Gravity Form – RTD

Therapist Name: Tammy Samour, LPC-S, LCDC, CEAP, SAP

Attention: Required Payor Identification and Payment Method Used

Due to increased payment fraud, please carefully read the following and provide the payment documents required:

acknowledge and agree to provide a copy of my government issued identification, such as my driver’s license, AND a copy of the front side of my card used to make payment. I understand that if I do not provide this information, my final report will not be completed and sent to the agency needing this file.

I understand that if someone paid in my behalf, I and the cardholder will need to send pictures of the following:

• Copy of my driver’s license
• Copy of the driver’s license of the person who made the payment in my behalf 
• Copy of the front side of the credit/debit card used to make payment. The name on the 
• card must match the payor’s ID.

I understand that if I do not provide this information, my final report will not be completed and sent to the agency needing this file./p>

Teletherapy Health Informed Consent

(name of patient/ parent/ guardian) hereby consent to participate in Teletherapy health with Tammy Samour as part of my evaluation. I understand that Teletherapy health is the practice of delivering mental health care services via technology assisted media or other electronic means between a practitioner and a patient who are in two different locations.

I understand the following with respect to Teletherapy health:

1. I understand that I have the right to withdraw consent at any time without affecting my right to future care, services, or program benefits to which I would otherwise be entitled.
2. I understand that there are risk and consequences associated with teletherapy health, including but not Limited to, disruption of transmission by technology failures, interruption and/or breaches of confidentiality by unauthorized persons around me if not in a private area, and/or limited ability to Respond to emergencies.
3. I understand that there will be no recording of any of the online sessions by either party. All information disclosed within sessions and written records pertaining to those sessions are confidential and may not be disclosed to anyone without written authorization, except where the disclosure is permitted And/or required by law.
4. I understand that the privacy laws that protect the confidentiality of my protected health information (phi) also apply to teletherapy health unless an exception to confidentiality applies (I.E. Mandatory Reporting of child, elder, or vulnerable adult abuse; danger to self or others; I raise mental/emotional Health as an issue in a legal proceeding).
5. I understand that if I am having suicidal or homicidal thoughts, actively experiencing psychotic symptoms or experiencing a mental health crisis that cannot be resolved remotely, it may be determined That teletherapy health services are not appropriate, and a higher level of care is required.
6. I accept that teletherapy does not provide emergency services. If I am experiencing an emergency, I  Understand that I can call 911 or proceed to the nearest hospital emergency room for help. If I am having suicidal thoughts or making plans to harm myself, I can call the national suicide prevention lifeline at 1.800.273.Talk (8255) for free 24 hour hotline support. Clients who are actively at risk of harm to self or others are not suitable for teletherapy services. If this is the case or becomes the case in future, my therapist will recommend more appropriate services. 
7. I understand that during a teletherapy health session, we could encounter technical difficulties resulting in service interruptions. If this occurs, end and restart the session. If we are unable to reconnect within ten minutes, I will contact you to reschedule the remainder of the appointment.
8. I understand that my therapist may need to contact my emergency contact and/or appropriate authorities in case of an emergency.

I have read the information provided above and discussed it with my therapist. I understand the information contained in this form and all my questions have been answered to my satisfaction.

Affordable Evaluations / Milestones Counseling
Health Insurance Portability Accountability Act (HIPAA)
Client Rights & Therapist Duties

This document contains important information about federal law, the Health Insurance Portability and Accountability Act (HIPAA), that provides privacy protections and patient rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations.

HIPAA requires that I provide you with a Notice of Privacy Practices (the Notice) for use and disclosure of PHI for treatment, payment and health care operations. The Notice explains HIPAA and its application to your PHI in greater detail.

The law requires that I obtain your signature acknowledging that I have provided you with this. If you have any questions, it is your right and obligation to ask so I can have a further discussion prior to signing this document. When you sign this document, it will also represent an agreement between us. You may revoke this Agreement in writing at any time. That revocation will be binding unless I have acted in reliance on it.

LIMITS ON CONFIDENTIALITY

The law protects the privacy of all communication between a patient and a therapist. In most situations, I can only release information about your treatment to others if you sign a written authorization form that meets certain legal requirements imposed by HIPAA. There are some situations where I am permitted or required to disclose information without either your consent or authorization. If such a situation arises, I will limit my disclosure to what is necessary. Reasons I may have to release your information without authorization:

1. If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the psychologist-patient privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order, or if I receive a subpoena of which you have been properly notified and you have failed to inform me that you oppose the subpoena. If you are involved in or contemplating litigation, you should consult with an attorney to determine whether a court would be likely to order me to disclose information.
2. If a government agency is requesting the information for health oversight activities, within its appropriate legal authority, I may be required to provide it for them.
3. If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself.
4. If a patient files a worker’s compensation claim, and I am providing necessary treatment related to that claim, I must, upon appropriate request, submit treatment reports to the appropriate parties, including the patient’s employer, the insurance carrier or an authorized qualified rehabilitation provider.
5. I may disclose the minimum necessary health information to my business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. My business associates sign agreements to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.

There are some situations in which I am legally obligated to take actions, which I believe are necessary to attempt to protect others from harm, and I may have to reveal some information about a patient’s treatment:

1. If I know, or have reason to suspect, that a child under 18 has been abused, abandoned, or neglected by a parent, legal custodian, caregiver, or any other person responsible for the child’s welfare, the law requires that I file a report with the Texas Abuse Hotline. Once such a report is filed, I may be required to provide additional information.
2. If I know or have reasonable cause to suspect, that a vulnerable adult has been abused, neglected, or exploited, the law requires that I file a report with the Texas Abuse Hotline. Once such a report is filed, I may be required to provide additional information.
3. If I believe that there is a clear and immediate probability of physical harm to the patient, to other individuals, or to society, I may be required to disclose information to take protective action, including communicating the information to the potential victim, and/or appropriate family member, and/or the police or to seek hospitalization of the patient.

Consent to Release Information

hereby authorize the release of my personal information and communication pertaining to my case as described below. 

1. Information to be Released: reports, evaluations, and all other communication as it pertains to my case 
2. Purpose of Release: To facilitate my case and communicate with all agencies involved 
3. Duration of Authorization: No expiration date unless our office is notified in writing
4. Parties Authorized to Release Information: Affordable Evaluations and its agents 
5. Parties Authorized to Receive Information and communicate back and forth:

Please check all that apply to you: (if usure, you may consider checking them all) 

• DISA 
• ASAP
• S&B Companies 
• FMCSA and all future employer/agency inquiries or requests for my return to duty report 
• USCG and all future employer/agency inquiries or requests for my return to duty report
• FRA and all future employer/agency inquiries or requests for my return to duty report
• PHMSA and all future employer/agency inquiries or requests for my return to duty report
• FAA and all future employer/agency inquiries or requests for my return to duty report
• FRA and all future employer/agency inquiries or requests for my return to duty report
• Employer/Other: 

***If you want your report sent to an employer or agency not listed above, you must enter their information below, including an email address, fax number, or both.

I understand that by signing this authorization, I am voluntarily releasing my personal information and that once disclosed, the information will no longer be protected by privacy laws, including HIPPA. I reserve the right to revoke this authorization at any time by providing written notice to Affordable Evaluations, Milestones Counseling, except to the extent that action has already been taken based on this authorization.