INFORMED CONSENT FOR ASSESSMENT AND TREATMENT
I understand that while psychotherapy and counseling may provide significant benefits, they may also pose risks. Psychotherapy may elicit uncomfortable thoughts and feelings or may lead to the recall of troubling memories. I also understand that not everyone improves with treatment but that my Plan Your Recovery (PYR) providers will recommend to me other courses of treatment and/or other providers if they believe that I am not improving.
I understand that a range of mental health professionals, some of whom are in training, provide PYR services. All professionals-in-training are supervised by licensed staff.
I understand that some services are delivered in a group setting and that group therapy can confer benefits such as increased peer support, and knowledge developed from shared experience. I understand that I am responsible for keeping the identity of all group members and all information shared in group settings confidential. I understand that despite the expectation that participation in group involves mutual confidentiality among group members, group treatment increases the risk for disclosure of private health information. I understand that my participation in group treatment is voluntary and may be discontinued at any time.
If I have any questions regarding this consent form or about the services offered at PYR, I may discuss them with my therapist. I have read and understand the above. I consent to participate in the evaluation and treatment offered to me by PYR. I understand that I may stop treatment at any time.
Signature:
INFORMED CONSENT FOR TELEHEALTH VISITS
Telehealth involves the use of electronic communications to enable healthcare providers to provide services to patients using live two-way audio and video.The electronic communication systems used by Plan Your Recovery, LLC (hereafter 'Plan Your Recovery') incorporate network and software security protocols to protect the confidentiality of patient identification and include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.
Expected Benefits:
- Improved access to care by enabling you to remain in your home while Plan Your Recovery providers provide you services.
- More efficient care evaluation and management.
Possible Risks:
- Delays in evaluation and treatment could occur due to deficiencies or failures of the equipment and technologies.
- In rare events, our provider may determine that the telehealth is insufficient to address your mental health problems, thus necessitating a rescheduled telehealth visit or an in-office visit with a healthcare provider.
- In very rare events, security protocols could fail, causing a breach of privacy of personal medical information.
- In rare events, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors.
If you need to receive follow-up care, assistance in the event of an adverse reaction to the treatment, or in the event of an inability to communicate as a result of a technological or equipment failure, please contact 314-467-8393.
By signing below, you acknowledge that you understand and agree with the following:
- I hereby consent to receiving Plan Your Recovery's services via telehealth technologies. I understand that Plan Your Recovery and its providers offer telehealth-based services, but that these services do not replace the relationship between me and my primary care doctor. I also understand it is up to the Plan Your Recovery provider to determine whether or not my specific clinical needs are appropriate for a telehealth encounter.
- I understand that making a request for treatment (by completing a telehealth visit and making payment) does not in and of itself create a duty of care or create a practitioner-patient relationship.
- I understand that federal and state law requires health care providers to protect the privacy and the security of health information. I understand that Plan Your Recovery will take steps to make sure that my health information is not seen by anyone who should not see it.
- I understand there is a risk of technical failures during the telehealth encounter beyond the control of Plan Your Recovery. I agree to hold harmless Plan Your Recovery for delays in evaluation or for information lost due to such technical failures.
- I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time, without affecting my right to future care or treatment. I understand that I may suspend or terminate use of the telehealth services at any time for any reason or for no reason. I understand that if I am experiencing a medical emergency, that I will be directed to dial 9-1-1 immediately and that the Plan Your Recovery providers are not able to connect me directly to any local emergency services.
- I understand that alternatives to telehealth consultation, such as in-person services are available to me, and in choosing to participate in a telehealth consultation, I understand that some parts of the services involving tests may be conducted by individuals at my location, or at a testing facility, at the direction of the Plan Your Recovery provider (e.g. labs or bloodwork).
- I understand that I may expect the anticipated benefits from the use of telehealth in my care, but that no results can be guaranteed or assured.
- I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes.
- I understand that if I participate in a consultation, that I have the right to request a copy of my medical records which will be provided to me at reasonable cost of preparation, shipping and delivery.
Signature:
Our Privacy Policy
Plan Your Recovery, its facilities, and all associates are committed to providing you with quality behavioral healthcare services. An important part of that commitment is protecting your health information according to applicable law. This notice (“Notice of Privacy Practices”) describes your rights and our duties under Federal Law. Protected health information (“PHI”) is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition; the provision of healthcare services; or the past, present, or future payment for the provision of healthcare services to you.
