I understand this document is a Consent to Treatment and a Financial Agreement for ambulatory/outpatient treatment at Lindner Center of HOPE (Lindner Center), an Authorization for Required Release of Information and Required Disclosures.
a. Consent to Treatment: For myself or for the patient named below, I hereby voluntarily consent to care as a patient at Lindner Center for mental health or co-occurring disorder treatment and consent to and authorize the administration and performance of medical treatment and procedures, the use of pharmaceutical products including contrast media, therapeutic agents, anesthesia and/or anesthetic agents and the use of diagnostic procedures by Lindner Center as considered necessary for my condition, or the condition of the patient named below, as directed by the attending physician and/or associates or assistants of his or her choice.
b. Telehealth Consultation: If my healthcare provider and I decide to engage in a telehealth consultation, in which my visit will be conducted remotely via telehealth technology, I agree to the following: I understand that telehealth involves the communication of my medical/mental health information in an electronic or technology-assisted format. I understand that the audio and/or video conference the technology used to perform the consultation will not be the same as a direct patient/healthcare provider visit, because I will not be in the same room as my healthcare provider. I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my healthcare information may be shared with other individuals for treatment, payment, and/or healthcare operations purposes such as for scheduling or billing. Others involved in my care may also be present during the consultation other than my healthcare provider, and I will be informed of their presence in the consultation and will have the right to terminate the consultation at any time. I understand that electronic communications may be used to communicate highly sensitive medical information, such as treatment for or information related to HIV/AIDS, sexually transmitted diseases, or addiction treatment (alcohol, drug dependency, etc.). I understand that my healthcare provider or I can discontinue the telehealth consult visit if it is felt that the audio and/or videoconferencing technology is not adequate for the situation. I understand there is no guarantee the telehealth sessions will eliminate the need to see my healthcare provider in person. I understand that the alternative to a telehealth consult/visit is an in-person visit. I understand I may ask questions prior to having a telehealth consultation. By signing below, I acknowledge that I have read and understand the risks and benefits of a telehealth consultation, and I wish to proceed with the telehealth consultation.
c. Medical Education Acknowledgement: I understand that Lindner Center is a teaching facility, and I agree that interns, residents, fellows, nurses, medical students, and other health personnel in training may participate with or assist my clinician(s), or the clinician(s) of the patient named below.
d. Blood Tests and Samples: I authorize Lindner Center to obtain blood samples for testing of communicable or sexually transmitted diseases including, but not limited to HIV and Hepatitis, if a qualified clinician orders the test for diagnostic purposes for me or the patient named below or in the event a health care worker has been exposed to my blood or bodily fluids or the blood or bodily fluids of the patient named below. I authorize Lindner Center and my, or the below named patient’s, clinicians to receive and/or use the results of these tests. Except when an HIV test is performed in a medical emergency and the test results are medically necessary to avoid or minimize an immediate danger to me, or the patient named below, or others, I understand that in Ohio, I, or the patient named below, has the right to an anonymous HIV test.
e. Laboratory and Diagnostic Testing: I further authorize Lindner Center to take samples, specimens and cultures, to perform medically necessary laboratory and diagnostic tests and procedures and dispose of such in the customary fashion, and to take such precautions as may be necessary for my treatment and safety, or the treatment and safety of the patient named below, and the safety of others.
f. Authorization for Emergency Care: I hereby give permission to both Lindner Center and the attending clinician to transfer me, or the patient named below, to a general medical hospital for treatment, if necessary. If a medical emergency arises, which if left untreated, is likely to endanger life while I or the patient named below is in the care of Lindner Center, I authorize Lindner Center to provide emergency treatment as is deemed, through the exercise of good clinical judgment, to be appropriate to minimize risks to me or the patient named below and others. Lindner Center may release to any general medical hospital or health agency performing emergency medical treatment and/or diagnostic examination such information that Lindner Center and the attending clinician determine to be pertinent to the emergency care or diagnostic examination. In addition, any general medical hospital, clinician or health agency performing emergency examination or treatment, is authorized to release information relating to the emergency condition and disposition of the treatment to Lindner Center.
g. Personal Valuables: I acknowledge that personal valuables, such as money and jewelry, should not be brought to the hospital. I hereby release the hospital from any responsibility for or liability arising from the loss or damage to valuables, money, personal, or other possessions brought to the hospital. I understand that patients are strongly encouraged to send all valuables home with a family member.
h. Health Status and Medical History: I understand that it may be important to the development of my personalized treatment plan or that of the patient named below for Lindner Center to have a complete understanding of my health status and medical history, or that of the patient named below, and acknowledge that I may be asked to authorize Lindner Center to obtain such information from healthcare providers who have previously treated me or the patient names below. I further acknowledge that I may be asked to offer my specific consent and authorization to permit Lindner Center to obtain this information about me or the patient named below.
i. No Guarantee: I understand that the practice of medicine is not an exact science and acknowledge that no guarantees have been made to me concerning the outcome of the treatment to be rendered at Lindner Center. I understand that there may be some risks from some medications if I am, or the below named patient is, pregnant. I know that it is my responsibility to discuss possible pregnancy with the clinicians and staff involved in my care.
I understand that if I, or the patient named below, leaves the Linder Center facility against the advice of any clinician or refuses treatment, medication or other therapeutic services, Lindner Center is not responsible for any ill effect the decision may cause.
j. Right to Revoke: I understand that I may revoke my consent at any time and that this decision is mine alone. This consent shall remain in full force and effect until revoked in writing.