Medical Consulting Services Intake

Welcome to Medical Consulting Services

Your provider has referred you to Medical Consulting Services for a pre-surgical psychological evaluation. This is an independent evaluation; as such, a copy of the report will not be released to you. The results of this evaluation will be released to your referring doctor and your insurance company for further review, and they will ultimately determine whether or not you are approved for surgery.

CANCELATION AND NO-SHOW POLICY

Same day cancelations and no shows are subject to 10 day delay in rescheduling as they require staffing by your provider to ensure that we are providing the appropriate level of care to meet your unique needs. This may also add a $50 fee to your account.

Being LATE puts the clinic behind. If you are late, you will not be seen until an open appointment. If there are no open appointments on the same day, you will have to reschedule and will be billed for $50 for the no-show.

Health Insurance Portability and Accountability Act, HIPAA.

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW THIS NOTICE CAREFULLY.

Your health record contains personal information about you and your health. This information about you that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services is referred to as Protected Health Information (“PHI”). This Notice of Privacy Practices describes how we may use and disclose your PHI in accordance with applicable law, including the Health Insurance Portability and Accountability Act (“HIPAA”) and regulations promulgated under HIPAA, including the HIPAA Privacy and Security Rules. It also describes your rights regarding gaining access to and controlling your PHI.

We are required by law to maintain the privacy of PHI and to provide you with notice of our legal duties and privacy practices with respect to PHI. We are required to abide by the terms of this Notice of Privacy Practices. We reserve the right to change the terms of our Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that we maintain at that time. We will provide you with a copy of the revised Notice of Privacy Practices by posting a copy on our website, sending a copy to you in the mail upon request or providing one to you at your next appointment.

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU

For Treatment.

Your PHI may be used and disclosed by those who are involved in your care for the purpose of providing, coordinating, or managing your health care treatment and related services. This includes consultation with clinical supervisors or other treatment team members. We may disclose PHI to any other consultant only with your authorization.

For Payment.

We may use and disclose PHI so that we can receive payment for the treatment services provided to you. This will only be done with your authorization. Examples of payment-related activities are: making a determination of eligibility or coverage for insurance benefits, processing claims with your insurance company, reviewing services provided to you to determine medical necessity, or undertaking utilization review activities. If it becomes necessary to use collection processes due to lack of payment for services, we will only disclose the minimum amount of PHI necessary for purposes of collection.

For Health Care Operations.

We may use or disclose, as needed, your PHI in order to support our business activities, including, but not limited to, quality assessment activities, employee review activities, licensing, and conducting or arranging for other business activities. For example, we may share your PHI with third parties that perform various business activities (e.g., billing or typing services) provided we have a written contract with the business that requires it to safeguard the privacy of your PHI. For training or teaching purposes, PHI will be disclosed only with your authorization.

Required by Law.

Under the law, we must disclose your PHI to you upon your request. In addition, we must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining our compliance with the requirements of the Privacy Rule.

Without Authorization.

Following is a list of the categories of uses and disclosures permitted by HIPAA without an authorization. Applicable law and ethical standards permit us to disclose information about you without your authorization only in a limited number of situations.

Child Abuse or Neglect. We may disclose your PHI to a state or local agency that is authorized by law to receive reports of child abuse or neglect.

Judicial and Administrative Proceedings.

We may disclose your PHI pursuant to a subpoena (with your written consent), court order, administrative order or similar process.

Deceased Patients.

We may disclose PHI regarding deceased patients as mandated by state law, or to a family member or friend that was involved in your care or payment for care prior to death, based on your prior consent. A release of information regarding deceased patients may be limited to an executor or administrator of a deceased person’s estate or the person identified as next-of-kin. PHI of persons that have been deceased for more than fifty (50) years is not protected under HIPAA.

Medical Emergencies.

We may use or disclose your PHI in a medical emergency situation to medical personnel only in order to prevent serious harm. Our staff will try to provide you a copy of this notice as soon as reasonably practicable after the resolution of the emergency.

