling or to refuse any treatment modality that a clinician uses at Teri’s Health Services. No penalties regarding your care will be provided for refusing counseling. As a client you have a right to participate in treatment decisions and in the development and periodic review and revision of the client's treatment plan. You have the right as the client to refuse and withdraw from treatment at any time. There are no consequences at Teri’s Health Services for withdrawing for treatment. However, if you are court ordered to be in treatment or a third party has interest in your treatment of which you signed and consented for their involvement we will have to provide an accurate and truthful update to them of your refusal and withdrawal from treatment and why. You have a right regardless, at all times, at Teri’s Health Services to refuse any treatment recommendation or to withdraw consent to treatment at any time.

Consent to Treatment
Your signature below indicates that you have had an opportunity to read and review this information and that pertinent questions regarding you have been satisfactorily answered. Furthermore, it indicates your willingness and agreement to participate in treatment.

Minors in Treatment

Purpose: Obtaining legal consent for child and adolescent psychiatric evaluations, medical, and counseling treatment.

Policy: Decisions about psychiatric, other behavioral health and medical care must be made by the child's legal guardian(s), who must be physically present to provide consent, have an opportunity to be fully informed of the evaluation process, be provided with an opportunity to ask questions, and in order for identity to be verified. In the situation of a parental separation or divorce (except in the case of one parent having sole physical and legal custody), both guardians have a right to consent and decline treatment and both parents are invited and encouraged (as they are able to) participate in the process of evaluation and treatment. If one parent retains sole physical and legal custody, this guardian MUST provide legal documentation of this in order for the psychiatric evaluation to occur as scheduled if the other guardian is declining services. Guardians have a legal right to medical records.

If services are being rendered to minors, please also provide with forms minor's birth certificate and parental ID to ensure the parents/guardians are requesting the services. If legal documents state one parent is sole guardian please provide these documents as well with enrollment forms.

Even in the case where one guardian has "final decision making" both guardians have a right to consent to treatment or deny treatment when on the court documents custody is granted to both guardians. Final decision making does not mean the guardian without final decision making is left out of treatment decisions.

At intake of a minor we will require: 

Guardian Drivers License
Insurance Card
Minor birth certificate
Signed consents by at least one guardian
If there is legal court documentation signed by a judge that states specific treatment or custody arrangements that means one parent can be left out of treatment by the other parent copies of this documentation needs to be provided in its entirety. 
If one guardian signs only and there is another legal guardian this guardian has a right to medical records if requested. Also either guardian can deny treatment at any time and determine length of treatment. If one guardian wants treatment and the other does not then treatment cannot start or continue, referrals will be offered, and treatment will pause or end. 

Treatment of Minors

Purpose: Obtaining legal consent for child and adolescent psychiatric evaluations, medical, and counseling treatment.

Policy: Decisions about psychiatric, other behavioral health and medical care must be made by the child's legal guardian(s), who must be physically present to provide consent, have an opportunity to be fully informed of the evaluation process, be provided with an opportunity to ask questions, and in order for identity to be verified. In the situation of a parental separation or divorce (except in the case of one parent having sole physical and legal custody), both guardians have a right to consent and decline treatment and both parents are invited and encouraged (as they are able to) participate in the process of evaluation and treatment. If one parent retains sole physical and legal custody, this guardian MUST provide legal documentation of this in order for the psychiatric evaluation to occur as scheduled if the other guardian is declining services. Guardians have a legal right to medical records Even in the case where one guardian has "final decision making" both guardians have a right to consent to treatment or deny treatment when on the court documents custody is granted to both guardians.
Final decision making does not mean the guardian without final decision making is left out of treatment decisions.
At intake of a minor we will require:
Guardian Drivers License
Insurance Card
Minor birth certificate
Signed consents by at least one guardian
If there is legal court documentation signed by a judge that states specific treatment or custody arrangements that means one parent can be left out of treatment by the other parent copies of this documentation needs to be provided in its entirety.
If one guardian signs only and there is another legal guardian this guardian has a right to medical records if requested. Also either guardian can deny treatment at any time and determine length of treatment. If one guardian wants treatment and the other does not then treatment cannot start or continue, referrals will be offered, and treatment will pause or end.

