Consent and Policy
Agreement
Welcome to Altruist Healthcare ! This document contains important information about our professional services and business policies. When you sign this document, it will represent an agreement between you and Altruist Healthcare . It is very important that you understand the concepts discussed below. Take your time reading it and discuss any questions you have with your clinician.
About our Services. It’s our goal to offer a positive, empowering, and life-enriching experience for our clients. Counseling has both benefits and risks. It often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems. Risks may include
experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness because the process of counseling may require discussing the unpleasant aspects of your life. Counseling requires active effort on your part. In order to be most successful, you will have to work on things outside of sessions that are discussed in sessions. Further, medication(s) may be
recommended after consultation with a Altruist Healthcare Nurse Practitioner. Medications have benefits such as reductions in symptoms as well as potential side effects specific to each medication. Our providers will address risks and benefits and make adjustments accordingly. Lastly, if you are on other medications, our providers may need to consult with your prescribers outside of Altruist Healthcare , with your consent, to ensure the appropriateness and safety of any medications potentially prescribed.
Confidentiality. You may discuss personal information with your clinician. Confidentiality of that information and your overall privacy are extremely important to us. The Health Insurance Portability and Accountability Act (HIPAA), along with relevant state and local laws, strictly governs how Altruist Healthcare handles your protected health information (PHI). Altruist Healthcare is considered a “covered entity” under HIPAA, meaning that we comply with HIPAA privacy rules. Generally, there are three things we can use your protected health information for – treatment, payment, and health care operations.
As a HIPAA covered entity, Altruist Healthcare keeps all of your PHI (including any communications you have with your clinician) strictly confidential. However, there are exceptions to this confidence – including situations where Altruist Healthcare must disclose information pursuant to state and federal law. The following is a list of some, but not all, exceptions:
- The client signs a written consent or authorization to use or disclose PHI;
- The client expresses serious intent to harm self or someone else;
- There is reasonable suspicion of abuse or neglect against a minor, elderly person, or dependent adult;
- For billing purposes;
- For supervision purposes;
- A subpoena or court order requires disclosure
If you decide to take part in couples, family or group treatment (“Client Unit”), confidentiality rules must adapt. For example, in compliance with applicable ethical codes including section 2.2. and 2.3 of the AAMFT Code of Ethics, PHI relating to the Client Unit will not be shared outside of the treatment session (even with other session participants) without a written authorization from each individual competent to execute a release, subject to any legal exceptions requiring disclosure. If you have any concerns, please ask your clinician about these policies before beginning Client Unit sessions. You agree to this policy regardless of who is listed as the ‘identified patient’ for 3rd party payments.
Additionally, Altruist Healthcare has a No Secrets Policy. This means that your clinician may, within their clinical discretion, share information within sessions with other members of the Client Unit participating in treatment. Your clinician will always use their best clinical judgment regarding your therapeutic treatment, however, Altruist Healthcare will not guarantee that the information provided to the clinician will be kept secret from the other members of the Client Unit. This does not include the release of medical records to any member of the Client Unit or any PHI to a third-party without separate written authorization from every member.
Your clinician may live and work in the community in which treatment is being provided. If you see your clinician outside of a session, Altruist Healthcare policy is that your clinician will not acknowledge you unless you acknowledge your clinician first. This is to protect your confidentiality.
Lastly, you hereby agree not to summon your clinician to court as a witness for any purpose or involve your clinician in any legal proceeding that would require them to compromise the duty of confidentiality, aside from a general records request.
Medical Records. We are required to keep appropriate records of the healthcare services that we provide to you. Your records are maintained in a secure electronic health record. Except in unusual circumstances that involve danger to yourself, you have the right to a copy of your health records with proper authorization. Please also see the reference to Client Unit sessions explained above.
