STATEMENT OF UNDERSTANDING

BJC Behavioral Health Authorization for Treatment and Financial Responsibility

Consent to Treat
I request treatment of BJC Behavioral Health. I consent to routine diagnostic evaluation, case management, therapy, and medication management deemed medically necessary. I understand that BJC Behavioral Health makes no guarantees to me as to the results of treatment or evaluation.

Utilization Review
In the event the client herein is covered by an insurance agreement, Missouri Department of Mental Health funds, health maintenance organization and/or preferred provider organization, my treatment may be subject to utilization review concerning my care at BJC Behavioral Health.

Financial Responsibility
In Consideration of services rendered and to be rendered to the client herein, the undersigned Responsible Party agrees to pay BJC Behavioral Health for services rendered to the above-named client. A Client eligible for services under the Department of Mental Health criteria is not responsible for more than the amount determined by the Department of Mental Health Standard Means Test. Members of health maintenance organizations and/or preferred provider organizations are generally required to comply with certain policies and procedures requiring use of participating providers and compliance with plan requirements for primary referral, emergency admission, pre-certification and utilization review. These are conditions to payment of benefits by companies, health maintenance organization and/or preferred provider organizations. By signing this form, which includes a statement about financial responsibility, I, as the client and/or guarantor, acknowledge and agree that I am responsible for payment of billed charges rendered in any case in which payments denied by the companies, health maintenance organizations and/or preferred provider organizations because of a failure to comply with such coverage requirements or for any other reason.

Assignment of Outpatient Behavioral Health Benefits
I hereby assign payment of any insurance benefits, including Medicare and Medicaid, otherwise payable to me, to be paid directly to BJC Behavioral Health for treatment charges. I also authorize and direct any holder of medical and other information about me, as it pertains to my health care, to release all needed information to determine benefits payable. I request that payment of authorized benefits be made on my behalf.

Medicare Assignment Certification
I certify that the information given by me in applying for payment under Title XVIII of the Social Security Act is correct. I authorize and direct the release of medical or other information to the Medicare Program or its intermediaries or carriers concerning this or a related claimed by BJC Behavioral Health. I request that payment of authorized benefits be made on my behalf.

Acknowledgement of Receipt of Notice of Privacy Practices
I have received, or I have been provided the opportunity to receive, a copy of the “Notice of Privacy Practices” that explains when, where, and why my confidential health information may be used or shared. I acknowledge that BJC Behavioral Health, the physicians, the nurses, and other BJC Behavioral Health staff may use and share my confidential health information with others in order to treat me, in order to arrange for payment of my bill and for issues that concern BJC Behavioral Health’s operations and responsibilities.

Confirmation

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Authorization to Utilize Unencrypted Communications for Sharing Protected Health Information

Electronic mail (email), phone calls, and text messaging are very common and convenient forms of communication. These methods may be used to share information between you and your doctors. As a patient, you have the right to confidentiality of your Protected Health Information (PHI). It is important for you to understand that unencrypted email and text messaging are not secure communications. This means that there is a potential risk that messages containing your PHI may be intercepted by a third party. Encryption is the process of making information unreadable unless you have the password or key to decrypt the information. BJC does not encrypt text messages. We have the ability to encrypt email communications with you. We will encrypt email communications unless you tell us that you prefer to use unencrypted email. If you would like us to communicate with you by text or phone and you understand that we will not use encryption. please initial below.

If you elect to receive communications in this manner, we will use text messaging or phone calls to remind you of upcoming appointments, follow-up regarding clinical management and inquire about symptoms, events. We will limit information sent to you to the minimum deemed necessary to benefit your health.

Email, phone, and other messaging communications may become a part of your patient medical record and accessible to the clinical support staff responsible for your care.

Your email, phone and text responses will be recorded and reviewed by a designated healthcare provider. Not all responses will receive follow-up. If you expect a response from your provider’s office and have not heard back, please call the office during regular business hours. EMAIL OR TEXT MESSAGE COMMUNICATION SHOULD NEVER BE USED IN THE CASE OF AN EMERGENCY OR FOR UREGNT REQUESTS FOR INFORMATION.

If you elect to communicate from a workplace computer or email account, please be aware that your employer and workplace agents might have access to those email communications. This authorization may be revoked at any time and must be done in writing. It is understood that the revocation will not apply to information that has already been released.

Authorization is valid while in a treatment relationship with any BJC provider.

My signature indicates that I understand and accept the terms and conditions outlined herein. I authorize communications from my health care provider to the email address, messaging application, and/or phone number provided below.

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