Family Involvement in Care.

We may disclose information to close family members or friends directly involved in your treatment based on your consent or as necessary to prevent serious harm.

Health Oversight.

If required, we may disclose PHI to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies and organizations that provide financial assistance to the program (such as third-party payors based on your prior consent) and peer review organizations performing utilization and quality control.

Law Enforcement.

We may disclose PHI to a law enforcement official as required by law, in compliance with a subpoena (with your written consent), court order, administrative order or similar document, for the purpose of identifying a suspect, material witness or missing person, in connection with the victim of a crime, in connection with a deceased person, in connection with the reporting of a crime in an emergency, or in connection with a crime on the premises.

Specialized Government Functions.

We may review requests from U.S. military command authorities if you have served as a member of the armed forces, authorized officials for national security and intelligence reasons and to the Department of State for medical suitability determinations, and disclose your PHI based on your written consent, mandatory disclosure laws and the need to prevent serious harm.

Public Health.

If required, we may use or disclose your PHI for mandatory public health activities to a public health authority authorized by law to collect or receive such information for the purpose of preventing or controlling disease, injury, or disability, or if directed by a public health authority, to a government agency that is collaborating with that public health authority.

Public Safety. We may disclose your PHI if necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. If information is disclosed to prevent or lessen a serious threat, it will be disclosed to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat.

Research.

PHI may only be disclosed after a special approval process or with your authorization.

Verbal Permission.

We may also use or disclose your information to family members who are directly involved in your treatment with your verbal permission.

With Authorization.

Uses and disclosures not specifically permitted by applicable law will be made only with your written authorization, which may be revoked at any time, except to the extent that we have already made a use or disclosure based upon your authorization. The following uses and disclosures will be made only with your written authorization: (i) most uses and disclosures of psychotherapy notes which are separated from the rest of your medical record; (ii) most uses and disclosures of PHI for marketing purposes, including subsidized treatment communications; (iii) disclosures that constitute a sale of PHI; and (iv) other uses and disclosures not described in this Notice of Privacy Practices.

Patient Email and Text Message Informed Consent

We use these methods to communicate only non-sensitive and non-urgent issues.

All communications to or from you may be made a part of your medical record. You have the same right of access to such communications as you do to the remainder of your medical record. We will not disclose your emails or text messages to researchers or others unless allowed by state or federal law. Please refer to our Notice of Privacy Practices for information as to permitted uses of your health information and your rights regarding privacy matters.

Risk of using email and text messages:

The use of email and text messages has a number of risks that you should consider. These risks include, but are not limited to, the following:

a) Emails and texts can be circulated, forwarded, stored electronically and on paper, and broadcast to unintended recipients.

b) Senders can easily misaddress an email or text and send the information to an undesired recipient.

c) Backup copies of emails and texts may exist even after the sender and/or recipient has deleted his or her copy.

d) Employers and online services have a right to inspect emails and texts sent through their company systems.

e) Emails and texts can be intercepted, altered, forwarded or used without authorization or detection.

f) Emails and texts can be used as evidence in court.

g) Email and text messaging may not be secure, and therefore, it is possible that a third party may breach the confidentiality of such communications.

Conditions of the use of email and text message:

Medical Consulting Services cannot guarantee but will use reasonable means to maintain security and confidentiality of email/text information sent and received. You must acknowledge and consent to the following conditions:

a) IN A MEDICAL EMERGENCY, DO NOT USE EMAIL, CALL 911. Do not email for urgent problems. If you have an urgent problem during regular business hours, please call the office. Urgent messages or needs should be relayed to us by using regular telephone communication and may include text messages.

b) Emails should not be time sensitive. While we try to respond to email messages daily, we cannot guarantee that any particular email will be read and responded to within any particular period of time. If you have not heard back from us within three days, call our office to follow up if we have received your email.

