Michelle Turbide, LICSW
Telehealth Behavioral Health Care Provider- Vermont 802.881.9001
CLIENT’S DISCLOSURE CONFIRMATION AND INFORMED CONSENT
I have read (or have had read to me) the Practice Policies and Telehealth policies and have discussed it where I needed clarification. My signature at the end of this documents acknowledges that I have been given the professional qualifications, office policies, experience of Michelle Turbide, LICSW, a statement of after-hours emergencies, and a listing of actions that constitutes unprofessional conduct according to Vermont statutes. I have also been informed of the methods for making a consumer inquiry for filing a complaint with the Office of Professional Regulation and I have reviewed HIPPA confidentiality (See Privacy Notice).
My signature also indicates that I agree and consent to participate in behavioral health care services offered and provided by Michelle Turbide, LICSW, a licensed independent clinical social worker. I understand that I am consenting and agreeing only to those services that Michelle Turbide, LICSW is qualified to provide within the scope of her license, certification, and training. I also understand that Michelle Turbide is an independent contractor.
If the patient is under the age of eighteen or unable to consent to treatment, I attest that I have legal custody of this individual and am authorized to initiate and consent for treatment and/or legally authorized to initiate and consent to treatment on behalf of this individual.
TELEHEALTH INFORMED CONSENT
I hereby consent to engaging in telehealth with Michelle Turbide, LICSW. I understand that “telehealth” includes the practice of health care delivery, assessment, diagnosis, consultation, treatment, transfer of medical data, and psychoeducation using interactive audio, video, or data communications. I understand that, with my signed consent, telehealth may also involve the communication of my mental health information, both orally and visually, to other health care providers located in Vermont.
Technology: I understand that I will need to download an application and/or software to use this platform. I also need to have a broadband internet connection or a smart phone device with a good cellular connection at home or at the location deemed appropriate for services. I also understand that in case of technology failure, I may contact Michelle via phone to coordinate alternative methods of treatment.
Insurance and Fees: If you reside in the state of Vermont, telehealth services will be billed through your insurance provider just as if you were coming in to the office. Due to licensing regulations, I will not be able to provide services to you if you are out of state.
Scheduling: I understand that scheduling is conducted through Michelle Turbide and is based on my provider’s normal office hours. Telehealth appointments are considered outpatient services and not intended as a substitute for emergency or crisis services. Crisis or mental health emergencies should be directed to the local county crisis line or by dialing 911.
Video/Audio Recording: Following legal and ethical guidelines, telehealth sessions will not be recorded. (Please see my office policy on this)
Confidentiality: I understand that the laws that protect the confidentiality of my medical information also apply to telehealth. As such, I understand that the information disclosed by me during the course of my therapy is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited to: reporting child, elder, and dependent adult abuse; expressed threats of violence towards self or others. Michelle will use a HIPAA compliant platform to provide telehealth services to protect my privacy and confidentiality. (See policy for more detail on disclosures).
I understand that I have the following rights with respect to telehealth:
- I have the right to withdraw my consent at any time.
- I understand that there are risks and consequences associated with telehealth including, but not limited to
the possibility that despite reasonable efforts on the part of my therapist, the transmission of my medical
information could be disrupted or distorted by technical failures.
- I understand that I may benefit from telehealth but that results cannot be guaranteed or assured.
- I understand that I have a right to access my mental health information and copies of medical records in
accordance with Vermont state law.
I have read and understand the information provided above. I have asked my therapist questions and had them answered to my satisfaction. My signature below indicates my informed and willful consent to treatment using a telehealth platform.
Release of PHI
I hereby authorize the release of information of my protected health information for treatment, payment, and health care operations and to file a claim with my insurance company and for insurance benefits to be paid directly to Michelle Turbide, LICSW. I understand that I may revoke this consent in writing, except that the therapist has already taken action based upon my prior consent. If consent is revoked, I will be responsible for any treatment services rendered.
I understand that I am financially responsible for any unpaid balance, including deductible and co-payment, which are due at the time of service. There will be a $30 charge for any returned checks. All credit card payments processed through the Jituzu portal will be listed on your credit/debit account as “medical billing” and will not have identifying information. (The exact identifier is subject to change). Please keep track of your payment dates/amounts so that you can recognize them on your banking statements. Any fees associated with reversal of payments will be the responsibility of the client.
MISSED OR CANCELED APPOINTMENTS
I understand that there will be a charge for missed or canceled appointments if less than 24 hours notice is given. Cancelations fees are $30 for the first missed session and the usual and customary rate of session reimbursement thereafter (which can vary based on insurance).
If there are more than 3 sessions missed without proper notice there may be a discontinuation of services. (please see longer policy description under this policy for more detail).
For clients whose insurance does not allow for missed session fees per contract there will be the same 3 missed session policy.
FEES FOR SERVICES
The initial evaluation fee is $130 for the first session. Follow up visits, which last 45-50 minutes, are $120 per sessions. Sessions that last longer than 50 minutes are billed at $140, which may require pre-authorization and a larger copay or copayment if you are billing insurance.
I understand that my participation in therapy is completely voluntary, and that I may terminate treatment at any time. The goals of my treatment have been agreed upon with my provider.
I have read this document and understand and consent with the content.
NAME OF CLIENT:
For Minor Clients:
I hereby give permission for Michelle Turbide, LICSW to treat ___________________________(If Client is a Minor)
Client or Parent/Guardian