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Consent Form

Medication Policy:

If medication needs are identified, I agree to comply with medication treatment as prescribed. It is not our policy to renew prescription medication over the telephone. Due to the need for close medication monitoring, prescription refills are disbursed only at the time of an office/tele-psychiatry visit. Therefore, it is imperative that the patient keeps his/her medication appointment.

Litigation Disclosure:

I understand that PIRC Clinic, Inc. will not become involved with custody battles or other legal exchanges with attorney’s etc. PIRC will exchange written information to the patient or the patient’s legal guardian and it will be up to the patient or the patient’s legal guardian to share the information with the attorney or other interested parties.

Fee Agreement:

I also understand that while I am participating in treatment, I may be expected to pay a fee for all social and/or medical services that I received, unless other fee arrangements are made. I understand that PIRC will bill any of the following sources:

Government Funded Program (free of charge), including Medicaid or Medicare (I will pay the Medicaid /Medicare Copay of $ )

Private Insurance and I will pay the Co-pay of $ per session.

Grant/Private funding which is free of charge to me based on the funding criteria

Self-pay and I will pay the full cost of $ per (1) hour counseling session. I understand that I am required to pay the regular fee for appointment that I miss unless cancelled within 24 hours of my scheduled appointment.

Client Signature

SIGNATURE

Client`s Notice of Privacy Practice

This agency is committed to ensuring that you receive professional and humanistic services, directed toward your needs, and in a manner that protects your dignity and feelings of self worth. To this end, the following Statement of Rights has been formulated:

CIVIL RIGHTS

You have the right to be treated with dignity and respect.
You retain all rights, benefits and privileges guaranteed by law.

DISCRIMINATION

Services will be provided to you and/or your family members without discrimination. Ethnic background, personal or social creed, racial membership, sex, religion, or age will not affect our services to you.
You will not be refused any services based on lack of, or limited, personal financial resources. Travel and loss of work time will be discussed and kept at a minimum. No physical barriers will preclude treatment.
Services will be provided with a minimum waiting time. Agency service hours will be reasonably convenient

CONFIDENTIALITY

Your medical and social service records are confidential and cannot be released to anyone without express consent given by you or your guardian. However, the Court without your permission can subpoena your records, especially if you are court-mandated to treatment. Also, knowledge of child abuse, elder abuse, and intent to harm others or you must, by law be reported in addition to knowledge of communicable diseases.
You have the right to review and approve any information being requested by another provider agency.

TREATMENT

You have the right to an individual plan for treatment and will be expected to participate in your plan for treatment.
You have the right to know the name and professional credentials of anyone working with you.
You may request to participate in any staff meeting regarding yourself.
You may review your clinical record upon written request.
You will be advised of the positive effect and possible complication of any drugs or medications prescribed by any physician involved in your treatment.
You have the right to refuse to participate in, or be interviewed for, research purposes.
You have the right to refuse any electronic and/or visual recording of your treatment without your expressed written approval.
You have the right to terminate treatment at anytime.

GRIEVANCE PROCEDURE

If you feel that your treatment program has not been provided fairly, or reasonably, you may present your concerns, in writing to the PIRC's management / supervisory staff.
You have the right to legal recourse; you have the right to confer with family, attorney, physician, clergyman, and others at any time.
You may contact the Alcohol, Drug Abuse and Mental Health Office of the Department of Children and Families at (954) 467-4298 if you have a grievance regarding the treating agency.
You are under the protection provided under Florida Statute 491 Section 10E-16004 (27) as follows: Protection of patient’s – the rights of the patient’s who are admitted to this program shall be assured and defined in each program operating standards. This shall include operating standards, which protect the dignity, health and safety of patient’s.

EVALUATION

Consistent with providing professional and quality services, you will be given and opportunity to evaluate all aspects of your services and the personnel with whom you were involved. (You may be asked to evaluate your treatment, in writing, during or upon completion of treatment).

Client Signature:

CLIENT SIGNATURE