c) You should speak to our office directly to discuss complex and/or sensitive situations rather than send email or text messages regarding such situations.

d) Email and text messages may be filed electronically into your medical record.

e) Clinical staff will not forward your identifiable email/texts to outside parties without your written consent, except as authorized by law.

f) You should use your best judgment when considering the use of email or text messages for communication of sensitive medical information. Clinical staff are not responsible for the content of messages.

g) Medical Consulting Services is not liable for breaches of confidentiality caused by you or any third party.

h) It is your responsibility to follow up with Medical Consulting Services if warranted

YOUR RIGHTS REGARDING YOUR PHI

You have the following rights regarding PHI we maintain about you. To exercise any of these rights, please submit your request in writing to our Privacy Officer at 272 E 36th St, Garden City, ID 83714

Right of Access to Inspect and Copy.

You have the right, which may be restricted only in exceptional circumstances, to inspect and copy PHI that is maintained in a “designated record set”. A designated record set contains mental health/medical and billing records and any other records that are used to make decisions about your care. Your right to inspect and copy PHI will be restricted only in those situations where there is compelling evidence that access would cause serious harm to you or if the information is contained in separately maintained psychotherapy notes. We may charge a reasonable, cost-based fee for copies. If your records are maintained electronically, you may also request an electronic copy of your PHI. You may also request that a copy of your PHI be provided to another person.

Right to Amend.

If you feel that the PHI we have about you is incorrect or incomplete, you may ask us to amend the information although we are not required to agree to the amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us. We may prepare a rebuttal to your statement and will provide you with a copy. Please contact the Privacy Officer if you have any questions.

Right to an Accounting of Disclosures.

You have the right to request an accounting of certain of the disclosures that we make of your PHI. We may charge you a reasonable fee if you request more than one accounting in any 12-month period.

Right to Request Restrictions.

You have the right to request a restriction or limitation on the use or disclosure of your PHI for treatment, payment, or health care operations. We are not required to agree to your request unless the request is to restrict disclosure of PHI to a health plan for purposes of carrying out payment or health care operations, and the PHI pertains to a health care item or service that you paid for out of pocket. In that case, we are required to honor your request for a restriction.

Right to Request Confidential Communication.

You have the right to request that we communicate with you about health matters in a certain way or at a certain location. We will accommodate reasonable requests. We may require information regarding how payment will be handled or specification of an alternative address or other method of contact as a condition for accommodating your request. We will not ask you for an explanation of why you are making the request.

Breach Notification.

If there is a breach of unsecured PHI concerning you, we may be required to notify you of this breach, including what happened and what you can do to protect yourself.

Right to a Copy of this Notice.

You have the right to a copy of this notice.

COMPLAINTS

If you believe we have violated your privacy rights, you have the right to file a complaint in writing with our Office Manager. We will not retaliate against you for filing a complaint.

I am eligible for the insurance indicated on this form, and I understand that payment is my responsibility regardless of insurance coverage. I will be responsible for any services or tests that are not covered by insurance.

I authorize MCS to release any medical information to my insurance carrier or third-party payer to facilitate the processing of my insurance claims. I request payment of authorized insurance benefits for any and all services furnished to me be made payable to MCS on my behalf.

I understand that failure to pay outstanding balances will result in the termination of the clinic and submission to an outside collection agency. A $20 returned check fee will be charged for checks returned due to insufficient funds.

I understand that I am responsible for any updates, including name, address, phone, insurance, etc. I choose to receive communications from MCS by text or email (if provided), including but not limited to communications about appointments, treatment, and payment. I understand that such texts and emails may not be secure, and there is a risk that they may be read by a third party.

FSC INFORMED CONSENT

Faith Sawyer Casper LCPC

License No. LCPC-6470

This document contains important information about my professional services and business policies. Please read it carefully and jot down any questions you might have so that we can discuss them at our next meeting. When you sign this document, it will represent an agreement between us.

