Informed Consent

WELCOME

Welcome to the Institute for HEALing, LLC or “iHEAL.” This pamphlet contains important information about iHEAL's professional services and business policies. It also contains information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights about the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. When you sign the Patient Acknowledgment Form, you are acknowledging that you received this document and giving us consent to treat you.

CONFIDENTIALITY

Most of what you say in treatment is confidential, which means that it stays between the members of your treatment team. However, there are some things that cannot remain private. Things that cannot remain private include:

1) threats or plans to kill yourself or someone else,

2) disclosure of abuse/neglect of a vulnerable person (e.g., person who is under-age, elderly, and/or differently-abled), or

3) anything subpoenaed by a court. Your clinical team will consult about your cases to offer the highest level of care.

 

Only pertinent information for the purposes of consultation and treatment planning will be shared. Part of the mission of iHEAL is to train budding mental health providers (interns). Interns will be working under a professional who is fully-licensed. Your provider will share details about your case with his/her clinical supervisor in order to provide you with highest level of care. Interns may need to observe some sessions or video/audio record their own health sessions. Session observations and recordings are for training purposes solely, and you can decline being observed or recorded. Recordings are typically digital and will be destroyed every three weeks if not sooner.

 

RISKS

As with any health intervention, there are potential risks to mental health treatment. Treatment non-compliance puts you at risk for adverse drug reactions, a reoccurrence of mental health symptoms, and even death. For example, you put yourself at great risk when you change your medication dosage or timing without consulting your medical provider.

Missed appointments also puts you risk for mental health concerns and lapses in medication management. Make sure that you have an appointment scheduled BEFORE your medication runs out

OUTPATIENT MENTAL HEALTH  SERVICES

Mental Health Services. iHEAL offers psychotherapy, which has benefits and risks, for individuals, families, and groups. Benefits may include releasing emotional turmoil and psychological distress, learning effective coping skills/strategies, fostering a deeper understanding of self and others, resolving specific problems, and attaining better life satisfaction. One risk of psychotherapy is experiencing uncomfortable feelings, such as sadness, guilt, or anger. This process requires an active effort on your part to work inside and outside of sessions.

Addiction Services. We provide addictions evaluations and counseling for individuals and groups. Addiction services include chemical addictions (e.g., heroin/ opioids, cocaine/stimulants, marijuana, alcohol) and behavioral addictions (eating/food, gambling, pornography, sex). Benefits are similar to listed in the Mental Health Counseling Services section above. Risks include uncovering deep-rooted issues that initiated use/abuse and discussing these issues might induce feelings of discomfort and/or an urge to return to previous use.

Psychiatric/Medication Services.We provide psychiatric services through our medical team. Psychiatric evaluations, medication management, and medical intervention are provided by psychiatrists and licensed nurse practitioners. Risks associated with this service are similar to those of any medical intervention (e.g., adverse drug reactions, allergic reactions, etc.). Please know that there could be a delay in receiving controlled-substance prescriptions as they may need to be mailed or faxed to your pharmacy.

 

Psychoeducational Services. iHEAL provides testing to uncover learning disabilities and giftedness, emotional issues that impact academic functioning (i.e., test anxiety), and ADHD. Benefits associated with psychological testing include getting an official diagnosis of a disability; receiving recommendations to maintain academic strengths and mitigate academic weaknesses. Test fatigue is the major risk of psychoeducational testing session.

Psychological Evaluation Services. We conduct psychological evaluations for work, school, and personal use as well. Common uses for evaluations include clearances to return to work or school, bariatric surgery, and clarifying diagnoses. Benefits include satisfying requirements to proceed with medical intervention or return to normal functioning at work or school. Risks include unearthing psychological concerns that may need to be addressed immediately and test fatigue.

Consultation Services. Professional consultation services like follow-up telephone calls and written documentation are offered free of charge if they take less than 10 minutes. Any professional services that require longer than 10 minutes may be subject to a prorated fee.

 

Telehealth Services. iHEAL provides telehealth services, which is the delivery of health treatment using a secure, HIPAA-compliant video conferencing system set up to protect your confidentiality and maintain your privacy. Of course, this modality of intervention is not a substitute for in-person services; however, the same details that are discussed in your face-to-face sessions will be discussed in telehealth sessions. To keep team members and patients safe during the outbreak of COVID-19, 100% of wellness services are offered via telehealth. If you do not have video access to participate in secure  telehealth sessions, we may conduct treatment sessions over the phone (voice only) to ensure that you get access to services as quickly as possible. If treatment is conducted this way, the same level of privacy does NOT apply. Treatment offered telephonically has a greater risk of privacy breaches than treatment offered via our secure, HIPAA-compliant video conferencing system.

 

PRESCRIPTION POLICIES

Patients must complete a clinical intake before a psychiatric evaluation. After the intake, the patient and therapist may discuss a psychiatric evaluation as a treatment option.

 

Patients requesting refill must be active iHEAL patients. At is someone who has attended a therapy or medication management appointment within the last 90 days. A refill can only be requested by the patient receiving treatment with the exception of minors or patients with legal guardians. All medications must be consented and approved by the guardian prior to dispensing.

Patients who need a medication refill should make an appointment for monitoring and treatment management. Requests for refills must be submitted through our patient portal or patient request. We will not accept faxed refill requests from pharmacies or patients.