I understand and agree to the terms and conditions of Teri's Health Services and agree to: counseling consent, telehealth consent, privacy policy, patient rights, minor in treatment (when applicable), and our no show and cancellation policy. You can find these forms on our website at: https://www.terishealthservices.org/consenttotreat
When we update these sections we will update on the website and place the updated date on it.

Patient Rights
Patient Rights

PURPOSE:

The purpose of this policy is to ensure that all patients of Teri’s Health Services (THS) are aware of their rights and are treated with dignity, respect and consideration.

II. POLICY

This policy shall be posted conspicuously in the patient lobby on the premises. At the time of admission, the patient or the patient’s representative will receive a copy of this policy.

All THS personnel shall ensure that each patient is treated with dignity, respect, and consideration.

III. DEFINITIONS“Informed consent” means:

(i) advising a patient or a patient’s representative of a proposed treatment, surgical procedures, psychotropic drug medication, opioid, or diagnostic procedure; alternatives to the treatment, surgical procedure, psychotropic drug medication, opioid, or diagnostic procedure; and associated risks and possible complications; and

(ii) obtaining documented authorization for the proposed treatment, surgical procedure, psychotropic drug medication, opioid or diagnostic procedure from the patient or the patient’s representative. “Medical record” means communications related to a patient’s physical or mental health or condition that are recorded in any form or medium and that are maintained for purposes of patient diagnosis or treatment, including medical records that are prepared by a health care provider or by other providers. Medical records do not include materials that are prepared in connection with utilization review, peer review or quality assurance activities, including records that a health care provider prepares pursuant to A.R.S. §§ 36-441, 36-445, 36-2402 or 36-2917.

Medical records do not include recorded telephone and radio calls to and from a publicly operated emergency dispatch office relating to requests for emergency services or reports of suspected criminal activity but include communications that are recorded in any form or medium between emergency medical personnel and medical personnel concerning the diagnosis or treatment of a person.“Patient” means an individual receiving physical health services or behavioral health services from a health care institution.“Patient’s representative” means any of the following:

A patient’s legal guardian;
If a patient is less than 18 years of age and not an emancipated minor, the patient’s parent;
If a patient is 18 years of age or older or an emancipated minor, an individual acting on behalf of the patient with written consent of the patient or a patient’s legal guardian; or
A surrogate as defined in A.R.S. § 36-3201.
IV. PROCEDURE

All THS personnel shall ensure that a patient is not subjected to:

a. Abuse;b. Neglect;c. Exploitation;d. Coercion;

Title: PATIENT RIGHTS

Section:

Patient’s Rights

f. Sexual abuse;g. Sexual assault;h. Restraint or seclusion, except as allowed in A.A.C. R9-10-1012

(B) (THS does not provide restraint or seclusion of patient’s as a matter of policy);i. Retaliation for submitting a complaint to the Department or another entity; orj. Misappropriation of personal and private property by a THS personnel member, employee, volunteer, or student.

All THS personnel shall ensure that a patient or the patient’s representative:a. Except in an emergency, either consents to or refuses treatment;b. May refuse or withdraw consent for treatment before treatment is initiated;c. Except in an emergency, is informed of alternatives to a proposed psychotropic medication or surgical procedure and associated risks and possible complications of a proposed psychotropic medication or surgical procedure;d. Is informed of the following:i.

THS’ policy on health care directives CR 500.01, andii. The patient complaint process QP 200.00;e. Consents to photographs of the patient before a patient is photographed, except that a patient may be photographed when admitted to an outpatient treatment center for identification and administrative purposes; andf. Except as otherwise permitted by law, provides written consent to the release of information in the patient’s:i. Medical record, orii. Financial records.

