We try to keep policies to the minimum, but have a few that we want to make sure you understand before starting treatment.

The purpose of this form is to obtain your consent to receive treatment at the Mood Treatment Center and to participate in a telehealth visit using secure HIPAA-compliant systems.

I will pay for in-person office visits at the time of service.  I agree to have my credit card on file run the day of any telehealth appointment as detailed in the Billing and Scheduling Section below.   If I miss or cancel an office or telehealth appointment with less than 24 hours notice, even for a good reason,  I agree to have my credit card on file run for the late cancellation or missed appointment fee as detailed in the Billing and Scheduling Section below.

If using insurance, I accept responsibility for any charges not covered by my plan. If my insurance has not been verified, is out of network, or my deductible still needs to be met, I will pay the full patient cost-share at my visit. I authorize payment of medical benefits to the Mood Treatment Center and the release of any diagnostic, medical, psychiatric, and substance abuse information to my insurer that is needed to process my claims. 

If you are in crisis outside of an office appointment or telehealth session, please contact the MTC crisis line (336-525-9090), the National Suicide Prevention Hotline (1-800-273-8255), 911, or visit https://crisissolutionsnc.org for your local crisis team.

I have received the Privacy Notice (at bottom of page).

Telehealth involves the use of electronic communications to enable clinicians to provide virtual individual or group sessions either through HIPAA-compliant software or over the phone. You will receive a link by text or e-mail to access each session.  Please be aware that session access should be accessed by clicking the link received and not through the Zoom mobile app.  

We will uphold the same principles of confidentiality whether your visit is conducted in person or via telehealth. There are risks associated with using technology as a means of transmitting sensitive information, and there may be authorized or unauthorized access to such transmissions and records. To ensure confidentiality to the best of our ability, MTC will be using encryption software during telehealth visits. You are strongly encouraged to receive your telehealth visits in a private setting.

To avoid breaches of confidentiality, your clinician will take steps to confirm your identity at the beginning of each telehealth session. Provider will also verify your current phone number and physical address to retain contact should connectivity be lost or should emergency personnel be needed to help you in a medical emergency.

Telehealth visits help to maintain access to care when in-office visits are not feasible. However, you may experience technological difficulties such as interrupted internet connection, lagging or freezing of video transmission, delays in sound, etc., that could impair the quality of care you receive should connection or format issues cause misunderstandings between you and your provider. Should the technology fail during a session, please plan to continue via phone. Although MTC will do its best to uphold confidentiality standards, we are aware that there are inherent risks associated with using technology as a means of service.

Though telehealth is an internet-based modality, using telehealth does not imply an open digital relationship with your provider. To maintain confidentiality and professional boundaries, your provider will not interact with you on any social media or other internet platforms.

All existing laws regarding your access to medical information and copies of your medical records apply to in-person office visits and telehealth visits. Records associated with in-person office visits and telehealth visits will become a part of your medical record.

You may withhold or withdraw consent to telehealth visits in writing at any time without affecting your right to future care or treatment.

If an in-person office visit is not possible at MTC and you cannot access or choose to not access telehealth sessions, MTC will provide you with appropriate referrals to equivalent mental health services.

Payment for in-person office visits is due at the time of service. For telehealth appointments, clients are required to complete payment through our secure patient portal prior to the start of the session.   All clients must have a valid credit or debit card on file at all times. If the credit card on file declines or payment is not completed, the appointment may be canceled and rescheduled. If a payment issue is identified after a session has already occurred, all future appointments will be placed on hold until the balance is resolved.   Telehealth appointments are scheduled in the same manner as in-person visits. The estimated cost share is based on information provided by your insurance company and may be adjusted once claims are processed.   Fees for missed or late-canceled appointments will be charged to the card on file within 48 hours of the charge being posted to your account. Medication Visit: Late Cancellation and No-Show Fee: $50.00

By signing below, I agree to the terms outlined above and consent to receive treatment at Mood Treatment Center, including participation in telehealth sessions using secure HIPAA-compliant systems unless otherwise indicated. This authorization will expire 12 months from the date signed.

All clients are required to have a credit or debit card on file at all times. Card information is stored securely in our HIPAA-compliant electronic health record system.   By signing below, I authorize Mood Treatment Center to charge the card I have placed on file for telehealth sessions prior to the start of the session, in-person services at the time of service, any applicable fees related to missed or late-canceled appointments, and any patient responsibility amounts not covered by insurance.   I understand that I can update the card on file at any time through the secure patient portal or by contacting Mood Treatment Center at 336-722-7266. A Credit Card Change Form will need to be completed for any updates to the credit card on file. Prior to your appointment, you will be required to provide detailed credit/debit card information to store electronically in our billing system. If this information is not provided 24 hours before the appointment, the appointment will be canceled and rescheduled. By signing this form, you authorize Mood Treatment Center to charge fees that you are financially responsible for to the credit or debit card listed above. This authorization will remain in effect for 12 months from the date signed or upon termination of services with the organization.

I understand and voluntarily agree that (initial each statement after reviewing):

Authorization for the Disclosure of Protected Health Information for Treatment, or Healthcare Operations (164.508(a)) As part of a client’s care, the client should understand that the Mood Treatment Center originates and maintains health records describing the client’s health history, symptoms, examination, and test results, diagnosis, treatment, and any future care or treatment. This information serves as:   A.   a basis for planning the client’s care and treatment; B.   a means of communication among the health professionals who may contribute to the client’s health care; C.   a source of information for applying the client’s diagnosis and medical information; D.   a means by which a third-party payer can verify that services billed were provided; E.   a tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals.   I have been provided with a copy of the notice of privacy practices that provides a more complete description of the information and uses and disclosures.    I understand that as part of my care and treatment, it may be necessary to provide my protected health information to another covered entity. I have the right to review Mood Treatment Center's notice before signing this authorization. I authorize the disclosure of my protected health information as specified below for the purposes and to the parties designated by me. 

I understand that:    1.    I have the right to review Mood Treatment Center's Privacy Practices prior to signing this consent; 2.    That Mood Treatment Center reserves the right to change their Privacy Practices at any time and, if requested, will mail a copy of         any notice to the address I’ve provided; 3.    I have the right to object to the use of my health information for directory purposes; 4.    I have the right to request restrictions as to how the client’s protected health information may be used or disclosed to carry out        treatment, payment, or healthcare operations, and Mood Treatment Center is not required by law to agree to the restrictions         requested; 5.    I may revoke their consent in writing at any time, except to the extent that the Mood Treatment Center has already taken action in         reliance thereon.