TREATMENT CONSENT

Please read this entire document carefully before agreeing.

Welcome to Skycloud Mental Health: This agreement provides those who seek treatment from Skycloud Mental Health with a clear understanding of how we manage our office. This document is intended to provide you with enough information to make an informed consent to participate in treatment. Please read it carefully and do not hesitate to discuss your questions or concerns about this information with Skycloud Mental Health.

ASSESSMENT
Your provider will gather historical information to help them learn about your situation and determine what treatment intervention will be best for you. If your provider determines that Skycloud Mental Health cannot offer you the services you need after your initial assessment, you may receive a referral to a provider who can offer you appropriate treatment as determined by your initial assessment.

TREATMENT
Once it has been established that Skycloud Mental Health is an appropriate resource for you, you and your provider will develop a plan of care to guide your recovery. In order for the plan of care to be successful, you must actively be engaged in your care by informing your provider of any disagreements or issues related to your care then following the agreed-upon recommendations such as medication regimens and attending appointments as scheduled. You will be offered services specifically designed for you. These may include medication management with Skycloud Mental Health or therapy.

APPOINTMENTS
If you arrive late to your appointment, you may be asked to reschedule your appointment. Missed appointments, late cancellations, or failure to follow appointment recommendations may lead to your dismissal as a client of Skycloud Mental Health at the discretion of your provider. Missed appointments and cancellations with less than 24 hours notice will be charged the following fees: $200 for intakes and $100 for follow up appointments.

TELEPHONE CALLS
Skycloud Mental Health has a 24-hour answering system (503-694-3381), you may leave messages at any time. Messages may not be returned for 1-2 business days. If you are in a crisis situation, please do not leave a message. Go to the closest emergency room for treatment, call 911, call the National Suicide Hotline at 988, or text CONNECT to 741741.

CONTROLLED SUBSTANCES
Skycloud Mental Health has a strict policy regarding controlled substances. Examples of controlled substances are Vyvanse, Adderall, Concerta, Ritalin, Klonopin, Ativan, Xanax, and Valium. We may prescribe controlled substance medication to individuals in Oregon and Washington when clinically appropriate in accordance with our controlled substance policies. We do not prescribe Suboxone or methadone. We do not prescribe stimulant medications in any other states. We require an an-office visit once per year for controlled substance medications. In-office visits are available in Oregon only (i.e., residents of Washington must travel to Oregon for the required in-office appointment). Not all of our providers are able to prescribe controlled substance medications within our practice. A thorough evaluation is required prior to the prescription of a controlled substance and a prescription should never be expected at the first visit. Signing our controlled substance agreement is also required. Other requirements include a baseline Urine Drug Screen, random Urine Drug Screens, an EKG when clinically necessary, and obtaining a home blood pressure cuff. The Prescription Drug Monitoring Program is reviewed. If you are recently prescribed a stimulant and your goal is to continue treatment, you must sign the release of information form for your current provider so we may obtain records. Contact our practice with questions.

MEDICATION REFILLS
Medication refills are only provided to existing patients and refill requests should be made at least one week in advance. If you have not yet had a psychiatric evaluation at Skycloud Mental Health, you should contact your most recent prescriber for refills. Medication refills outside of appointments are determined on an individual basis. You may be required to have an appointment prior to receiving a refill or may only receive enough medication to get you to your next scheduled appointment. Please allow for at least 5 business days to receive a response regarding medication refills. Medication refill requests should be made by calling/texting 503-694-3381 or using the messaging system in your patient portal. Please include the patient’s first and last name, the patient’s date of birth, the relation of the person requesting a refill if not the patient, preferred pharmacy name/phone number, name of the medications being requested, and date of the patient’s next scheduled appointment.

TERMINATION
Termination is inevitable. It should not be done casually. Skycloud Mental Health providers can terminate your treatment at any time for non-adherence to your plan of care. Either you or your provider can terminate your treatment. We will assume you have disengaged from treatment if you do not engage for five months. At that point, you will be discharged from Skycloud Mental Health.

MAILED NOTICES
Skycloud Mental Health sends discharge letters, billing-related notices, and other important letters via certified mail to your mailing address on file, when appropriate. If for any reason you cannot receive mail at your mailing address, please inform our practice.

COMPLAINTS
If you are dissatisfied with any aspect of your treatment, please discuss it with your provider. You may also voice complaints by calling 503-694-3381. Skycloud Mental Health respectfully requests that we be given the opportunity to address your complaints before you post a complaint publicly.