All patients have the following rights:

1. Not to be discriminated against based on race, national origin, religion, gender, sexual orientation, age, disability, marital status, or diagnosis;

2. To receive treatment that supports and respects the patient’s individuality, choices, strengths, and abilities;

3. To receive privacy in treatment and care for personal needs;

4. To review, upon written request, the patient’s own medical record according to A.R.S. §§ 12-2293, 12-2294, and 12-2294.01;

5. To receive a referral to another health care institution if the outpatient treatment center is not authorized or not able to provide physical health services or behavioral health services needed by the patient;

6. To participate or have the patient's representative participate in the development of, or decisions concerning, treatment;

7. To participate or refuse to participate in research or experimental treatment; and

8. To receive assistance from a family member, the patient’s representative, or other individual in understanding, protecting, or exercising the patient’s rights.TitleV. RELATED POLICIESRC 300.04 – Medical Records PolicyQP 200.00 – Grievance and Complaints

 

Notice of Privacy Practices
Notice of Privacy Practices

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.

Purpose Teri’s Health Services is required by law to maintain the privacy of your health information in accordance with federal and state law. This Notice of Privacy Practices ("Notice") outlines our legal duties and privacy practices with respect to health information. We are required by law to provide you with a copy of this Notice and to notify you following a breach of your unsecured health information. We will abide by the terms of the Notice. We reserve the right to make changes to this Notice as permitted by law. We reserve the right to make the new Notice provisions effective for all health information we currently maintain, as well as any health information we receive in the future. If we make material or important changes to our privacy practices, we will promptly revise our Notice. Each version of the Notice will have an effective date listed on the first page.

If we change this Notice, you can access the revised Notice on our website (terishealthservices.org) or from the receptionist at any Teri’s Health Service location.Uses and Disclosures of Your Health InformationThe following categories describe the ways that we may use and disclose your health information without your written authorization. Treatment. We may use and disclose your health information to provide you with medical treatment and services. For example, your health information may be disclosed to physicians, nurses, or other health care providers who are involved in your care to coordinate or manage your health care services or to facilitate consultations or referrals as part of your treatment. If you are in a group home or facility we will coordinate care with these entities and provide your information of treatment to the home staff and owners. We will provide your documentation for the facility or group home to have a copy and place in their state file, use for their licensing requirements, placing your notes in their state file in house.

Payment. We may use and disclose your health information to obtain payment for the services we provide to you. For example, we may disclose your health information to seek payment from your insurance company or from another third party. We may also inform your insurance company about a treatment you are going to receive so that we obtain prior approval for the treatment or in order to determine whether your insurance company will cover the cost of the treatment.Advise of Appointments. We will call or email within 48 hours prior to appointment on the phone and email you provided.

Health Care Operations. We may use and disclose your health information to conduct certain of our business activities, which are called health care operations. These uses and disclosures are necessary to run our business and make sure our patients receive quality care. For example, we may use your health information for quality assessment activities, necessary credentialing, and for other essential activities. We may also disclose your health information to third party "business associates" that perform various services on our behalf, such as transcription, billing, and collection services. In these cases, we will enter into a written agreement with the business associates to ensure they protect the privacy of your health information.

Family Members and Friends for Care and Payment and Notification. If you verbally agree to the use or disclosure and in certain other situations, we may make the following uses and disclosures of your health information. We may disclose certain health information to your family, friends, and anyone else whom you identify as involved in your health care or who helps pay for your care; the health information we disclose would be limited to the health information that is relevant to that person's involvement in your care or payment for your care. We may also make these disclosures after your death as authorized by Arizona law unless doing so is inconsistent with any prior expressed preference. We may use or disclose your information to notify or assist in notifying a family member, personal representative, or any other person responsible for your care regarding your location, general condition, or death. We may also use or disclose your health information to disaster-relief organizations so that your family or other persons responsible for your care can be notified about your condition, status, and location.

Required by Law. We may disclose your health information when required by law to do so.Public Health Reporting. We may disclose your health information to public health agencies as authorized by law. For example, we may report certain communicable diseases to the state’s public health department.

Reporting Victims of Abuse or Neglect. We may disclose health information to the appropriate government authority if we believe you have been the victim of abuse, neglect, or domestic violence. We only make this disclosure if you agree or when we are required or authorized by law to make the disclosure. Licensed professionals are required report abuse and neglect, breaking confidentiality to ensure safety.Health Care Oversight. We may disclose your health information to authorities and agencies for oversight activities allowed by law, including audits, investigations, inspections, licensure and disciplinary actions, or civil, administrative, and criminal proceedings, as necessary for oversight of the health care system, government programs, and civil rights laws.