Our Duties
We are required by law to maintain the privacy of your PHI; provide you with notice of our legal duties and privacy practices with respect to your PHI; and to notify you following a breach of unsecured PHI related to you. We are required to abide by the terms of this Notice of Privacy Practices. This Notice of Privacy Practices is effective as of the date listed on the first page of this Notice of Privacy Practices. This Notice of Privacy Practices will remain in effect until it is revised. We are required to modify this Notice of Privacy Practices when there are material changes to your rights, our duties, or other practices contained herein.
We reserve the right to change our privacy policy and practices and the terms of this Notice of Privacy Practices, consistent with applicable law and our current business processes, at any time. Any new Notice of Privacy Practices will be effective for all PHI that we maintain at that time. Notification of revisions of this Notice of Privacy Practices will be provided as follows:
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Upon request;
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Electronically via our website or via other electronic means; and
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As posted in our place of business.
In addition to the above, we have a duty to respond to your requests (e.g. those corresponding to your rights) in a timely and appropriate manner. We support and value your right to privacy and are committed to maintaining reasonable and appropriate safeguards for your PHI.
Confidentiality of Substance Use Disorder Records
The confidentiality of substance use disorder patient records maintained by us is protected by Federal law and regulations. Generally, we may not say to a person outside the treatment center that you are a patient of the treatment center, or disclose any information identifying you as a person with a substance use disorder unless:
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You consent in writing (as discussed below in “Authorization to Use or Disclose PHI”);
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The disclosure is allowed by a court order (as discussed below in “Uses and Disclosures”); or
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The disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit, or program evaluation (as discussed below in “Uses and Disclosures”).
Violation of the Federal law and regulations by the treatment center is a crime. Suspected violations may be reported to appropriate authorities in accordance with Federal regulations.
Federal law and regulations do not protect any information about a crime committed by you either at the treatment center or against any person who works for the treatment center or about any threat to commit such a crime (as discussed below in “Uses and Disclosures”).
Federal laws and regulations do not protect any information about suspected child abuse or neglect from being reported under State law to appropriate State or local authorities (as discussed below in “Uses and Disclosures”).
See 42 U.S.C. 290dd-3 and 42 U.S.C. 290ee-3 for Federal laws and 42 CFR part 2 for Federal regulations.
Uses and Disclosures
Uses and disclosures of your PHI may be permitted, required, or authorized. The following categories describe various ways that we use and disclose PHI.
Among Plan Your Recovery Personnel. We may use or disclose information between or among personnel having a need for the information in connection with their duties that arise out of the provision of diagnosis, treatment, or referral for treatment of substance use disorders, provided such communication is within the treatment center. For example, our staff, including doctors, nurses, and clinicians, will use your PHI to provide your treatment care. Your PHI may be used in connection with billing statements we send you and in connection with tracking charges and credits to your account. Your PHI will be used to check for eligibility for insurance coverage and prepare claims for your insurance company where appropriate. We may use and disclose your PHI in order to conduct our healthcare business and to perform functions associated with our business activities, including accreditation and licensing.
Secretary of Health and Human Services. We are required to disclose PHI to the Secretary of the U.S. Department of Health and Human Services when the Secretary is investigating or determining our compliance with the HIPAA Privacy Rules.
Business Associates. We may disclose your PHI to Business Associates that are contracted by us to perform services on our behalf which may involve receipt, use or disclosure of your PHI. All of our Business Associates must agree to: (i) Protect the privacy of your PHI; (ii) Use and disclose the information only for the purposes for which the Business Associate was engaged; (iii) Be bound by 42 CFR Part 2; and (iv) if necessary, resist in judicial proceedings any efforts to obtain access to patient records except as permitted by law.
Crimes on Premises. We may disclose to law enforcement officers information that is directly related to the commission of a crime on the premises or against our personnel or to a threat to commit such a crime.
Reports of Suspected Child Abuse and Neglect. We may disclose information required to report under state law incidents of suspected child abuse and neglect to the appropriate state or local authorities. However, we may not disclose the original patient records, including for civil or criminal proceedings which may arise out of the report of suspected child abuse and neglect, without consent.
Court Order. We may disclose information required by a court order, provided certain regulatory requirements are met.
Emergency Situations. We may disclose information to medical personnel for the purpose of treating you in an emergency.
Audit and Evaluation Activities. We may disclose your information to persons conducting certain audit and evaluation activities, provided the person agrees to certain restrictions on disclosure of information.
Reporting of Death. We may disclose your information related to cause of death to a public health authority that is authorized to receive such information.