EMERGENCIES
We may use or disclose your health information to notify or assist in the notification of a family member or anyone responsible for your care, in case of emergency involving your care, your location, your general condition, or death. If at all possible, we will provide you with an opportunity to object to this use of disclosure. Under emergency conditions or if you are incapacitated, we will use our professional judgment to make reasonable inference of your best interest by allowing someone to pick up a prescription, or other similar forms of health information and/or supplies unless you have advised otherwise.

APPOINTMENT REMINDERS
We may use and disclose health information to contact you as a reminder that you have an appointment for treatment at our office by call, text, or e-mail. If you do not wish to be contacted by these methods, please inform the clinic.

ALTERNATIVE TREATMENT
We may use and disclose health information to inform you about treatment alternatives and other health related benefits that we believe may be of interest to you.

ELECTION TO SELF-PAY
If you have a health insurance provider in network with Skycloud Mental Health but would prefer to self-pay for services, you can do so by agreeing with a form to indicate this. Any services provided prior to the form being agree to billed to your insurance. You can revoke this at any time by agreeing with a separate revocation form. These forms can be obtained by asking your provider or office staff. Any medical services provided from the time of agreement, the election to self-pay form until the date of agreement, the revocation form will not be billed to your insurance and you will be expected to pay as a self-pay client. Any medical services provided after the date of the agreeing, the revocation form will be billed to your insurance. Self-pay clients may be offered a discounted rate. You can inquire about self-pay rates by asking your provider or asking office staff. THIS DOES NOT APPLY TO INDIVIDUALS WITH MEDICARE. Skycloud Mental Health is not able to provide services to individuals with Medicare, cannot bill Medicare for services, and cannot accept individuals with Medicare as self-pay patients.

GOOD FAITH ESTIMATE
Please click here to view our good faith estimate for self-pay clients. If you have any questions please inform our practice. https://skycloudhealth.com/skycloud-good-faith-estimate/

LEGAL PROCEEDINGS
Skycloud Mental Health does not participate in court/legal proceedings. Evaluations provided by Skycloud Mental Health are for the purpose of diagnosis and treatment. Testimony in court, at depositions, administrative hearings, board reviews, and all time necessary for preparation and travel, whether requested by you or ordered by a court, board, government agency or other legal authority, will be charged at a rate of $400 per hour.

NURSE PRACTITIONER STUDENTS
Skycloud Mental Health offers clinical experiences for psychiatric mental health nurse practitioner students. Students are supervised by licensed board certified nurse practitioners at all times. Your provider will ask you at the beginning of every appointment if you are okay with a student observing and/or conducting your appointment. You may contact our office at any time to let us know if you do not want a student nurse practitioner involved in your treatment, or you may directly inform your provider at any time.

TELEHEALTH POLICIES
Skycloud Mental Health offers video appointments through www.skycloudhealth.com to individuals in the states in which the health care provider is licensed (updated on website). Patients must be located in one of these states at the time of the appointment but otherwise may be at any private location of their choice for the appointment. Video appointments require access to a device with audio and video capabilities as well as internet connection. Insurances may not cover video appointments. Pricing is posted on www.skycloudhealth.com.

Sessions and visits will be held via “telehealth”: using video conferencing software with audio capability and/or a separate software/device for audio (e.g, telephone, headset, etc.). Of note, telehealth establishes a formal provider-patient relationship used to maintain regular assessment, diagnostics, therapy, and/or prescription. We will be utilizing Health Insurance Portability and Accountability Act (HIPAA) protected software to ensure that your protected health information is secure from unauthorized access and that confidentiality is maintained. This document serves as a consent form for treatment via telehealth in general.

HIPAA-COMPLIANT TRANSCRIPTION TECHNOLOGY CONSENT
Your psychiatric provider may use transcription technology during your virtual and in-person office visits. The purpose of this is to help your provider focus on you more effectively by freeing them from note-taking during conversations. To provide effective assistance, the transcription technology will require access to relevant information related to your mental health, medical history, and treatment. This may include text-based conversations, medical records, and assessments provided by you or your mental health professional. Your information will be securely stored and only accessible to your provider and you if you request it. Your privacy is of utmost importance. All information shared with this technology will be treated with the strictest confidentiality. Data security measures are in place to protect your information from unauthorized access or disclosure. I have read and understood the information provided in this consent form regarding the use of transcription technology for psychiatric support. I consent to the use of transcription technology as part of my mental health care, and I acknowledge that I can withdraw this consent at any time and that this will not change the quality of my care.

