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Currently serving clients residing in California, Hawaii and Pennsylvania.

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Welcome to Calmwater Clinical Services

Please complete this intake form to help us provide you with the best possible care. All information is confidential and protected under HIPAA.

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Consent to Treat & Guarantee of Payment

Through Calmwater Clinical Services licensed mental health care providers (“Providers”) clients receive telemental health sessions (“Services”).

By confirming below, you acknowledge your understanding and agreement to the following:

Consent to Treat

I hereby give my consent as a (client/authorized representative of client) to receive behavioral health services, including, without limitation, counseling, psychotherapy, psychological assessment, medication management and/or psychiatric care from the health care provider contracted with a professional corporation or other professional legal entity associated with Calmwater Clinical Services (“Practice”). The provider responsible for my care has explained to me the proposed treatment plan, the general nature and extent of any risks involved in the treatment, and alternative treatment options, if any.

I understand that confidentiality is an important aspect of the delivery of behavioral health services, and that Calmwater Clinical Services providers are bound by law and ethics to safeguard such patient-provider communications. I also understand that, although the law may allow me the right to examine treatment records, a Calmwater Clinical Services provider, in their reasonable professional discretion, may elect not to share certain information with me, but only as permitted or required by applicable federal and state privacy laws.

Guarantee of Payment

I understand that Calmwater Clinical Services renders services on the basis that insurance companies may or may not pay for all or a portion of its charges. I understand that I am personally responsible for knowing and understanding the coverage and eligibility conditions of my own insurance policy, including co-payment deductible, eligibility and coverage for all charges not paid by my insurance plan (Exception: services paid by a third party; EAP, Employer sponsored benefit). If I wish to self-pay for services provided by Calmwater Clinical Services, I have read and signed the Acknowledgment of Financial Responsibility. I understand that my obligation is subject to the Supplemental Payment Terms (available on request) and, if I do not pay for the charges for which I am responsible, Calmwater Clinical Services may turn my account over to a collection agency.

This consent may be revoked at any time by notifying Calmwater Clinical Services in writing.


I have read the information provided above, understand its contents and all questions have been answered to my satisfaction.

 

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Telehealth Consent

Telehealth Informed Consent

Through a Calmwater Clinical Services licensed mental health care providers (“Providers”) clients receive telemental health sessions (“Services”).

By confirming below, you hereby consent to receive the Services as part of your psychotherapy treatment. This consent means that you authorize information related to your health care to be securely electronically transmitted in the form of images and data through an interactive video or telephonic connection between you and the Provider, who are located in two different locations.

By confirming below, you acknowledge your understanding and agreement to the following:

  1. There are possible benefits of telemental health, including, without limitation, increased accessibility and efficiency to mental health care, the ability to obtain mental health care services at times that are convenient to me, and the ability to interact with providers without the necessity of an in-office visit.

  2. There are possible risks and limitations of telemental health, including, without limitation, disruption of transmission by technology failures, breaches of confidentiality by unauthorized persons, and/or limited ability to respond to emergencies.

  3. While telemental health has been found to be effective in treating a wide range of mental health conditions and disorders, there is no guarantee that the treatment of all clients will be effective. While I understand that I may benefit from the Services, results cannot be guaranteed or assured.

  4. There will be no recording of the Services by either party (except as otherwise disclosed by Calmwater Clinical Services and agreed upon prior to receipt of the Service). All federal and state laws protecting the privacy and confidentiality of health information also apply to the Services. As such, the information disclosed during the Services and written records pertaining to those Services are confidential and may not be disclosed without the proper written authorization, unless a disclosure is permitted and/or required by law (e.g., mandatory reporting of child, elder or vulnerable adult abuse; danger to self or others; and/or as allowed by law in a legal proceeding).

  5. If I am having suicidal or homicidal thoughts, actively experiencing psychotic symptoms or experiencing a mental health crisis that cannot be resolved remotely, my Provider may determine in his/her sole discretion that the Services are not appropriate and/or a higher level of care is required.

  6. During the Services, technical difficulties may result in service interruptions that require an end to, and a possible restart of, the Services. If reconnection is not possible within ten minutes, please call or text to discuss rescheduling the appointment.

  7. If during the course of the Services there is an emergency, my provided emergency contact and/or appropriate authorities may be contacted.

  8. Calmwater Clinical Services may collect, use, share and otherwise process (including de-identifying and aggregating) my information, including health information and other information regarding the Services, as described in Calmwater Clinical Services’ Notice of Privacy Practices and Privacy Policy and for any other lawful purpose, including, without limitation, to provide the Services and improve and develop Headway’s technology.

  9. A technical failure affecting the Services may result in the loss of my information and/or interrupt my telemental health session. In addition to any disclaimers that I agreed to by accepting the Terms of Use, I agree to hold Calmwater Clinical Services harmless for any loss of information or delay in care resulting from a technical failure.


