The following is a consent for treatment, authorization for parties to release information for treatment/billing purposes and a summary of how your health information may be disclosed:
GOODMAN MENTAL HEALTH may use my health care information to provide treatment, coordinate with my treatment team and provide alternatives, obtain payment, conduct health care operations, to contact me or my POA, to report abuse, neglect or violence, administrative oversight, or in judicial proceedings, as legally required. I have a right to request restrictions to my health care information, receive confidential and private communications, inspect my record, amend my health care information, and request an accounting of disclosures.
I acknowledge that the facility in which I reside has contracted with GOODMAN MENTAL HEALTH to provide behavioral health services to the facility’s residents. I willingly admit myself for all treatment consistent with the treatment program, patient rights, and billing procedures as will be explained to me by the behavioral health consultant, Dr. David J. Goodman.
I understand that GOODMAN MENTAL HEALTH will bill Medicare and/or other insurance or through an agreement with the facility for the services rendered. All charges not covered by Medicare, other insurance or the facility are the responsibility of me, the undersigned (resident’s POA, guardian and/or trust.) In cases where it is medically necessary and appropriate to bill other payors, I request that payment of authorized Medicare or other insurance benefits be made on my behalf to GOODMAN MENTAL HEALTH for services furnished me by Dr. David J. Goodman, and I hereby assign medical reimbursement rights to GOODMAN MENTAL HEALTH and authorize such insurance providers to make payments for services rendered directly to GOODMAN MENTAL HEALTH.
I understand that I am financially responsible to the provider for all co-insurance charges or other fees not covered by my health care plan. This Authorization and Consent are provided throughout my care with GOODMAN MENTAL HEALTH but may be revoked at any time by written notification. A copy of this consent shall be considered as valid as the original.