This form is called a Consent for Services (the "Consent"). Your nurse practitioner, therapist, counselor, psychologist, doctor, or other health professional ("Provider") has asked you to read and sign this Consent before you begin care at Sunshine Health. Please review the information. If you have any questions, contact your Provider.
THE PROCESS of Care
Healthcare is a collaborative process where you and your Provider will work together on equal footing to achieve mutually defined goals. This means that you will follow a defined process supported by scientific evidence, where you and your Provider have specific rights and responsibilities. Better outcomes are often associated with a good relationship between a client and their Provider. To foster the best possible relationship, it is important you understand as much about the process before deciding to commit.
TELEHEALTH SERVICES
To use telehealth, you need an internet connection and a device with a camera for video such as a smartphone. Your Provider can explain how to log in and use any features on the telehealth platform. There are some risks and benefits to using telehealth:
• Risks
• Privacy and Confidentiality.
You may be asked to share personal information with the telehealth platform to create an account, such as your name, date of birth, location, and contact information. Your Provider carefully vets any telehealth platform to ensure your information is secured to the appropriate standards.
Benefits
• Flexibility. You can attend therapy wherever is convenient for you.
• Ease of Access. You can attend telehealth sessions without worrying about traveling, meaning you can schedule less time per session and can attend therapy during inclement weather or illness.
Recommendations
• Make sure that other people cannot hear your conversation or see your screen during sessions.
• Do not use video or audio to record your session unless you ask your Provider for their permission in advance.
• Make sure to let your Provider know if you are not in your usual location before starting any telehealth session.
CONFIDENTIALITY
Your Provider will not disclose your personal information without your permission unless required by law. If your Provider must disclose your personal information without your permission, your Provider will only disclose the minimum necessary to satisfy the obligation. However, there are a few exceptions.
• Your Provider may speak to other healthcare providers involved in your care.
• Your Provider may speak to emergency personnel.
• If you report that another healthcare provider is engaging in inappropriate behavior, your Provider may be required to report this information to the appropriate licensing board. Your Provider will discuss making this report with you first and will only share the minimum information needed while making a report. If your Provider must share your personal information without getting your permission first, they will only share the minimum information needed. There are a few times that your Provider may not keep your personal information confidential.
• If your Provider believes there is a specific, credible threat of harm to someone else, they may be required by law or may make their own decision about whether to warn the other person and notify law enforcement. The term specific, credible threat is defined by state law. Your Provider can explain more if you have questions.
• If your Provider has reason to believe a minor or elderly individual is a victim of abuse or neglect, they are required by law to contact the appropriate authorities.
• If your Provider believes that you are at imminent risk of harming yourself, they may contact law enforcement or other crisis services. However, before contacting emergency or crisis services, your Provider will work with you to discuss other options to keep you safe.
RECORD KEEPING
Your Provider is required to keep records about your treatment. These records help ensure the quality and continuity of your care, as well as provide evidence that the services you receive meet the appropriate standards of care. Your records are maintained in a secure electronic health record.
COMMUNICATION
You can reach the Sunshine Health office one of two ways below.
• Texting/Email using the number 4094491989 or email SunshineCare2023@gmail.com
*PLEASE UNDERSTAND PRESCRIPTIONS OR CARE WILL NOT BE GIVEN VIA TEXT OR EMAIL AND REQUIRE AN APPOINTMENT*
• Texting and email are not secure methods of communication and should not be used to communicate personal information. You may choose to receive appointment reminders via text message or email. You should carefully consider who may have access to your text messages or emails before choosing to communicate via either method.
Social Media/Review Websites
• If you try to communicate with your Provider via these methods, they will not respond. This includes any form of friend or contact request, @mention, direct message, wall post, and so on. This is to protect your confidentiality and ensure appropriate boundaries in therapy.
• Your provider may publish content on various social media websites or blogs. There is no expectation that you will follow, comment on, or otherwise engage with any content. If you do choose to follow your Provider on any platform, they will not follow you back.
