Child/Minor Consent Child/Minor Consent Form Packet Welcome Child/Minor Consent Form Telehealth Consent Form Standard Authorization Form HIPPA and Checklist Office Policies Please review and retain this document for your records. If you have any questions regarding the information listed here, please discuss it with your treatment provider during the course of your initial visit. You will be asked to acknowledge receipt of this information with your signature. Office Hours and Appointment Schedules The office is open Monday through Friday, between the hours of 9:00 am and 5:00 pm. During these hours, office staff will be available to receive telephone calls and provide you with information relevant to your requests. Appointments can be scheduled during regular office hours by speaking with the office staff in most instances. The clinical staff at Comprehensive Health Services (CHS) have diverse schedules. In some instances, the clinician will be responsible for scheduling your appointments during times that are mutually agreeable. Click on the "Next" to start the form. View and Download Welcome Packet Next Child/Minor Demographic Information First Name (Client/Patient)* M.I. Last Name* Nickname Date of Birth* Gender* Select One Male Female Gender Diverse Address Line 1* Address Line 2 City* State* Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming District of Columbia Puerto Rico Guam American Samoa U.S. Virgin Islands Northern Mariana Islands Zip* Guardian #1 First Name* M.I. Last Name* Relation to Client* Phone (Primary)* Phone (Alternate) Email Address Address (Same as Client/Patient) Yes No Address Line 1* Address Line 2* City State Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming District of Columbia Puerto Rico Guam American Samoa U.S. Virgin Islands Northern Mariana Islands Zip* Emergency contact Yes No Responsible for Insurance Yes No Legal Rights: Does guardian 1 have legal rights and documentation to sign consent for treatment of this minor? Yes No If yes, please upload related documentation at the bottom of this page. Guardian #2 Yes No First Name* M.I. Last Name* Relation to Client* Phone (Primary)* Phone (Alternate) Email Address Address (Same as Client/Patient) Yes No Address Line 1*: Address Line 2*: City State Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming District of Columbia Puerto Rico Guam American Samoa U.S. Virgin Islands Northern Mariana Islands Zip* Emergency contact Yes No Responsible for Insurance Yes No Legal Rights: Does guardian 2 have legal rights and documentation to sign consent for treatment of this minor? Yes No If yes, please upload related documentation at the bottom of this page. Other Emergency Contact First Name* M.I. Last Name* Relation to Client* Phone Number* Email Other Person for Legal Rights First Name* M.I Last Name* Relation to Client* Phone Number* Email Insurance Information Guardian Photo ID Insurance Card Primary Insurance* Select One AARP Aetna Blue Cross Blue Shield Boston Medical Center Cigna Commonwealth Care Alliance Fallon Community GIC Unicare Harvard Pilgrim HealthCare Health Plans Inc. MassHealth MBHP Medicare Meritain Health Tricare Tufts Health Plan Tufts Medicare Preferred Tufts Navigator UMR United Behavioral Health United Healthcare United Healthcare Oxford Self Pay Other Subscriber ID* Group Number* Name of Other Primary Insurance* Policy Holder First Name* M.I. Policy Holder Last Name* DOB of Policy Holder* Secondary Insurance Select One AARP Aetna Blue Cross Blue Shield Boston Medical Center Cigna Commonwealth Care Alliance Fallon Community GIC Unicare Harvard Pilgrim HealthCare Health Plans Inc. MassHealth MBHP Medicare Meritain Health Tricare Tufts Health Plan Tufts Medicare Preferred Tufts Navigator UMR United Behavioral Health United Healthcare United Healthcare Oxford Self Pay Other Subscriber ID* Group Number* Name of Other Secondary Insurance* Policy Holder First Name* M.I. Policy Holder Last Name* DOB of Policy Holder* Person responsible for payment (if not client) First Name M.I. Last Name Relation to Client Phone Number Email Address Line 1 Address Line 2 City State Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming District of Columbia Puerto Rico Guam American Samoa U.S. Virgin Islands Northern Mariana Islands Zip Primary Care Provider First Name* M.I. Last Name* Location* Phone Form Completed by First Name* M.I. Last Name* Date* Signature of Client/Patient/Legal Guardian* Date of Signature* Signature of Insurance Policy Holder* Date of Signature* Upload Documents (Supported files .pdf, .jpg, .jpeg, .png) This field is required Drag and Drop Files Here Or Browse Start Over Previous Next First Name (Client/Patient)* M.I. Last Name* Date of Birth* Introduction Telehealth includes teletherapy and telemedicine, allowing patients to access therapeutic and psychiatric care using audio-video interfaces such as video conferencing. Electronic systems used at CHS incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data. They also include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption. Expected Benefits Improved access to psychiatric care and therapy More efficient psychiatric evaluation and management Obtaining expertise of a distant specialist Possible Risks The potential risks associated with the use of teletherapy include, but may not be limited to the following: Information transmitted (e.g., visual images, sound) may not be sufficient to allow for appropriate assessment by therapist or