I have read the information provided above, understand its contents and all questions have been answered to my satisfaction.

 

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Financial Agreement

Assignment of Benefits / Financial Responsibility

I acknowledge the payment and insurance information set forth below and agree to pay for services rendered to me and/or facilitate the payment for services rendered to me by the providers affiliated with Calmwater Clinical Services (Practice)

1.      Payment of Fees: I agree to pay for charges for services as described in this agreement. I understand that:

Payment for sessions with providers affiliated with Practice is payable online through debit or credit card or ACH transfer, unless otherwise established

Payment for sessions is due after each session unless otherwise agreed upon and Practice will charge my card or bank account for my responsibility. Receipts may be provided at the time of the charge or monthly

I will be charged for sessions that I do not keep, unless I provide enough notice to the provider affiliated with the Practice (your treating provider will tell you how much notice is required to avoid being charged for sessions you do not keep)

I understand that I cannot submit bills for cancellations to my insurance company or managed care plan

2.      Insurance and Managed Care Plans:

Practice participates in a number of insurance and managed care plans. If Practice participates in my plan, I agree to pay all applicable deductibles, co-payments, co-insurances and any other form of cost-sharing. If my insurance benefits run out, Practice will inform me of the ending date, and I will then be responsible for all charges dating from the end of insurance coverage. If my insurance plan denies the visit despite Practice following necessary procedures, I understand I may be responsible to pay in full for the service.

3.      Assignment of Insurance Fees; Release of confidentiality for authorization of benefits and for clinical care:

I agree to allow my insurance plan or managed care plan to pay Practice directly, instead of paying me. In the event that my plan pays me directly, I will promptly turn the payment over to Practice unless I have already paid the charges myself. I authorize Practice to provide my insurance plan or managed care plan any information reasonably required to obtain insurance benefits and authorization for services. I authorize Practice to obtain at any time during my treatment here, any and all relevant clinical information from clinicians and facilities that have treated me and to furnish relevant clinical information to providers who will continue to treat me. I will indicate in writing any exceptions to this.

                                              

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Confidentiality & PHI

 

Confidentiality

Confidence in client/provider confidentiality is an essential component of mental health treatment. Information that you share with our practice will be kept strictly confidential and will not be disclosed without your consent. A written release of information is usually required for the transfer of information, except as discussed below.

There are some exceptions where we may share information without your authorized release. For example, we are required to report abusive treatment and/ or neglect of a child, elder, or disabled person to the proper authorities. 

We must report the threat of serious bodily harm to oneself or others and take appropriate steps to prevent it. We may seek a client's hospitalization in order to protect the individual. If warranted, we may notify the potential victim of a threat, as well as the potential victim’s family members or police.

In some legal proceedings, upon the order of the court, we may be obligated to testify or render records of your treatment. If a client or a member of their family brings legal action against any of us and/or the practice, information may be disclosed if necessary and relevant to the case.

For clients under the protection of a legal guardian, we will need to report general feedback on treatment progress to the guardian. In the event of non-payment of our treatment fees, we may need to disclose information to a collection service or small claims court. We also from may share de-identified and anonymized data for the purposes of conducting research using real- world evidence and adhere to the highest standards for the de-identification of PHI.

Please note that loved ones or other concerned parties may at any time disclose information with providers at our practice. We are not able to confirm that a client is under our care or provide other information without a signed release, except in case of emergency as noted above, but cannot reject information that is provided to us from people who know a client. It is our practice to notify you if we do receive information like this from people in your life.

NOTICE OF PRIVACY PRACTICES

 

THIS NOTICE DESCRIBES HOW PROTECTED HEALTH INFORMATION (“PHI”) MAY BE USED AND DISCLOSED AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

 

PHI is information about you, including demographic information that may identify you and that relates to your past, present, or future physical health or condition, treatment, or payment for health care services and includes information that we have created or received regarding your health or payment for your health. It also includes both your medical records and personal information such as your name, social security number, address, and phone number.

OUR PLEDGE REGARDING HEALTH INFORMATION:

We understand that health information about you and your health care is personal. We are committed to protecting health information about you. We create a record of the care and services you receive from us. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this mental health care practice. This notice will tell you about the ways in which we may use and disclose health information about you. We also describe your rights to the health information we keep about you, and describe certain obligations we have regarding the use and disclosure of your health information. Under federal law, we are required to:

Protect the privacy of your PHI. All of our employees and clinicians are required to maintain the confidentiality of PHI and receive appropriate privacy training

 

Provide you with this Notice of Privacy Practices explaining our duties and practices regarding your PHI

 

Follow the practices and procedures set forth in the Notice

 

We can change the terms of this Notice, and such changes will apply to all information we have about you. The new Notice will be available upon request, in our office, and on our website.