 

All medication-related requests (i.e.,pharmacy changes, medication changes, medication refills) will be addressed within 48 business hours. No more than a 90-day supply of prescriptions will be written at a time. A patient requesting a medication change related to their treatment plan will be required to be reevaluated. A medical team member may authorize a change in medication without an appointment only if s/he deems it clinically appropriate. 

 

iHEAL medical team members may reserve the right to withhold a refill if clinically indicated. According to iHEAL policies and procedures, all patients being prescribed controlled substances may be asked to submit for urinalysis. Controlled substances will not be dispensed at a quantity greater than 30-day supply at a time. Patients who are receiving controlled substances at more than one facility will not be prescribed that medication at iHEAL. Your iHEAL medical team member may refuse a controlled substance prescription request if there are concerns of abuse, misuse, addiction, or illegal distribution of medication.

INSURANCE

In order for us to set realistic treatment goals, it is important to evaluate the financial resources that you have for treatment. iHEAL accepts some insurance companies, but not all. Please discuss insurance plans and co-pays with the front desk staff. We use an independent billing companies to securely bill for treatment services. If we don’t accept your insurance plan, but you have out-of-network benefits, you can still use your health insurance coverage to get treatment. You can ask the wellness team in the reception area for documentation of services to send to your insurance company. Some insurance companies have a deductible, which means that you will be responsible for paying for 100% of your treatment until your deductible has been met. Additionally, most insurance companies require deductibles to be met each year, so you may need to pay 100% of treatment at the start of each calendar year. Also, many patients have to pay a co-pay for each office visit.

 

PATIENT RECORDS

We are required by law and industry practice to keep appropriate records of the services that we provide. Your records are maintained in a secure electronic medical record (EMR). Except in unusual circumstances that involve danger to yourself or someone else, you have the right to a copy of your file.

 

Be aware that medical records may be misinterpreted and/or upsetting to untrained readers. Therefore, it is recommended that you initially review them with your iHEAL provider or have them forwarded to another mental health professional to discuss the contents. If your access request to your records is denied, you have a right to receive an explanation for the denial and seek legal counsel to obtain your record.

APPOINTMENTS

Appointments vary based on the type of service that you need. These specifics will be discussed when you talk about treatment recommendations with your provider.

Timeliness. You are responsible for showing up to your appointment on time. If you are late, your appointment may be canceled. If you are still seen, your appointment will end on time regardless of your arrival time.

Recording/Photographing Sessions and/or Providers. You may not audio or video record any part of their treatment sessions without the written consent of the treatment agency and treatment provider. This includes recordings during face-to-face treatment sessions as well as telehealth sessions. You may also not take screenshots or photo images of your treatment provider without the written consent of the treatment agency and treatment provider.

Canceling & Rescheduling Appointments. If you need to cancel or reschedule an appointment, we ask that you provide 24 hours' notice. If you miss an appointment without canceling or cancel with less than 24-hours' notice, you may be charged a no-show/late cancellation fee. Please be advised that your insurance companies do not reimburse for cancelled appointments, so you will be responsible for these fees. If the treatment schedule allows, we would be happy to accommodate you during that same week. If you miss three (3) out of six (6) scheduled appointments, your treatment may be ended.

PARENTS/MINORS

While privacy in treatment is crucial to healing, parental involvement is also important. An assent agreement may be signed between the provider, patient, and his/her parents/guardians allowing iHEAL to share some treatment information, but not all. Of course, there is some treatment information that must be shared immediately. For example, if there is a safety concern, iHEAL will attempt to notify the parent/guardian and/or emergency personnel (see CONFIDENTIALITY section).

 

PROFESSIONAL FEES

With all treatment services, you are responsible for paying at the time of your appointment. Payments must be made by check, money order, or credit card. We do not accept cash in the office. Returned checks are subject to an additional fee of up to $35.00. Patient accounts that are not paid will be forwarded to our collection agency.

 

CONTACT US

The iHEAL treatment team is not always immediately available by telephone because we are treating other patients. At these times, you may leave a message on iHEAL’s confidential voicemail and your call will be returned as soon as possible. If you are in the middle of a medical emergency, please do not wait for a return phone call from your therapist at iHEAL. Instead, please go to your local hospital emergency room or call 911.

 

Your therapist will make every attempt to inform you in advance of planned absences and discuss plans during his/her absence if necessary.

 

OTHER RIGHTS

If you are unhappy with what is happening in therapy, please discuss your dissatisfaction with your therapist so that s/he can respond to your concerns. Such comments will be taken seriously and handled with care and respect.

 

You may also request that your therapist refer you to another therapy at iHEAL or a different treatment agency as you are free to end therapy at any time. You have the right to considerate, safe, and respectful care, without discrimination as to race, ethnicity, color, gender, sexual orientation, age, religion, immigrant status, national origin, or any other cultural identity factor. You have the right to ask questions about any aspects of therapy and about specific academic and clinical training and experience of your therapist. 

9419 Common Brook Road Suite 208

Owings Mills, MD 21117

Tel: (410) 864-0211

Fax: (410) 618-4163

info@myiHEAL.com

Monday through Friday 9am-8pm

Saturday 9am-4pm

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© 2020 Institute for HEALing, LLC