Amazing Grace Behavioral Health Center

I acknowledge that I have received, read, and understand the Amazing Grace Behavioral Health Center and Policies.

I voluntarily consent to participate in outpatient mental health evaluation and treatment services provided by Amazing Grace Center. Services may include psychiatric evaluation, psychological assessments and screening tools, individual psychotherapy, group therapy, medication management, and treatment planning. When necessary, referrals for Medication-assisted treatment for addiction, Interventional psychiatric services, Intensive outpatient patient treatment, Partial Psychiatric Hospitalization, and Inpatient Psychiatric Hospitalization will be provided as clinically appropriate.

I understand that treatment may be provided by a psychiatrist, psychologist, psychiatric nurse practitioner, licensed therapist, counselor, social worker, trainee, or other qualified mental health professional acting within the scope of Ohio law and under appropriate supervision when applicable.

I understand that I will receive information regarding: Benefits of treatment, Alternative treatment options, Risks, side effects, or limitations of treatment and medications and when applicable, The way treatment will be provided, and Possible consequences of declining treatment.

I understand that evaluation and treatment may help identify emotional, behavioral, psychological, cognitive, interpersonal, trauma-related, or substance use concerns affecting daily functioning. Potential benefits may include improved coping skills, emotional regulation, symptom reduction, self-awareness, relationships, and overall quality of life. I understand that no specific outcome or guarantee of improvement can be promised.

I understand that I may withdraw consent for treatment at any time by notifying the clinic in writing, though doing so may affect the clinic’s ability to continue providing services.

I have had the opportunity to ask questions, understand my rights and responsibilities as a patient, including my financial responsibility for services received, and agree to the terms outlined in these policies.

This document explains your financial responsibilities and authorizes Amazing Grace Center to communicate with your health plan and process insurance claims related to your care.

1. Financial Responsibility: I understand that I am financially responsible for all applicable copayments, coinsurance, deductibles, non-covered services, and any balance determined to be my responsibility by my health insurance plan or applicable law. Insurance coverage is not a guarantee of payment, and I remain responsible for charges not paid by my insurer.

2. ASSIGNMENT OF BENEFITS: I authorize payment of my health insurance, Medicare, Medicaid, or other applicable benefits directly to Amazing Grace Center for covered services provided to me. I understand this authorization remains in effect until revoked in writing, to the extent permitted by law.

3. Authorization to Bill Insurance: I authorize Amazing Grace Center to submit claims to my insurance carrier(s), Medicare, Medicaid, managed care organization, or other third-party payer on my behalf and to take reasonable actions necessary to obtain payment for services provided.

This authorization includes obtaining prior authorizations, verifying eligibility and benefits, correcting claims, responding to payer requests, appealing claim denials, and communicating with my health plan regarding payment for services.

4. Authorization to Release Information for Payment: I authorize Amazing Grace Center to use and disclose protected health information necessary to obtain payment for healthcare services, including billing, claims processing, utilization review, prior authorization, coordination of benefits, payment audits, and other healthcare operations as permitted by HIPAA and applicable law. When applicable, disclosures involving substance use disorder treatment records protected under 42 CFR Part 2 will be made only as permitted or authorized by federal law.

5. Medicare & Medicaid Certification (If Applicable): If I am a Medicare or Medicaid beneficiary, I certify that the information I have provided is accurate to the best of my knowledge. I authorize the release of information necessary to process claims and request payment of benefits for covered services as permitted by applicable federal and state requirements.

6. GOOD FAITH ESTIMATE (Self-Pay Patients): Patients who are uninsured or elect to self-pay may have rights under the No Surprises Act to receive a Good Faith Estimate of expected charges before services are provided. Amazing Grace Center will provide a Good Faith Estimate when required by applicable federal law.

By signing below, I acknowledge that:

• I have read and understand this Financial Responsibility & Insurance Authorization.
• I understand my financial responsibilities for services provided.
• I authorize Amazing Grace Center to bill my insurance and receive payment of benefits on my behalf.
• I authorize the release of information necessary for payment and healthcare operations as permitted by HIPAA, applicable Ohio law, and, when applicable, 42 CFR Part 2.
• I understand that I may request a copy of this document for my records.

1. I consent to receive healthcare services through telehealth and understand that telehealth involves the electronic transmission of my health information through secure technology platforms including telephone, video conferencing, secure messaging, patient portals, remote monitoring, and other technology-assisted methods. Participation in telehealth is voluntary. I may withdraw my consent at any time without affecting my right to future treatment.
2. Telehealth services may only be provided when I am physically located in a state where my provider is licensed to practice. I agree to verify my identity and location at each telehealth appointment.
3. Telehealth services are billed similarly to in-person visits. I remain responsible for any applicable copays, deductibles, coinsurance, denied claims, or fees not covered by insurance.
4. I understand the potential risks of telehealth, including technology failures, interruptions in communication, reduced ability to observe nonverbal cues or perform physical examinations, delays in diagnosis or treatment, and potential privacy or security risks despite reasonable safeguards. No specific outcome, diagnosis, treatment response, or improvement can be guaranteed through telehealth services.
5. Amazing Grace Center will make reasonable efforts to protect the privacy and confidentiality of my health information in accordance with HIPAA and applicable federal and state laws. I understand that electronic communications may carry inherent security risks. I understand that confidentiality may be compromised if I participate in telehealth from a non-private location or through unsecured devices or networks. I am responsible for taking reasonable steps to protect my privacy during telehealth visits.
6. Telehealth may not be appropriate for all clinical situations. Certain situations including acute psychosis or mania, high suicide risk, active substance use, or other safety concerns, may be recommended to receive in-person treatment services. I understand that telehealth is not appropriate for psychiatric emergencies and in the event of an emergency, I will call 911, contact the crisis line 988, or go to the nearest emergency department.
7. Patients receiving addiction treatment or controlled substance prescribing may be required to complete in-person evaluations, random urine drug screening within seventy-two (72) hours of request, laboratory testing, blood pressure monitoring, medication counts or face-to-face follow-up appointments as clinically appropriate.
8. I authorize the use of secure AI scribe dictation technology to assist with transcribing audio for the purpose of organizing clinical information and generating draft clinical documentation. During my medical appointments, verbal information provided by me or my healthcare provider may be recorded using AI scribe dictation (such as Upheal, Chartnote, or similar technologies). The AI scribe will not be used to make any decisions about your care. My information will be handled in accordance with applicable privacy and security laws, including HIPAA. AI-generated documentation is reviewed, edited when necessary, and approved by the treating clinician before becoming part of the medical record.