Electronic Communication & Online Counseling. Telephone (including text), email, tele health and videoconference are not encrypted methods of communication, and some confidentiality risk exists with their use. Our team communicates using these methods. While we do our best to verify your email address, phone number and address at the time of intake, it is your responsibility to update your record if you would like to communicate via a different means, or if any of your contact information has changed. By signing this Consent and Services Agreement, you consent to your clinician, or someone from our team, following up with you by telephone, text or email for scheduling, billing, quality assurance, or other reasons. If you would prefer not to be contacted by email and/or text or need to update your information, you may contact us at info@altruisthealthcare.com or 1 (301) 835-0777. If you and your clinician are participating in online counseling sessions, the clinician will abide by the laws and ethical codes of their state of licensure. While a growing base of research has shown that online counseling services-through various electronic means-can be effective, such services are relatively new in comparison to traditional in-person counseling, which has a much longer track record of positive outcomes. Online counseling may not be appropriate for some clients and for the treatment of some mental health issues
Consent to use TeleHealth with my Provider
Your provider will use technology services to conduct Tele-health video conferencing appointments. It is simple to use and there are no passwords required to log in. You will receive a link by email or text message, depending on my preference. By signing this document, I acknowledge: Tele-health is not an Emergency Service and in the event of an emergency, I will use a phone to call 911. Though my provider and I may be in direct virtual contact through the Telehealth Service, Tele-health Service itself does not provide any medical or healthcare services or advice for emergency or urgent medical services.
The Tele-health program facilitates the videoconferencing and is not responsible for the delivery of any healthcare, medical advice or care. I understand that technical difficulties may arise as times that require external technical support to resolve and may require rescheduling of my telehealth visit. To maintain confidentiality, I will not share my Tele-health appointment link with anyone unauthorized to attend the appointment.
Conflicts. We work hard to ensure that you have a positive experience. If you don’t have a great experience, please tell us and we will try and make it right. If a conflict occurs, it is agreed that any disputes shall be negotiated directly between the parties. If these negotiations are not satisfactory, then the parties agree to mediate any differences. Litigation shall be considered only if these methods are given a good faith effort.
Emergency Contacts. Ensure to provide emergency contacts, such as a family member. These contacts may be used if your clinician perceives a need. If you are actively suicidal, or have been hospitalized for a mental health reason in the past 90 days prior to signing this Agreement, please inform our support staff by calling 1-301-835-0777. If you are in crisis, please go to your nearest emergency room or call the hotline emergency number by dialing 988.
Inactive Clients. If you, as the client, fail to attend a session within 30 days of your last counseling session, or within 3 months of your last psychiatry session, Altruist Healthcare will assume you have concluded your counseling relationship with your current clinician unless discussed with your clinician. At any time after you have concluded your relationship with your clinician, you may contact Altruist Healthcare to schedule an appointment with your former clinician or a new clinician. You agree that
Altruist Healthcare may contact you when you become an inactive client for feedback or other purposes. You may opt out by contacting us at info@AltruistHealthcare .com or 1 (301-835-0777).
Minors. In order to provide services to clients younger than 18 years old, Altruist Healthcare requires written consent from each parent or legal guardian (or other individual legally authorized to provide consent) who legally must provide consent pursuant to state law or court order, including custody agreements. Note, however, that in certain circumstances Altruist Healthcare ‘ policies may be more strict than what is legally required in order to protect a minor client’s interests. We will use reasonable efforts to determine who has the legal authority to consent to treatment of a minor. If the parents of a minor are separated or divorced, a copy of the divorce decree or custody agreement must be provided, if available. If you are signing this consent on behalf of a minor and are aware that consent of additional individuals is required prior to treatment, it is your responsibility to provide Altruist Healthcare with that information.
Coordination of Care. Altruist Healthcare believes in integrated health care. Therefore, we ask that you provide your clinician with your primary care physician’s (PCP) name and contact information shortly after your initial appointment. If needed, your clinician will also request a Release of Information (ROI) form be completed so that they may coordinate your care with your PCP, to ensure the best possible outcome.
Psychiatry Program. At Altruist Healthcare , we offer well-rounded treatment by providing our clients the ability to obtain psychiatry services through our clinicians qualified to prescribe and manage prescription medication. If you choose to utilize these services, you understand and give consent for Altruist Healthcare to retrieve your prescription history as part of your participation in the program. Altruist Healthcare uses a Prescription Monitoring Program which serves as a registry to track prescriptions for controlled substances. When you sign up for these services, you will receive information on how the service works, client-facing policies, and how to obtain prescriptions. Make sure to read and review these carefully.
Billing. You agree that Altruist Healthcare may bill any insurance through the information you provide.
