Healthcare EBP Addendum

HEALTHCARE EBP ADDENDUM

This Evidence-Based Practice (EBP) Addendum supplements the existing treatment agreement between the patient and the treating provider. It documents the use, purpose, anticipated scope, data collection, and patient authorizations associated with delivery of evidence-based clinical interventions.

Addendum Identification

Client Name:    Date of Addendum:

Treating Provider:    Clinic/Program:

Patient Information

Male    Female    Other (specify):

Insurance / Payer Information

EBP Intervention Details

Selected Evidence-Based Intervention(s) (check all that apply):

Cognitive Behavioral Therapy (CBT)    Dialectical Behavior Therapy (DBT)    Motivational Interviewing (MI)    Trauma-Focused CBT    Exposure Therapy    Other:

Outcome Measurement & Data Use

Standardized measures that may be used to track progress (check all that apply):

PHQ-9    GAD-7    Beck Inventories    Other:

The provider may collect and use de-identified or identifiable outcome data for clinical decision-making, quality assurance, supervision, and permitted reporting to payers. By initialing below the patient acknowledges the specific data uses described in this addendum and authorizes the uses checked.

I consent to collection and use of my treatment outcome data for the purposes described above.

Risks, Benefits, and Patient Rights

Benefits: The selected evidence-based interventions have demonstrated effectiveness for stated clinical problems. Expected benefits include symptom reduction, improved functioning, and acquisition of coping skills.

Risks: As with all clinical interventions, potential risks may include temporary increases in distress, activation of emotions or memories, and the need to address difficult material. The provider will use clinical judgment to mitigate risks and will collaborate with the patient regarding pacing and safety planning.

Patient Rights: Participation in the specified EBP is voluntary. The patient has the right to ask questions, refuse or discontinue the intervention, request alternative interventions, and withdraw authorization for data use at any time without jeopardizing access to other services within the limits described in the treatment agreement and applicable law.

I acknowledge that I have discussed the risks and benefits of the selected EBP intervention(s) with my provider and that my questions have been answered to my satisfaction.

I acknowledge risks and benefits as described above.

Confidentiality and Limits

All information disclosed during treatment is subject to confidentiality protections under applicable law. Exceptions include imminent risk of harm to self or others, suspected abuse or neglect of a vulnerable person, and other legally mandated disclosures. Data sharing to payers or other entities will only occur as authorized above or as required by law.

HIPAA and Privacy Acknowledgment

I acknowledge that I have been provided a Notice of Privacy Practices describing how my protected health information may be used and disclosed and my rights regarding that information.

I acknowledge receipt of the privacy notice.

Authorization Duration and Revocation

Unless otherwise revoked in writing, this authorization is valid until:

Revocation of this authorization must be submitted in writing to the treating provider. Revocation will not affect disclosures made in reliance on this authorization prior to receipt of revocation.

Patient Certification

By signing below I certify that I have read and understand the information contained in this EBP Addendum, I have had an opportunity to ask questions, and I voluntarily consent to the use of the specified evidence-based interventions, data collection, and authorized disclosures as indicated above.

Sign Now