Legal Proceedings. We may disclose your health information in the course of certain administrative or judicial proceedings. For example, we may disclose your health information in response to a court order.Law Enforcement. We may disclose your health information to a law enforcement official for certain specific purposes, such as reporting certain types of injuries. In addition, if you report you are in danger or are going to endanger someone else we may send police to complete a welfare check or attend to the threats to others.Deceased Persons. We may disclose your health information to coroners, medical examiners, or funeral directors so that they can carry out their duties.

Organ and Tissue Donation. We may use and disclose your health information to organizations that handle procurement, transplantation, or banking of organs, eyes, or tissues.Research. Under certain circumstances, we may disclose your health information to researchers who are conducting a specific research project. For certain research activities, an Institutional Review Board (IRB) or Privacy Board may approve uses and disclosures of your health information without your authorization.

To Avert a Serious Threat to Health or Safety. If there is a serious threat to your health and safety or the health and safety of the public or another person, we may use and disclose your health information in a very limited manner to someone able to help lessen the threat.

Specialized Government Functions. In certain circumstances, HIPAA authorizes us to use or disclose your health information to authorized federal officials for the conduct of national security activities and other specialized government functions.Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may disclose your health information to the correctional institution or law enforcement official to assist them in providing you health care, protecting your health and safety or the health and safety of others, or providing for the safety of the correctional institution.

Minors: If you are a minor (17 years old or younger) your guardian has full rights to your charts including all documentation by any provider who provides treatment to you. We are also required to have your guardians sign all paperwork for you to receive treatment and continue treatment, to take medications, to make changes to your treatment, and discharge planning.

Workers’ Compensation. We may disclose your health information as necessary to comply with laws related to workers’ compensation or other similar programs. Please be aware that Arizona and other federal laws may have additional requirements that we must follow or may be more restrictive than HIPAA on how we use and disclose certain of your health information. If there are specific more restrictive requirements, even for some of the purposes listed above, we may not disclose your health information without your written permission as required by such laws. For example, we will not disclose your mental health or alcohol or drug abuse treatment records without obtaining your written permission, except as permitted by Arizona and federal law. We may also be required by law to obtain your written permission to use and/or disclose your HIV, STD, or other communicable disease related information, developmental disability information, or your genetic test results.

Other Uses and Disclosures specific written authorization. Some examples include:• Psychotherapy Notes: We will not use and disclose your psychotherapy notes without your written authorization except as otherwise permitted by law.

Marketing: We will not use or disclose your health information for marketing purposes without your written authorization except as otherwise permitted by law.

Sale of Your Health Information: We will not sell your health information without your written authorization except as otherwise permitted by law. If you change your mind after authorizing a use or disclosure of your health information, you may withdraw your permission by revoking the authorization. However, your decision to revoke the authorization will not affect or undo any use or disclosure of your health information that occurred before you notified us of your decision, or any actions that we have taken based upon your authorization.

To revoke an authorization, you must notify us in writing to:Teri’s Health Services14040 N. Cave Creek Rd. Suite 210 Phoenix, Az 85022

Fundraising. We do not utilize your information for any type of fundraising.

Your Right Regarding Your Health Information

This section describes your rights regarding the health information we maintain about you. All requests or communications to us to exercise your rights discussed below must be submitted in writing to:

Teri’s Health Services14040 N. Cave Creek Rd. Suite 210Phoenix, Az 85022

Right to Request Restrictions. You have the right to request restrictions on how your health information is used or disclosed for treatment, payment, or health care operations activities. However, we are not required to agree to your requested restriction, unless that restriction is regarding disclosure of health information to your health insurance company and:

(1) the disclosure is for the purpose of carrying out payment or health care operations and is not otherwise required by law; and

(2) the health information pertains solely to a health care item or service for which you or another person (other than your health insurance company) paid for in full. If we agree to your requested restriction, we will comply with your request unless the information is needed to provide you emergency treatment.