prescriber Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment or associated software Security protocols could fail, causing a breach of privacy of personal health information Limited access to medical records may result in adverse drug interactions, allergic reactions, or other medication management errors Such risks are generally rare if tools of technology are maintained and staff is trained in their use for the benefit of patient care. National Emergency Crisis: Consent to telehealth services I understand that due to the COVID-19 related national emergency crisis, telehealth is offered by CHS to appropriate patients. This is an effort to comply with federal and state mandates of isolation and social distancing while providing continuity of patient care that keeps everyone safe and protected. Signature of Client/Patient/Legal Guardian* By signing this form, I understand the following I understand that the laws that protect privacy and the confidentiality of medical information also apply to teletherapy, and that no information obtained in the use of teletherapy which identifies me will be disclosed to researchers or other entities without my consent. I understand that I have the right to withhold or withdraw my consent to the use of teletherapy in the course of my care at any time, without affecting my right to future care or treatment. I understand that I have the right to inspect all information obtained in the course of a teletherapy interaction, and may receive copies of this information for a reasonable fee. I understand that a variety of alternative methods of psychiatric and therapeutic care may be available to me, and that I may choose one or more of these at any time. I understand that it is my duty to inform my psychiatrist and/or therapist of any other healthcare providers involved in my therapeutic/psychiatric care. I understand that I may expect the anticipated benefits from the use of teletherapy in my care, but that no results can be guaranteed or assured. Patient Consent To The Use of Teletherapy I have read and understand the information provided above regarding teletherapy, have discussed it with my psychiatrist or such assistants as may be designated, and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of teletherapy in my medical care. Please note: Any co-pay, co-insurance or deductibles due for the date of service will still be client responsibility. I hereby authorize Comprehensive Health Services to use teletherapy in the course of my diagnosis and treatment. Signature of Client/Patient/Legal Guardian* Date of Signature* If authorized signer, relationship to patient Witness Date Start Over Previous Next First Name (Client/Patient)* M.I. Last Name* Date of Birth* I authorize the release of information from this person or organization First Name* M.I. Last Name* Phone* Address Line 1* Address Line 2 City* State* Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming District of Columbia Puerto Rico Guam American Samoa U.S. Virgin Islands Northern Mariana Islands Zip* To this person or organization First Name* M.I. Last Name* Phone* Address Line 1* Address Line 2 City* State* Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming District of Columbia Puerto Rico Guam American Samoa U.S. Virgin Islands Northern Mariana Islands Zip* The information may be used/disclosed for the following purposes For Example Date of Care included From* To* Signature of client or their personal representative* Date of Signature* Printed name of client or personal representative* Relationship to client* Start Over Previous Next First Name(Client/Patient)* M.I. Last Name* Date of Birth* HIPAA Acknowledgement I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize you to use and disclose my protected health information to carry out: Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment); obtaining payment from third party payers (e.g. my insurance company); the day-to-d a healthcare operations of your practice. I have also been informed of and given the right to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information and my rights under HIPAA. I understand that you reserve the right to change the terms of this notice from time to time and that I may contact you at any time to obtain the most current copy of this notice. I understand that I have the right to request restrictions on how my protected health information issued and disclosed to carry out treatment, payment and health care operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are then bound to comply with this restriction. I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent is not affected. Checklist By my signature, I acknowledge that I have received, understand, and agree to abide by the Comprehensive Health Services Office Policies as defined in the outpatient welcome packet that I received. Those policies and procedures include: Office Hours and Appointment Schedules After Hours Coverage Information Sharing Clients Beyond our Ability to Treat Client Complaints and Grievances Termination of Services Attendance No Show and Late Cancellation Policies Emergency Numbers Changes to Insurance and Demographic Information Client Rights and Responsibilities Consent to Treat Authorization to Bill Insurance Name of Legal Guardian (If applicable) Relationship to client/patient (if applicable) Signature of Client/Patient/Legal Guardian* Date of Signature* Upload Documents (Supported files .pdf, .jpg, jpeg, .png) Drag and Drop Files Here Or Browse Start Over Previous
