Online Consent for Treatment & Agreement to Pay Form

If you are NOT a current client or on our waiting list, please fill out our referral form for services.  Click here for our personal referral form or here for professional referral form.


CONSENT FOR TELEMENTAL HEALTH SERVICES & AGREEMENT TO PAY

WHAT IS TELEMENTAL HEALTHCARE?

Telemental health is a subset of telehealth services that uses online, interactive videoconferencing software to provide mental health services from a distance. Telemental health includes terms such as telepsychology, telebehavioral health, online counseling and distance counseling.  Telehealth does not include the use of fax, email or videotelephony products such as FaceTime and Skype.

WHAT ARE THE POTENTIAL RISKS OF TELEMENTAL HEALTH?

  • Technological failures such as unclear video, loss of sound, poor internet connection or loss of internet connection.
  • Nonverbal cues might be more difficult to observe and interpret during therapist and client interactions.
  • May electronically share and sign practice and consent forms and accept risks that come with transmitting information and documents over the internet.

WHAT ARE THE BENEFITS OF TELEMENTAL HEALTH?

  • Less limited by geographical location and transportation concerns. Decrease in travel time and ability to meet virtually during inclement weather conditions.
  • Ability to participate in treatment from your own home or other environment where you feel safe, secure and comfortable.
  • Ability to participate in treatment from your home or other environment when physical needs/disabilities may prevent you from coming to the office.

ELIGIBILITY

Family Solutions, PLLC and its clinical staff are only able to provide telemental health services to clients located in North Carolina where we hold valid licenses as mental health professionals.

Telemental heath may not be the most effective form of treatment for certain individuals or presenting problems. If it is believed the client would benefit from another form of service (e.g. face-to-face sessions) or another provider, an appropriate recommendation will be made.

PRIVACY AND CONFIDENTIALITY

The current laws that protect privacy and confidentiality also apply to telemental health services. Exceptions to confidentiality are described in the Notice of Privacy Practices. All existing laws regarding client access to mental health information and copies of mental health records apply.

Telemental health services are provided through the HIPAA compliant, secure software Clocktree. No permanent video or voice recordings are kept from telemental health sessions. Clients may not record or store videoconference sessions.

CLIENT EXPECTATIONS DURING TELEMENTAL HEALTH SESSIONS

You’ll need the following to join a telemental health session with your clinician:

  • Mac/PC/Chromebook, smart phone, or tablet with camera, microphone, and speakers
  • An internet connection with a bandwidth of at least 750kb/s download and upload speeds. We recommend an Ethernet cable over Wifi when possible to ensure you receive the best possible connection through your internet provider.
  • It may be helpful to shut down all background applications to ensure your telemental health session receives the majority of your internet’s bandwidth, especially applications that use your camera.
  • Access to Google Chrome, Mozilla Firefox or Safari (latest release versions) web browsers.
  • Proper lighting and seating to ensure a clear image or each participant’s face.
  • Dress and environment appropriate to an in-office visit.
  • Engage in sessions in a private location where you cannot be heard by others.
  • Only agreed upon participants will be present and the presence of individuals unapproved by both parties will be cause for termination of the session.
  • Client must disclose the physical address of their location at the start of the session. Unknown locations will be cause for termination of the session.
  • Client shall provide a phone number where they can be reached in the event of service disruption.

EMERGENCY PROTOCOL

Client is to provide the name and contact information for a local emergency contact. In the case of a mental health emergency during a telemental health session where a client is deemed at imminent risk of harming themselves or someone else, the therapist engaged in the session will contact the client’s local emergency services and/or 911.

Release of information forms will be completed for necessary entities unless confidentiality must be breached to protect the safety of the client or other identified individual.

AGREEMENT TO PAY:  INSURANCE, SELF-PAY RATES AND PAYMENT PROCEDURES

Telemental health is not covered by all insurance companies, plans and policies. Clients are responsible for calling their specific policy holder to receive verification that telemental health is a covered service on their policy prior to engaging in telemental health services with us.  

Family Solutions accepts and processes insurance payments through some insurance providers. If you are using your insurance to pay for our services, then we will:

(1) Expect and accept payment of your co-payment, co-insurance or self-pay fee amount at the time of service;
(2) File your claim with the insurance provider;
(3) Receive payment from your insurance provider;
(4) If there is a credit on your account, you will be provided a refund promptly or can be applied to future charges

Family Solutions files insurance as a courtesy to you, and that you (not your insurance company) are ultimately responsible for your bill. If your insurance company denies a claim filed on your behalf, then you are responsible to pay Family Solutions for the difference between the standard rate and the amount previously paid as copay unless approved otherwise by owners of Family Solutions.  Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request.  Your insurance benefit is a contract between you and your insurance company; we are not party to that contract.  

 I agree to (1) allow Family Solutions to bill my insurance directly for services provided under the Outpatient Services Agreement; (2) give Family Solutions permission to release any information the insurance company may require in order to process payment; appoint Family Solutions as my authorized representative to act for me in obtaining payment; (3) assign all of my rights to claims and payment by my insurance to Family Solutions; and (4) agree to assist with the claims process as required by Family Solutions or my insurance provider. I understand that if my insurance plan requires that I meet a deductible amount prior to coverage by insurance, I will be responsible for the full session fee until the required deductible amount has been met. I acknowledge that not all issues, conditions, and problems dealt within psychotherapy are reimbursed by insurance companies. 

Our self-pay rate for telemental health is the same as the in-session (face-to-face) rate of $100/session; these sessions are 53 minutes in length.  Intake assessment is $120. 

All clients must pay for telemental health services using a valid credit card. This credit card is placed on file in our electronic health record for security purposes. It is up to the client to notify Family Solutions, PLLC of any changes to their credit card information before a new telemental health session begins.

NOTICE OF RATES FOR COURT APPEARANCE & RECORD PREPARATION RELATED SERVICES

I have read and understand the charges, rates and how fees are collected for court appearances and record preparation.  See entire Notice Form for more details.

YOUR RIGHTS AS A CLIENT

As a client, you have many rights.  Understanding your rights will help you get the best possible care.  Knowing you rights can help you make better decisions about your care and resolve any problems that may occur.  You always have the right to ask questions and get the information you need to make the best decision for you.  A detailed description of rights of clients and grievance procedure and policy in contracted facilities of the Local MCO (Managed Care Organization) MH/MR/SA Program has been provided to me as well as any possible restrictions.  Along with the explanation of rights and restrictions, I have had the opportunity to ask questions.  Click here to view your Clients Rights.

TREATMENT PLAN CONSENT

My signature below notes I have had input into this plan and I agree with this plan.  

CONSENT FOR TELEMENTAL HEALTH TREATMENT

I hereby consent to engage in telemental health services with Family Solutions, PLLC and any member of its clinical staff. I understand that telemental health includes mental health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, and/or data communication of my medical and mental health information. I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment. 


Thank you for signing our forms!

We have received your consent for treatment and agreement to pay forms.  Our intake staff will contact you shortly via email or phone call. 

If you have not heard from us within two business, please call us so we can stay on top of it. 

Family Solutions’ Intake Staff

231 N Spring St

Greensboro, NC 27401

336-899-8800 ext 10 

intake@famsolutions.org