• If you see your Provider on any form of review website, it is not a solicitation for a review. Many such sites scrape business listings and may automatically include your Provider. If you choose to leave a review of your Provider on any website, they will not respond. While you are always free to express yourself in the manner you choose, please be aware of the potential impact on your confidentiality prior to leaving a review. It is often impossible to remove reviews later, and some sites aggregate reviews from several platforms leading to your review appearing other places without your knowledge.
FEES AND PAYMENT FOR SERVICES
You are required to pay for services and other fees. You will be provided with these costs prior to beginning care and should confirm with your insurance if part or all these fees may be covered. You should also know about the following:
• No-Show and Late Cancellation Fees are $75 for each follow-up session missed and $125 for each new patient visit missed.
• If you are unable to attend an appointment, you must contact your Provider's office at lease 2 business days before your session. Failure to cancel the appointment 2 business days in advance will cause you to be subject to fees as outlined above. Insurance does not cover these fees.
• Balance Accrual is not permitted. All services must be paid prior to or at the time care is rendered.
If you are unable to pay, your Provider will refer you to other low- or no-cost services elsewhere in the community.
Administrative Fees
• Your Provider may charge administrative fees for writing a letter or report at your request; consulting with another healthcare provider or other professional outside of normal case management practices; or for preparation, travel, and attendance at a court appearance. These fees are listed in the fee agreement below. Payment is due in advance.
Any court appearances require all required travel fees to be covered by the client. Documents/forms are $25 each. Court appearances are $1000 per day.
Understanding Insurance Benefits is the client's responsibility.
• Before beginning care, you should confirm with your insurance company if:
• Your benefits cover the type of care you will receive;
• Your benefits cover in-person and telehealth sessions;
• You may be responsible for any portion of the payment; and
• Your Provider is in-network or out-of-network.
Sharing Information with Insurance Companies
• If you choose to use insurance benefits to pay for services, you will be required to share personal information with your insurance company. Insurance companies keep personal information confidential unless they must share to act on your behalf, comply with federal or state law, or complete administrative work.
• Covered and Non-Covered Services
• When your Provider is in-network, they have a contract with your insurance company. Your insurance plan may cover all or part of the cost. You are responsible for any part of this cost not covered by insurance, such as deductibles, copays, or coinsurance. You may also be responsible for any services not covered by your insurance.
• When your Provider is out-of-network, they do not have a contract with your insurance company. You can still choose to see your Provider; however, all fees will be due at the time of your session to your Provider.
Payment Methods
• The practice requires that you keep a valid credit or debit card on file. This card will be charged for the amount due at the time of service and for any fees you may accrue. It is your responsibility to keep this information up to date, including providing new information if the card information changes or the account has insufficient funds to cover these charges.
Currently all insurance claims are billed through Headway, and it is your responsibility to keep your information current on the Headway website or with the Sunshine Health office.
I UNDERSTAND SUNSHINE HEALTH DOES NOT CONTRACT WITH MEDICARE OR MEDICAID AND PATIENTS WITH MEDICARE OR MEDICAID ARE FINANCIALLY RESPONSIBLE FOR THE COST OF CARE.
COMPLAINTS
If you feel your Provider has engaged in improper or unethical behavior, you can talk to them, or you may contact the licensing board that issued your Provider's license, your insurance company (if applicable), or the US Department of Health and Human Services.
PRACTICE POLICIES
Michelle Hext DNP, APRN, CPNP-PC, FNP-C, ENP-C, PMHNP-BC
Psychiatric Mental Health Nurse Practitioner
Sunshine Health
CONSENT TO PARTICIPATE IN PSYCIATRIC/MEDICAL CARE IN PERSON OR VIA TELEMEDICINE
1. I understand that I will be seeing a health care provider in person or via telemedicine.
2. It has been explained to me how the video conferencing technology will be used.
3. I understand that if I participate in telemedicine I will not be in the same room as my health care provider.
4. I understand there are potential risks to telemedicine technology including:
· Delays in medical evaluation and treatment may occur due to deficiencies or failures of the equipment.
· Information transmitted may not be sufficient (poor resolution of video or audio) to allow for appropriate medical decision making by the health care provider.