BENEFITS OF TELEHEALTH
Telehealth stands at the crossroads of cutting-edge technology and formal health services.You can expect the following benefits:

Telehealth eliminates barriers to accessing healthcare and provides an alternative means to obtain behavioral health services for patients who may otherwise have limited accessibility or encounter prolonged waiting lists in the community.

In addition to removing the burden of travel time to a physical medical office as well as the risks and costs associated with transportation, telehealth allows for flexible scheduling.

Telehealth offers a reduction of stigma by providing private treatment in the comfort of the patient’s personal space.

Telehealth can provide treatment to patients with disabilities and limited mobility without requiring extensive planning for transport.

LIMITATIONS OF TELEHEALTH
While it is not possible to anticipate all the limitations of any treatment, you should consider the following when consenting to treatment via telehealth:

Telehealth audio visual equipment may experience technical difficulties. While every precaution is taken to secure patient data and maintain confidentiality, the nature of electronic appointments results in additional exposure to security breaches.

Telehealth may not be suitable for certain illnesses that require higher levels of care. Certain illnesses may not be adequately treated by telehealth.

We reserve the right to assess suitability and appropriateness of telehealth candidates due to the potential limitations of the treatment modality mentioned above.
As telehealth is generally conducted remotely, safety protocols and alternate means of seeking help will be addressed in detail in your consultation. However, the following are generally accepted alternatives to treatment via telehealth: Treatment in a more traditional, in-office visit with another provider.

Pursuing treatment via telehealth is a decision made by you. If you choose to revoke your decision and pursue alternate treatment, you are able to withdraw your consent at any time. (Of course, we recommend discussing this decision with your provider first. We also recommend establishing your next provider prior to termination to eliminate any gaps in treatment).

By signing this form I certify that I:

– I understand that I am consenting to evaluation and treatment via telehealth.
I understand that no results can be guaranteed, despite our best efforts to deliver care.
– I have been given the opportunity to ask questions about telehealth or any aspects of the evaluation and treatment at any time.

Read further on your HIPAA Rights at https://www.hhs.gov/hipaa/for-professionals/privacy/guidance/privacy-practices-for-protected-health-information/index.html

RECORD SHARING BETWEEN PROVIDERS AND STAFF UNDER THE SKYCLOUD MENTAL HEALTH UMBRELLA

Skycloud Mental Health Providers may offer mutual coverage for one another (for example, to cover leave or vacation periods). Providers may consult with one another on patient cases when helpful or necessary for patient care. Providers within Skycloud Mental Health have access to each other’s records for these purposes. Additionally, administrative staff have access to necessary records to perform their job duties. These rules are applied in accordance with HIPAA.

CLIENT RIGHTS
– I have the right to receive information about my managed care companies’ services and treatment providers, clinical guidelines, and client’s rights and responsibilities.
– I have the right to be treated with respect and dignity.
– I have the right to privacy and confidentiality.
– I have the right to fair treatment. This is regardless of race, religion, gender, ethnicity, age, disability, or source of payment.
– I have the right to the rights and privileges granted by State and Federal Law.
– I have the right to participate with my treatment provider in decision-making regarding treatment planning.
– I have the right to voice a complaint or appeal should a dispute arise over treatment or claims.
– I have the right to make recommendations regarding client rights and responsibilities policies that may be implemented.
– I have the right to a candid discussion of appropriate or medically necessary treatment options for my condition(s), regardless of cost or benefit coverage.

CLIENT RESPONSIBILITIES
– I have the responsibility to provide, to the extent possible, information that my provider(s) need in order to care for me.
– I have the responsibility to follow the plans and instructions for care that I have agreed upon with my treatment provider.
– I have the responsibility to participate, to the degree possible, in understanding my behavioral health problem(s) and developing mutually agreed-upon treatment goals.
– I have the responsibility to inform my provider of changes in my address and insurance coverage.
– I have the responsibility to keep scheduled appointments and comply with my treatment provider’s cancellation policy.

By accepting, you acknowledge: I have read the forms and have had the opportunity to ask any questions I may have had about the forms. Any questions I may have had about this form have been answered to my satisfaction.