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU: 

The following categories describe different ways that we use and disclose health information. For each category of uses or disclosures, we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.

For Treatment Payment, or Health Care Operations: Federal privacy rules (regulations) allow health care providers who have direct treatment relationship with the patient/patient’s to use or disclose the patient/patient’s personal health information without the patient’s written authorization, to carry out the health care provider’s own treatment, payment or health care


operations. We may also disclose your protected health information for the treatment activities of any health care provider. This too can be done without your written authorization. For example, if a clinician were to consult with another licensed health care provider about your condition, we would be permitted to use and disclose your personal health information, which is otherwise confidential, in order to assist the clinician in diagnosis and treatment of your mental health condition.

Disclosures for treatment purposes are not limited to the minimum necessary standard because therapists and other health care providers need access to the full record and/or full and complete information in order to provide quality care. The word “treatment” includes, among other things, the coordination and management of health care providers with a third party, consultations between health care providers and referrals of a patient for health care from one health care provider to another.

Lawsuits and Disputes: If you are involved in a lawsuit, we may disclose health information in response to a court or administrative order. We may also disclose health information about your child in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

CERTAIN USES AND DISCLOSURES WHICH REQUIRE YOUR AUTHORIZATION:

 

Psychotherapy Notes. We do sometimes keep “psychotherapy notes” as that term is defined in 45 CFR § 164.501, and any use or disclosure of such notes requires your Authorization unless the use or disclosure is:

a. For our use in treating you.

b. For our use in training or supervising mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy.

c. For our use in defending ourselves in legal proceedings instituted by you. 

d. For use by the Secretary of Health and Human Services to investigate our compliance with HIPAA.

e. Required by law and the use or disclosure is limited to the requirements of such law. 

f. Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes.

g. Required by a coroner who is performing duties authorized by law.

h. Required to help avert a serious threat to the health and safety of others.

 

Marketing Purposes. As a mental health practice, we will not use or disclose your PHI for marketing purposes.

 

Sale of PHI. As a mental health practice, we will not sell your PHI in the regular course of my business.

CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION.

 

Subject to certain limitations in the law, we can use and disclose your PHI without your Authorization for the following reasons:


When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.

 

For public health activities, including reporting suspected child, elder, or dependent

adult abuse, or preventing or reducing a serious threat to anyone’s health or safety.

 

For health oversight activities, including audits and investigations.

 

For judicial and administrative proceedings, including responding to a court or administrative order, although our preference is to obtain an Authorization from you before doing so.

 

For law enforcement purposes, including reporting crimes occurring on my premises.

 

To coroners or medical examiners, when such individuals are performing duties authorized by law.

 

For research purposes, including studying and comparing the mental health of patients who received one form of therapy/treatment versus those who received another form of therapy/treatment for the same condition.

 

Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counterintelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions.

 

For workers’ compensation purposes. Although our preference is to obtain an Authorization from you, we may provide your PHI in order to comply with workers’ compensation laws.

 

Appointment reminders and health related benefits or services. We may use and disclose your PHI to contact you to remind you that you have an appointment with us. We may also use and disclose your PHI to tell you about treatment alternatives, or other health care services or benefits that we offer.

CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT.

Disclosures to family, friends, or others. We may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.


YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI:

 

The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask us not to use or disclose certain PHI for treatment, payment, or health care operations purposes. We are not required to agree to your request, and we may say “no” if we believe it would affect your health care.

 

The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full.

 

The Right to Choose How We Send PHI to You. You have the right to ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and we will agree to all reasonable requests.

 

The Right to See and Receive Copies of Your PHI. Other than “psychotherapy notes,” you have the right to get an electronic or paper copy of your medical record and other information that we have about you. We will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your written request, and we may charge a reasonable, cost-based fee for doing so as permitted by state law.

 

The Right to a List of the Disclosures We Have Made. You have the right to request a list of instances in which we have disclosed your PHI for purposes other than treatment, payment, or healthcare operations, or for which you provided us with an Authorization. We will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list we will give you will include disclosures made in the last six years unless you request a shorter time. We will provide the list to you at no charge, but if you make more than one request in the same year, we will charge you a reasonable cost based fee for each additional request.

 

The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI, or that a piece of important information is missing from your PHI, you have the right to request that we correct the existing information or add the missing information. We may say “no” to your request, but we will tell you why in writing within 60 days of receiving your request.

 

The Right to Get a Paper or Electronic Copy of this Notice. You have the right get a paper copy of this Notice, and you have the right to get a copy of this notice by e-mail. And, even if you have agreed to receive this Notice via e-mail, you also have the right to request a paper copy of it.


Acknowledgement of 

Receipt of Privacy Notice

 

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. By signing you are acknowledging that you understand and may request a copy of HIPAA Notice of Privacy Practices.

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