Right to Request Confidential Communications. You have the right to request that we communicate your health information to you in a certain manner or at a certain location. For example, you may wish to receive information about your health status through a written letter sent to a private address. We will grantreasonable requests. We will not ask you the reason for your request.Right to Inspect and Copy. You have the right to inspect and receive a copy of your health information.We may charge you a fee as authorized by law to meet your request. You may request access to your health information in a certain electronic form and format, if readily producible, or, if not readily producible, in a mutually agreeable electronic form and format. Further, you may request in writing that we transmit such a copy to any person or entity you designate. Your written, signed request must clearly identify such designated person or entity and where you would like us to send the copy. You will be required to sign a release of information for self before documentation will be released to you. We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to your health information, you may request that the denial be reviewed by a licensed health care professional chosen by us. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review. If you are in a facility or group home setting your request for documentation completed by Teri’s Health Services can only be requested and provided by Teri’s Health Services not directly by your group home or facility placement.Right to Amend. You have a right to request that we amend or correct your health information that you believe is incorrect or incomplete. For example, if your date of birth is incorrect, you may request that the information be corrected. To request a correction or amendment to your health information, you must make your request in writing and provide a reason for your request. You have the right to request an amendment for as long as the information is kept by or for us. Under certain circumstances we may deny your request. If your request is denied, we will provide you with information about our denial and how you can file a written statement of disagreement with us that will become part of your medical record.

Right to an Accounting of Disclosures. You have the right to request an accounting of disclosures we make of your health information. Please note that certain disclosures need not be included in the accounting we provide to you. Your request must state a time period which may not go back further than six years. You will not be charged for this accounting, unless you request more than one accounting per year, in which case we may charge you a reasonable cost-based fee for providing the additional accounting(s). We will notify you of the costs involved and give you an opportunity to withdraw or modify your request before any costs have been incurred.

Right to a Paper Copy of This Notice. You have the right to receive a paper copy of this Notice at any time, even if you previously agreed to receive this Notice electronically. A paper copy of this Notice can be obtained from the receptionist Teri's Health Services.

Complaints. You have the right to file a complaint if you believe your privacy rights have been violated. If you would like to file a complaint about our privacy practices, you can do so by sending a letter outlining your concerns to the leadership@terishealthservices.org. 

You also have the right to complain to the Secretary of the United States Department of Health and Human Services. You will not be penalized or otherwise retaliated against for filing a complaint.

 

Patient Rights: https://www.terishealthservices.org/patient-rights

Notice of Privacy Pratices: https://www.terishealthservices.org/notice-of-privacy-practices

1. I authorize Teri's Health Services to perform the treatment or necessary procedure to me/ or to my (for Parent/Guardian) dependent.
2. I confirm that I read the patient rights, disclosures, privacy practices, notice of health information, consent for treatment, financial agreement, consent and I agree with them.
3. I understand that I can decline treatment at anytime.
4. I understand that consent to treatment is ongoing and can be updated by either party.
5. I acknowledge that all information I provided in this form is true and accurate.

Adults (18 and above): provide drivers license or state ID (passports permitted), insurance card(s) front and back of each card. If you are using EAP insurance and have the authorization letter please include this letter. If you do not have the authorization letter we can request from the plan listed.

Minors (17 and under): One guardian drivers license or state ID (passports permitted), insurance card(s) front and back of each card. Birth Certificate of child or guardianship paperwork. We require one of these forms of identification to ensure the minor is accompanied by a legal guardian. If you are using EAP insurance and have the authorization letter please include this letter. If you do not have the authorization letter we can request from the plan listed. If you have any pertinent guardianship paperwork please include this.

Adult Dependent: Adult client and One guardian drivers license or state ID (passports permitted), insurance card(s) front and back of each card. If you are using EAP insurance and have the authorization letter please include this letter. If you do not have the authorization letter we can request from the plan listed. If you have any pertinent guardianship paperwork please include this.

Name of Authorized Team Member:

 

Signature of Authorized Team Member: 

 

Date of Signature: