Healthcare Service Delivery Overview

HEALTHCARE SERVICE DELIVERY OVERVIEW

Patient Information

Date of Birth:    Gender:

Primary Phone:    Email:

Emergency Contact

Relationship:    Phone:

Insurance Information

Policy Number:    Group Number:

Medical History (Relevant)

Service Summary and Goals

Expected Frequency:    Anticipated Start Date:    Anticipated Duration:

Scope of Services — Inclusions

The provider will furnish the services checked below as part of the care plan. Services will be provided consistent with applicable professional standards of care.

Assessment and treatment planning

Individual counseling / therapy sessions

Medication management (if applicable)

Care coordination with other providers

Home visits (as indicated)

Telehealth services (video or telephone)

Limitations, Exclusions, and Risks

The following services are not included in this plan unless expressly documented: emergency room services, inpatient hospitalization beyond pre-authorized stays, non-covered durable medical equipment, and any service outside the scope of licensed practice of the provider. Patient acknowledges that all clinical interventions carry potential risks and benefits. The provider has described material risks, potential side effects, and alternatives appropriate to the recommended services.

Responsibilities

Provider Responsibilities: The provider will deliver services in a professional manner, maintain clinical records, communicate with other treatment providers as authorized, and bill in accordance with stated policies.

Billing, Payment and Authorization

Charges for services will be submitted to the insurance identified above when permitted. The patient is responsible for co-payments, deductibles, and any non-covered charges. The patient authorizes the provider to seek payment from the listed insurer and to release necessary information to facilitate payment.

Insurance Assignment Consent: I authorize assignment of benefits to the provider and permit release of medical information necessary to process claims.

Privacy, HIPAA Acknowledgment and Record Release

The provider maintains a notice of privacy practices describing uses and disclosures of protected health information. By signing below, the patient acknowledges receipt of privacy practices and authorizes release of clinical information to other providers, payers, and authorized individuals as necessary for treatment, payment, and healthcare operations as permitted by law.

Authorization to Release Records: I authorize the release of medical records related to the services described in this document to other health care providers, payers, and authorized parties as needed for care coordination and payment.

Authorization Expiration Date:

Consent, Acknowledgement, and Right to Withdraw

By signing this Healthcare Service Delivery Overview, the patient (or legally authorized representative) confirms that the contents of this document have been explained and that the patient understands the scope of services, anticipated benefits and material risks, billing responsibilities, and privacy practices. The patient may withdraw consent to services at any time in writing, subject to the provider's policies regarding safe termination of services and continuity of care.

I acknowledge that I have had the opportunity to ask questions and that those questions have been answered to my satisfaction:
I acknowledge understanding of the information above.

Complaint, Termination and Emergency Procedures

Complaints regarding services, billing, or privacy may be submitted in writing to the provider. The provider reserves the right to terminate services when clinically indicated, for non-compliance with treatment plans, or for failure to meet financial obligations. In the event of a medical or psychiatric emergency, contact emergency services immediately.

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