Informed Consent

Informed Consent is based upon Idaho Code Sections 54-3410A (stating that Licensees are required to provide Clients with informed consent); 54-3407(5) (stating that the Idaho Board of Professional Counselors and Marriage and Family Therapists (“Board”) may discipline a Licensee for violating any provision of the Board’s laws or rules); 54-3408(1) (stating it is unlawful to violate any of the Board’s laws or rules); IDAPA 24.15.01.525 (stating that Licensees are required to document the process of obtaining informed consent at the beginning of treatment and at other appropriate times and that the receipt of the disclosure shall be acknowledged in writing by both the Client and the Licensee); IDAPA 24.15.01.004.01 and 24.15.01.350 (stating that the Board has incorporated the ACA Code of Ethics); and ACA Code of Ethics Sections A.2 (stating that counselors must provide Clients with informed consent). Violations of these laws and rules constitute grounds for disciplinary action against the Licensee’s license to practice professional counseling or marriage and family therapy in the State of Idaho.

Pursuant to IDAPA 24.15.01.525, (“Rule 525”), informed consent to a patient must include the following:

Name, Business Address, and Phone Number of Licensee or Intern;
License Type and License Number, Credentials, and Certifications;
Education and Training. Formal education and training with the name(s) of the institution(s) attended and the specific degree received;
Theoretical Orientation and Approach;
Relationship. Information about the nature of the clinical relationship; fee structure and billing arrangements; cancellation policy;
The Extent and Limits of Confidentiality;
Written Statement. A statement that sexual intimacy is never appropriate with a Client and should be reported to the Board; •
Client’s Rights. The Client’s rights to be a participant in treatment decisions, to seek a second opinion, to file a complaint without retaliation, and to refuse treatment; and
Board Information. The name, address, and phone number of the Board with the information that the practice of Licensees and interns is regulated by the Board.

Education and Credentials

I graduated with honors and received a Master of Science Degree in Mental Health Counseling from Walden University in 2011. Following graduate school, I completed an additional 1400 hours of supervised training in substance abuse counseling and received the designation of Qualified Substance Use Disorder Professional (QSUDP) from the State of Idaho. I have completed my clinical license requirements to include an additional 2000 hours of supervision and received the designation of Licensed Clinical Professional Counselor (LCPC-6470) from the State of Idaho as well as the designation of National Certified Counselor (NCC) from the National Board for Certified Counselors.

Counseling Services

Counseling is not easily described in general statements. It varies depending on the personalities of the psychologist and patient and the particular problems you hope to address. There are many different methods I may use to deal with those problems.

Counseling is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In fact, you have the right to participate in treatment decisions. For the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home. However, you also have the right to seek a second opinion and refuse treatment if you choose. Counseling can have benefits and risks. Because therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness.

On the other hand, counseling has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. But there are no guarantees as to what you will experience.

Our first few sessions will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow if you decide to continue with therapy. I generally use solution-focused and Rogerian counseling as well as CBT. You should evaluate this information along with your own opinions about whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you, and if so, I will give you referrals to other practitioners whom I believe are better suited to help you.

Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. Meetings I usually conduct an evaluation that will last one hour. During this time, we can both decide if I am the best person to provide the services you need to meet your treatment goals. If we agree to begin counseling, I will usually schedule one [45-minute] session per week, at a time we agree on, although some sessions may be longer or more frequent. Once an appointment hour is scheduled, you will be expected to pay a $50.00 No-Show fee unless you provide 48 hours advance notice of cancellation (unless we both agree that you were unable to attend due to circumstances beyond your control). If you do not show up to two or more appointments, you will be automatically discharged and unable to reschedule.

