Healthcare Behavioral Health Contract

HEALTHCARE BEHAVIORAL HEALTH CONTRACT

Parties and Effective Date

Provider Name:   Provider License/ID:

Provider Address:

Patient Name:   Date of Birth:

Effective Date of Agreement:

Scope of Services

The Provider agrees to deliver behavioral health services which may include assessment, psychotherapy, counseling, case management, and coordination of care. Specific services to be provided are described below.

Treatment Plan and Goals

Patient and Provider will collaborate to develop and periodically review a treatment plan that identifies goals, expected frequency of sessions, estimated duration, and measurable outcomes.

Duration, Sessions and Termination

Estimated start date:   Estimated end date:

Frequency of sessions:   Maximum anticipated sessions:

Either party may terminate services with written notice; however, the patient remains responsible for fees for services rendered through the date of termination and for any missed appointments per the cancellation policy below.

Fees, Billing and Insurance

Fee per session:   Insurance copay:

Patient is responsible for deductible, copayments, coinsurance, and any non-covered services. Provider will bill insurance as permitted; patient authorizes release of necessary information for claims submission.

Cancellation, No-Show and Late Fees

Appointments canceled with less than 24 hours' notice or missed without notification may be charged a late-cancellation/no-show fee.

Late-cancellation/no-show fee amount:

Confidentiality and Limits to Confidentiality

Communications between patient and provider are confidential and protected by law. Exceptions where information may be disclosed without patient consent include: suspected child or elder abuse or neglect; imminent risk of harm to self or others; mandated reporting by law; subpoena or court order; and where necessary for billing and treatment coordination as described above.

Patient authorizes the Provider to disclose treatment information to the extent required for payment, treatment coordination, and as otherwise required or permitted by law.

Telehealth and Electronic Communications

Telehealth sessions use interactive audio and video technologies. Risks include technical failure and reduced non-verbal cues. Patient consents to telehealth as indicated below and understands the Provider may discontinue telehealth if clinically inappropriate.

I consent to receive behavioral health services via telehealth.

Medication Management

If medication management is part of services, the Provider will review medications, monitor side effects, and coordinate with prescribing clinicians. Patient agrees to notify the Provider of all current medications and changes.

Current medications:

Risks, Benefits and Alternatives

Potential benefits of treatment include symptom reduction, improved functioning, and enhanced coping skills. Risks may include emotional discomfort, increased distress when addressing sensitive issues, and potential changes in personal relationships. Alternatives to proposed treatment include referral to other providers, different therapeutic modalities, or no treatment.

Patient Responsibilities

Patient agrees to attend scheduled appointments, notify the Provider of cancellations, provide accurate medical and medication history, participate in treatment planning, and fulfill financial obligations. Failure to comply may result in termination of services.

Emergencies and After-Hours

This Provider does not provide emergency services. For immediate danger to life or severe medical emergencies, contact emergency services or go to the nearest emergency department. The patient should use local emergency resources in such situations.

HIPAA and Privacy Acknowledgment

Patient acknowledges receipt of the Provider's privacy practices and understands how protected health information may be used or disclosed for treatment, payment, and healthcare operations.

I acknowledge receipt of the Provider's privacy practices and notice of how my protected health information may be used or disclosed.

Authorization and Expiration

By signing below, the Patient (or legal guardian) authorizes the Provider to deliver behavioral health services as described, to release information as necessary for billing and care coordination, and affirms understanding of the terms of this Agreement.

This authorization expires on:

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