Healthcare MHAC Agreement

Healthcare MHAC Agreement

This Mental Health Assessment and Care Agreement (MHAC Agreement) is entered into between the following parties for the purpose of establishing the terms governing mental health assessment, treatment planning, and ongoing care.

Patient Information

Insurance & Financial Responsibility

I agree that I am financially responsible for services not covered or not paid by my insurer, including co-payments, deductibles, late cancellation or missed appointment fees, and non-covered services. I authorize the provider to bill my insurance and to release information necessary for processing claims.

Medical & Mental Health History

Scope of Services

The provider will perform a mental health assessment and may provide treatment including psychotherapy, medication management, safety planning, coordination of care with other providers, crisis intervention, and referral to community resources as clinically indicated. Specific services to be provided are:

• Comprehensive psychiatric/psychological assessment and diagnostic formulation
• Individual psychotherapy and/or group therapy as appropriate
• Medication evaluation and management if indicated
• Crisis assessment and emergency safety planning
• Coordination and exchange of information with other treating providers as authorized below

Risks, Benefits & Alternatives

I understand that mental health treatment involves potential benefits and risks. Benefits may include symptom reduction, improved functioning, and better coping skills. Risks may include emotional discomfort, activation of painful memories, and no guarantee of improvement. Alternatives include no treatment, different therapies, or referral to other specialists.

Consent to Treatment & Telehealth

By signing this agreement I authorize the provider to deliver the assessment and treatment described. I consent to telehealth services when offered, understanding the technological, privacy, and clinical limitations associated with remote care. I have the right to refuse or withdraw consent at any time, subject to professional and legal obligations.

Telehealth consents: I consent to receive telehealth services as part of my care.

Confidentiality & Limits

All information disclosed within sessions is confidential and protected by law, except where disclosure is required or permitted, including: suspected abuse or neglect of a child, dependent adult, or elder; reasonable suspicion of intent to harm self or others; court order or subpoena; or to coordinate care with other providers when authorized. In emergencies, the provider may disclose information to emergency services or other appropriate entities to prevent harm.

Release for Coordination of Care

I authorize the provider to communicate with and exchange relevant information with the following individuals or organizations for purposes of treatment and coordination of care:

Authorization & Expiration

This authorization to provide care, communicate with authorized parties, and bill insurance shall remain in effect until revoked in writing by the patient or the expiration date below, whichever occurs first. Written revocation will not affect actions taken prior to receipt of revocation.

Expiration date (if different from ongoing care):

Patient Acknowledgments

I acknowledge that I have read and understand the terms of this MHAC Agreement, have had the opportunity to ask questions, and consent to the services described. I understand my rights and the limits of confidentiality as set forth herein.

HIPAA Privacy Notice: I acknowledge receipt of the provider's privacy practices and understand how my health information may be used or disclosed.

Termination of Services

Either the patient or the provider may terminate treatment at any time. If the provider determines continued provision of services is inappropriate or clinically contraindicated, the provider will offer referrals when practicable.

Complaints & Grievances

If you have concerns about the care you receive, you should raise them with your provider. You may also submit a formal grievance in writing to the practice administrator. Filing a grievance will not affect your access to services.

Sign Now