Contacting Me

I am often not immediately available by telephone. Though I am usually in my office, I probably will not answer the phone when I am with a patient. I do not call patients back as a practice, but my office manager may contact you to schedule an additional appointment if needed or relay information. Clients are expected to limit the contents of their communication to basic issues such as cancellations or changes in appointment times and/or contact information. Complex client concerns should be addressed during a scheduled appointment. When I am unavailable, my telephone is answered by voicemail, which I monitor frequently, or by my secretary, who knows where to reach me. My office manager will make every effort to return your call on the same day you make it, with the exception of weekends and holidays. If you are difficult to reach, please let me know when you will be available. If you are unable to reach me and feel that you cannot wait for me to return your call, contact your family physician or the nearest emergency room and ask for the psychologist [psychiatrist] on call.

Professional Fees

My hourly fee is $200. If we meet for more than the usual time, I will charge accordingly. In addition to weekly appointments, I charge this same hourly rate for other professional services you may need, though I will prorate the hourly cost if I work for periods of less than one hour. This fee can be billed to your insurance. If you become involved in legal proceedings that require my participation, you will be expected to pay for any professional time I spend on your legal matter, even if the request comes from another party. I charge $300.00 per hour for professional services I am asked or required to perform in relation to your legal matter.

Billing and Payments

You will be expected to pay for each session at the time it is held unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when such services are requested. If your account has not been paid for more than 30 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court. [If such legal action is necessary, its costs will be included in the claim.] In most collection situations, the only information I will release regarding a patient’s treatment is his/her name, the dates, times, and nature of services provided, and the amount due.

Billing and Payments

Insurance Reimbursement

In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. You (not your insurance company) are responsible for full payment of my fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience, and my office manager will be happy to help you in understanding the information you receive from your insurance company. If necessary, my office manager is willing to call the insurance company on your behalf to obtain clarification.

Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans often require authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. Though a lot can be accomplished in short-term therapy, some patients feel that they need more services after insurance benefits end. [Some managed-care plans will not allow me to provide services to you once your benefits end. If this is the case, I will try to assist you in finding another provider who will help you continue your counseling.] You should also be aware that most insurance companies require that I provide them with your clinical diagnosis.

Sometimes, I have to provide additional clinical information, such as treatment plans, progress notes or summaries, or copies of the entire record (in rare cases). This information will become part of the insurance company files. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any records I submit if you request it. You understand that, by using your insurance, you authorize me to release such information to your insurance company. I will try to keep that information limited to the minimum necessary. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end our sessions. It is important to remember that you always have the right to pay for my services yourself to avoid the problems described above (unless prohibited by the insurance contract).

Complaints/Grievances

Ideally, all grievances should be addressed directly with me. You do have the right to file a complaint with the Division of Occupational and Professional Licenses (“Division”) with the assurance that I will not retaliate against you for filing the complaint. If a Client or another person files a complaint with the Division related to my counseling services of the Client, I may disclose relevant information regarding the Client to defend myself. Sexual Intimacy with a Client is Never Appropriate Sexual intimacy is NEVER appropriate with a Client and should be reported to the Board through the Division:

Idaho Division of Occupational and Professional Licenses

700 West State Street P.O. Box 83720 Boise, ID 83720-0063

(208) 334-3233

http://ibol.idaho.gov/IBOL

Confidentiality

In general, the privacy of all communications between a patient and a counselor is protected by law, and I can only release information about our work to others with your written permission. But there are a few exceptions. In most legal proceedings, you have the right to prevent me from providing any information about your treatment. In some legal proceedings, a judge may order my testimony if he/she determines that the issues demand it, and I must comply with that court order. There are some situations in which I am legally obligated to take action to protect others from harm, even if I have to reveal some information about a patient’s treatment. For example, if I believe that a child is being abused or has been abused, I must make a report to the appropriate state agency. If I believe that a patient is threatening serious bodily harm to another, I am required to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the patient. If the patient threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her or to contact family members or others who can help provide protection. If a similar situation occurs during the course of our work together, I will attempt to discuss it with you fully before taking any action. I may occasionally find it helpful to consult other professionals about a case.