Altruist Healthcare will attempt to verify benefits on your behalf. However, benefits are not a guarantee of full or partial payment by your insurance company. For example, you may be responsible for a co-pay or payment of a deductible before your benefits are applied. You will be responsible for any co-pays or other non-covered fees or costs. Additionally, if your insurance has termed or is unable to be verified, our team will reach out to attempt to remedy the issue. If the issue cannot be remedied, you will be responsible for the self-pay rate of any sessions that may occur. As described above, there may be situations in which you are responsible for the entire cost of services (e.g. an unmet deductible) and we may be contractually obligated to charge you more than our advertised self-pay rate.
Self-pay Clients. If you are a self-pay client, meaning you do not have insurance or you choose not to use your insurance, you have the right to request a Good Faith Estimate (GFE) explaining how much your therapy or psychiatry services are likely to cost. This includes the total expected cost of any nonemergency item or service such as those offered at Altruist Healthcare. We will provide you with a GFE upon request at least one (1) business day before your scheduled session. You can request your GFE by emailing info@AltruistHealthcare.com or call 3018350777
Fees and Cancellation. You consent to Altruist Healthcare securely retaining the credit card information you provide. You are responsible for payment of all amounts not covered by insurance, and for ensuring your payment information is up-to-date. Costs may include a copayment, cost share, deductible, or other fees, which will be charged to the card on file as soon as possible after your insurance company provides Altruist Healthcare with your explanation of benefits. Any balance owed will be charged on a weekly basis. Payment must be made by credit or debit card; we are not able to accept cash or checks. To change your method of payment, you may contact info@Altruist Healthcare.com. If you refuse to pay your debt, we reserve the right to use an attorney or collection agency to secure payment. Please note that we may be required to provide limited information about you and your treatment to a third party who is associated with your payment method (e.g. if you utilize a parent’s or spouse’s credit card), but that disclosure will be limited to the information necessary to resolve the applicable billing issue.
If you miss a session without canceling, or cancel with less than 24-hours’ notice, our policy is to charge you a cancellation fee of $79 (see policy below). Insurance companies do not provide reimbursement for canceled sessions and you will be responsible for the cancellation fee. If possible, we will try to find another time to reschedule the appointment. We will keep your credit card information on file, and you agree for it to be used to collect these fees.
Altruist Healthcare charges for other professional services that you may require, such as producing your medical records to you or third parties, completing forms, report or summary writing, or the time required to perform any other service which you may request of your clinician.
Law: This Consent and Services Agreement is governed by the laws of the state in which you are located when receiving services. Where this Consent and Services Agreement differs from relevant state or federal laws, those laws will govern.
24-hour Cancellation Policy
What this Means for You: Altruist Healthcare requires at least 24-hours notice if you’re going to need to cancel or reschedule an appointment, otherwise you’ll be charged a standard $79 fee to cover your Clinician’s time.
This policy is important because, while a medical doctor can see 30 patients a day, our Clinicians can see lesser clients in a day! Your appointment requires your clinician to reserve the full duration of your scheduled time, which includes both your session time and clinical documentation. If you cancel with less than 24-hour notice, your Clinician loses an entire hour from their schedule, and someone else
who may need that Clinician’s help misses out. It’s important for you to know that insurance doesn’t pay for missed appointments, so when you miss your appointment, or cancel prior to the 24-hours, regardless of the reason, your Clinician does not get paid and everyone is missing out. This is the reason you will be responsible for the $79 fee, not just your standard copay/cost-share amount. The fee is there to cover your Clinician’s missed time. We also want to make sure that you agree to the policy and understand how strict it is so that we can, hopefully, prevent appointments from being missed.
Please know that we are never upset with our clients when they miss appointments. We know that’s life and it usually won’t be your fault. Our cancellation policy is not a penalty or a punishment and reasons for canceling are not judged based on if they’re “good enough.” Rather, we have a very strict and necessary policy so that we are able to provide our clients with the thoughtful care that they deserve.
To move forward, we need your agreement and promise that if the day comes that you miss a session for any reason, you will gladly pay the missed session fee, just like you pay for the sessions you attend.
ACKNOWLEDGEMENT: I have read and fully understand and agree to the terms of this Consent and Services Agreement.