Authorization to Use or Disclose PHI
Other than as stated above, we will not use or disclose your PHI other than with your written authorization. Subject to compliance with limited exceptions, we will not use or disclose psychotherapy notes, use or disclose your PHI for marketing purposes, or sell your PHI unless you have signed an authorization. If you or your representative authorize us to use or disclose your PHI, you may revoke that authorization in writing at any time to stop future uses or disclosures. We will honor oral revocations upon authenticating your identity until a written revocation is obtained. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect.
Patient/Client Rights
The following are the rights that you have regarding PHI that we maintain about you. Information regarding how to exercise those rights is also provided. Protecting your PHI is an important part of the services we provide you. We want to ensure that you have access to your PHI when you need it and that you clearly understand your rights as described below.
Right to Notice
You have the right to adequate notice of the uses and disclosures of your PHI, and our duties and responsibilities regarding the same, as provided for herein. You have the right to request both a paper and electronic copy of this Notice. You may ask us to provide a copy of this Notice at any time. You may obtain this Notice on our website at www.planyourrecovery.com or from facility staff or our director.
Right of Access to Inspect and Copy
You have the right to access, inspect and obtain a copy of your PHI for as long as we maintain it as required by law. This right may be restricted only in certain limited circumstances as dictated by applicable law. All requests for access to your PHI must be made in writing. Under a limited set of circumstances, we may deny your request. Any denial of a request to access will be communicated to you in writing. If you are denied access to your PHI, you may request that the denial be reviewed. Another licensed health care professional chosen by Plan Your Recovery will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the decision made by the designated professional. If you are further denied, you have a right to have a denial reviewed by a licensed third-party healthcare professional (i.e. one not affiliated with us). We will comply with the decision made by the designated professional.
We may charge a reasonable, cost-based fee for the copying and/or mailing process of your request. As to PHI which may be maintained in electronic form and format, you may request a copy to which you are otherwise entitled in that electronic form and format if it is readily producible, but if not, then in any readable form and format as we may agree (e.g. PDF). Your request may also include transmittal directions to another individual or entity.
Right to Amend
If you believe the PHI we have about you is incorrect or incomplete, you have the right to request that we amend your PHI for as long as it is maintained by us. The request must be made in writing and you must provide a reason to support the requested amendment. Under certain circumstances we may deny your request to amend, including but not limited to, when the PHI: 1. Was not created by us; 2. Is excluded from access and inspection under applicable law; or 3. Is accurate and complete. If we deny amendment, we will provide the rationale for denial to you in writing. You may write a statement of disagreement if your request is denied. This statement will be maintained as part of your PHI and will be included with any disclosure. If we accept the amendment we will work with you to identify other healthcare stakeholders that require notification and provide the notification.
Right to Request an Accounting of Disclosures
We are required to create and maintain an accounting (list) of certain disclosures we make of your PHI. You have the right to request a copy of such an accounting during a time period specified by applicable law prior to the date on which the accounting is requested (up to six years). You must make any request for an accounting in writing. We are not required by law to record certain types of disclosures (such as disclosures made pursuant to an authorization signed by you), and a listing of these disclosures will not be provided. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests. We will notify you of the fee to be charged (if any) at the time of the request.
Right to Request Restrictions
You have the right to request restrictions or limitations on how we use and disclose your PHI for treatment, payment, and operations. We are not required to agree to restrictions for treatment, payment, and healthcare operations except in limited circumstances as described below. This request must be in writing. If we do agree to the restriction, we will comply with the restriction going forward, unless you take affirmative steps to revoke it or we believe, in our professional judgment, that an emergency warrants circumventing the restriction in order to provide the appropriate care or unless the use or disclosure is otherwise permitted by law. In rare circumstances, we reserve the right to terminate a restriction that we have previously agreed to, but only after providing you notice of termination.
Out-of-Pocket Payments
If you have paid out-of-pocket (or in other words, you or someone besides your health plan has paid for your care) in full for a specific item or service, you have the right to request that your PHI with respect to that item or service not be disclosed to a health plan for purposes of payment or healthcare operations, and we are required by law to honor that request unless affirmatively terminated by you in writing and when the disclosures are not required by law. This request must be made in writing.
Right to Confidential Communications
You have the right to request that we communicate with you about your PHI and health matters by alternative means or alternative locations. Your request must be made in writing and must specify the alternative means or location. We will accommodate all reasonable requests consistent with our duty to ensure that your PHI is appropriately protected.
Right to Notification of a Breach
You have the right to be notified in the event that we (or one of our Business Associates) discover a breach involving unsecured PHI.