During a consultation, I make every effort to avoid revealing the identity of my patient. The consultant is also legally bound to keep the information confidential. Ordinarily, I will not tell you about these consultations unless I believe that it is important to our work together. Although this written summary of exceptions to confidentiality is intended to inform you about potential issues that could arise, it is important that we discuss any questions or concerns that you may have at our next meeting. I will be happy to discuss these issues with you and provide clarification when possible. However, if you need specific clarification or advice I am unable to provide, formal legal advice may be needed, as the laws governing confidentiality are quite complex, and I am not an attorney.

Your signature at the end of this document indicates the following:

·That you have been provided, have received, and have read the information in this document, including all of the information required by Rule 525;

·That you agree to abide by the terms contained in this document during our professional relationship;

·That you understand the rights and responsibilities of both the Patient and the Counselor; and

·That we may have expanded upon the above issues in more detail, addressed additional questions, or discussed other issues related to your treatment in verbal discussions.

Informed Consent

This document is intended to inform you about TeleHealth practices, risks, and benefits. Telehealth means the mode of delivering mental health and medical health services via technology-assisted media, such as, but not limited to, telephone, email, or synchronous video. Medical Consulting Services (MCS) will be using TeleHealth services in lieu of face-to-face appointments until further notice.
Platform MCS uses to conduct synchronous video sessions is Doximity, which is HIPPA compliant. In the event that you or MCS cannot access Doximity due to poor internet conditions, MCS will use audio only. You will be responsible for accessing the meeting in a safe and secure location and working with me to initially set up emergency procedures specific to TeleHealth Services.
Be advised this is a supplemental agreement to the Informed Consent you have already signed and agreed to and does not replace the original informed consent but rather details information specific to TeleHealth services.
TeleHealth services should not be viewed as a complete substitute for appointments conducted in the office. It is an alternative form of therapy or adjunct therapy and it involves limitations. When using technology there is always the risk of security issues as well as technical issues. When using technology there is the risk of PHI (protected health information) not remaining securely protected.
also be advised that while some insurance companies will pay for TeleHealth Services others do not. If it is not covered under your plan you will be responsible for the entirety of the session. Please know your benefit ahead of time.
Responsibilities for Confidentiality and Telehealth
Consider what information you are communicating and through what devices and their security. When conducting an appointment via synchronous video/audio, it is your responsibility to choose a secure location. Please be aware that family, friends, employers, coworkers, strangers, and hackers could either overhear your communications or have access to the technology that you are interacting with. Additionally, you agree not to record any Telehealth sessions or keep any such recordings on any devices.
At the beginning of each TeleHealth session, you will be required to indicate to me your location, including your address. This is done as a protective measure in case there is a crisis, I can help support you better in these particular situations.

Needs and Expectations

Operational device that runs Doximity (computer or cell phone)
Proper lighting and seating to ensure a clear image of each partyʼs face.
Dress and environment appropriate to an in-office visit.
Only agreed upon participants will be present.

Consent to TeleHealth Treatment

I agree to receive TeleHealth services and have been informed of the risks and benefits and limitations surrounding TeleHealth. By signing this Informed Consent, I, the undersigned client, acknowledge that I have both read and understood all the terms and information contained herein. Ample opportunity has been offered to me to ask questions and seek clarification.

I understand that if I am not currently in the state of Idaho or am engaging in any other activities during the time of my appointment (driving/shopping/eating lunch at a restaurant etc.) then my appointment will be immediately terminated.

Telehealth Code of Conduct

I understand that engaging in telehealth is not the same as engaging in a ‘phone call’ and as such I will conduct myself in the same manner as I would were I seeing my provider in a clinical setting.
I understand that I need to be sitting in a quiet place, alone, at the time of my appointment.
I will be available at the scheduled time of my appointment.
I understand that MCS will make two attempts to contact me (if you miss the first call, do not call the office as it may interfere with the provider’s ability to contact you).