· Security protocols can fail, causing a breach of privacy of my confidential medical information even though the system is secure, and it is almost impossible for anyone to access the communication.
· A lack of access to all the information that might be available in a face-to-face visit which is not available in a tele-psychiatry session may result in errors of medical judgement.
· I understand that my health care provider(s) or myself can discontinue the telemedicine consult/visit if it is felt that the videoconferencing connections are not adequate for the situation, or if the health care provider decides the patient requires a face-to-face evaluation with the health care provider in the same room with the client.
5. I understand that there are benefits to using telemedicine including:
· Client convenience.
· Increased accessibility to psychiatric or medical care where a care provider would not normally be available.
· Ability to see a health care provider more rapidly with faster symptom relief.
· In some cases, clients may be more comfortable talking to a health care provider over telemedicine than in the same room.
6. I understand that if I am not in a private location while accessing telemedicine, others may see or overhear my protected health information. I thus hereby consent and authorize Michelle Hext DNP, APRN, CPNP-PC, FNP-C, ENP-C, PMHNP-BC and her affiliates to disclose my protected health information to their telemedicine providers or to anyone present with me when I access Michelle Hext’s telemedicine service through Sunshine Health to the extent necessary to use the telemedicine services for the purpose of my treatment. This consent and authorization will remain in place until revoked by me. I may revoke this authorization at any time by contacting Sunshine Health.
7. I have had the alternatives to a telemedicine consultation explained to me and in choosing to participate in a telemedicine consultation I understand that some parts of the exam involving physical tests may be conducted by individuals at my location at the direction of Michelle Hext.
8. I understand that no part of the consultation in person or online will ever be recorded or photographed.
9. I have read this document carefully and understand the risks and benefits of telemedicine consultations/visits and have had my questions regarding the procedure explained. I hereby consent to participate in atelemedicine visit under the terms described herein.
CONSENT FOR MEDICAL TREATMENT AND PSYCHOTHERAPY
The undersigned client/parent/legal guardian/conservator voluntarily consents to and authorizes service as considered necessary by Michelle Hext and her affiliates. These services may include psychiatric care, medical care, psychotherapy, medication, laboratory tests, diagnostic procedures, referrals, or other appropriate treatments.
I understand omitted information or untrue information presented to the provider or staff of Sunshine Health related to my health history, symptoms, behavior, or other personal information could compromise my treatment and my health. I will make every effort to be truthful and clear with the provider and staff of Sunshine Health.
I give consent for providers and staff of Sunshine Health to communicate with my primary care provider, counselor, therapist, other medical specialists who care for me, and my pharmacy to best coordinate my healthcare needs.
The undersigned client/parent/legal guardian/conservator voluntarily consents to and authorizes services considered necessary by Michelle Hext and her affiliates. These services may include psychiatric care, medical care, psychotherapy, medication, laboratory tests, diagnostic procedures, referrals, or other appropriate treatments. FURTHER, I understand the provider will use best practice according to her training and education to choose the medication or treatment for my condition.
The undersigned also acknowledges that Michelle Hext DOES NOT PRESCRIBE CONTROLLED SUBSTANCES FOR CHRONIC PAIN MANAGEMENT OR FOR THE LONG-TERM TREATMENT OF ANXIETY (she will refer to pain management and treat anxiety as needed assuring appropriate treatment for such conditions).
Further, I understand I may be asked to submit to drug screening as part of my care and that the nurse practitioner is able to review my narcotics prescription history on the Texas Prescription Monitoring Program website. I further consent to the release of my prescription drug history from pharmacies when necessary.
I understand any forms requested to be completed by Sunshine Health require an appointment and turnaround time for such forms is 3 to 5 business days.
I understand prescription requests are issued only in association with an appointment and may require 3 to 5 business days to be issued.
I understand if I am suffering a psychiatric emergency such as suicidal thoughts, or a medical emergency of any kind, Sunshine Health is not available to treat such emergencies and I must seek care at the nearest emergency room, call 988 or 911 for such emergencies.
The undersigned understands that he or she has the right to:
1. Be informed and participate in the selection of treatments.
2. Receive a copy of this consent.
3. Withdraw this consent at any time.