Right to Voice Concerns
You have the right to file a complaint in writing with us or with the U.S. Department of Health and Human Services if you believe we have violated your privacy rights. Any complaints to us should be made in writing to our director at the address listed below We will not retaliate against you for filing a complaint.
Questions, Requests for Information, and Complaints
For questions, requests for information, more information about our privacy policy or concerns, please contact us. Our director can be contacted at:
Ned Presnall, LCSW
Plan Your Recovery, LLC
9904 Clayton Road, STE 135
Saint Louis, MO 63124
npresnall@planyourrecovery.com
We support your right to privacy of your Protected Health Information. You will not be retaliated against in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.
If you believe your rights have been violated and would like to submit a complaint directly to the U.S. Department of Health & Human Services, then you may submit a formal written complaint to the following address:
U.S. Department of Health & Human Services
Office for Civil Rights
200 Independence Avenue, S.W.
Washington, D.C. 20201
877-696-6775
OCRMail@hhs.gov
www.hhs.gov
Signature:
FINANCIAL CONTRACT
Card on File: I understand that Plan Your Recovery (PYR) keeps my credit card on file to charge me for the services I receive. This card is kept in a secure system that prevents PYR staff members from reading the card number (apart from the last four digits) once it has been input into the system. I understand that if I opt not to keep a card on file, I must make other payment arrangements for PYR for services rendered to me and/or my family member(s).
Laboratory Tests: PYR clinicians and staff regularly administer instant urine drug screens in the course of clinical care. Often instant results are sufficient for clinical assessment and decision making. When a clinician determines that confirmation testing for the presence of a substance or quantitative level is needed to inform clinical care, the urine sample will be sent to a 3rd party laboratory for testing. I understand that I will be charged for instant and confirmatory testing provided as part of my treatment.
General Pricing for in-person and telehealth services (subject to change):
| • Individual or Family therapy |
$60 - $250 (per 50 minute session, depending on clinician) |
| • Group Therapy |
$50 (per 60 minute group) |
| • Instant Urine Drug Screen: |
$15 |
| • Confirmation testing: |
$26 - $47.50 per substance tested, depending on substance |
Cancellations: Our office will make every effort to see you promptly when you need to be seen, to not overbook appointments and keep time in the waiting room to a minimum. Please be advised that you will be charged the regular session fee for missed appointments or appointments cancelled with less than 24 hours notice.
I hereby authorize PYR to charge my card for any services rendered to me, including my therapist appointments, groups, instant laboratory tests, confirmatory lab tests, and any late or missed appointments.
Signature:
COURTESY INSURANCE BILLING EXPLANATION AND AUTHORIZATION
Plan Your Recovery, LLC (PYR) does not contract with insurance carriers to provide in-network services. Clients must pay for program services directly to PYR at the time of service. Some insurance carriers will reimburse clients for services received and paid for out-of-network.
As a courtesy to our clients, we will, upon request, bill insurance for services received as part of our program. We do not guarantee any level of reimbursement. Insurance carriers may provide reimbursement for all, some, or none of the services we render. Services rendered by professional-in-training may be rejected due to their training status. For information about your out-of-network benefits, please contact your insurance company at the Member Services number listed on the back of your card.
If you would like us to submit courtesy out-of-network insurance claims, please complete the following authorization. Please also email a photo/scan of your insurance card to insurance@planyourrecovery.com.
AUTHORIZATION
I understand that my (or my dependent’s) diagnosis will be provided to my insurer along with identifying information and services rendered. I understand that the insurance company may request additional clinical information regarding the assessment or treatment, and I authorize PYR to provide such information, as requested.
The purpose of this disclosure is to seek out-of-network insurance reimbursement for services provided by PYR.
This consent is subject to revocation at any time except to the extent that Plan Your Recovery, LLC has already taken action in reliance on it. If not previously revoked, this consent will terminate one year after my last appointment at Plan Your Recovery, LLC.
I have read the explanation above and hereby authorize PYR to disclose my (or my dependent’s) private health information to bill my insurance company/employee assistance program for treatment received through PYR. I understand that PYR does not guarantee any level of insurance reimbursement and that I am responsible for all program fees.
PLEASE CHECK ONLY ONE OF THE OPTIONS BELOW.
I have read the explanation above and hereby authorize PYR to disclose my private health information in order to bill my insurance company/employee assistance program for treatment received through PYR. I understand that PYR does not guarantee any level of insurance reimbursement and that I am responsible for all program fees.
I DO NOT want PYR to bill my insurance for services.
Signature:
Plan your Recovery, LLC
9890 Clayton Road, Suite 100
Saint Louis, MO 63124
314-467-8393