CONSENT FOR SERVICES/TREATMENT AND PATIENT ACKNOWLEDGEMENT

1. CONSENT FOR TREATMENT. I voluntarily consent to behavioral health services and treatment performed by staff and providers at Diversus Health. This may also include treatment by a medical professional who can prescribe medication. I understand that the practice of behavioral health is not an exact science and no guarantees have been made to me as to the result of treatment. I understand that I have a right to consent to proposed treatment as well as a right to refuse proposed treatment. I also have a right to stop services and/or treatment at any time. I have a right to a second opinion regarding my diagnosis and my individual course of treatment.

2. CONTACT. I authorize Diversus Health to contact me regarding my services and/or treatment, appointment reminders, insurance items, or any call pertaining to my care. I authorize Diversus Health staff to contact me or my designated representative after discharge from services and/or treatment to obtain information for follow-up purposes only. I understand that these communications may occur in writing, secured email, phone, or text message. Should I choose not to receive text message reminders from Diversus Health, I will opt out of these services by contacting Diversus Health in writing.

3. TELEHEALTH SERVICES. I authorize Diversus Health to use secured telehealth services, if necessary, to provide services and/or treatment. I understand that all laws that protect the privacy and confidentiality of medical information also apply to telehealth. I have the right to withdraw my consent to telehealth services at any time and it will not impact my right to care. Please note that therapy and medication management services cannot be rendered via telehealth if you are in another State unless the provider is credentialed in that State as well as Colorado. For providers credentialed in Colorado only, guidelines require that you be in Colorado to receive therapy and medication management services.

4. AUTHORIZATION FOR RELEASE OF INFORMATION. I authorize Diversus Health to utilize confidential medical information or other information contained in my medical records as necessary for claims payments, medical management, or quality of care review purposes. I further authorize the release of such confidential information to my insurance company or other health coverage plan, including government payers, as necessary for claims payment, medical management, and quality review activities as conducted by such company or plan or its subsidiaries or designees.  This authorization includes the release of AIDS diagnosis or a positive HIV antibody result, alcohol and/or drug use/abuse information, genetic testing, congenital disorders, and mental health information. I understand this authorization for release of information can be revoked by me in writing at any time, but only with respect to the proposed treatment and not with respect to care and treatment that has already been provided to me.

5. WAIVER OF RESPONSIBILITY FOR PERSONAL VALUABLES. I understand that Diversus Health does not assume any liability for the loss or damage to my personal property while on Diversus Health premises. I understand all valuables should not be brought or left at Diversus Health.

6. PAYMENT AGREEMENT AND ASSIGNMENT. Except as prohibited by an agreement between my insurance company and Diversus Health or by state or federal law, I agree to be responsible for my co-payments, deductibles, or other charges for services not covered or paid by insurance or other third-party payers. I authorize Diversus Health to file any claims for payment of any portion of the patient bills and assign all rights and benefits to Diversus Health, as appropriate. I further agree, subject to state or federal law, to pay all costs, attorney fees, expenses, and interest in the event that Diversus Health takes action to collect same because of my failure to pay in full any and all incurred charges.

7. CANCELLATIONS. I will give a minimum of 24 hours' notice for all appointments I need to cancel or reschedule. I understand that if I arrive late for a scheduled appointment I may not be seen and agree that unattended or late appointments may result in Diversus Health discontinuing services and/or treatment.

8. Colorado Regional Health Information Organization (CORHIO). Clients who receive services at Diversus Health are automatically enrolled in CORHIO. CORHIO is the state-designated entity to lead efforts to expand the use of health information across Colorado. CORHIO facilitates the exchange of health information in the behavioral health community with the physical health care community to improve coordination of care so that important information about your healthcare is available to providers who render services for you. You do have the right to opt out of participation in CORHIO or revoke a previous opt out request you may have made.

To OPT OUT of participation in CORHIO, please visit the CORHIO site here: https://www.corhio.org/for-patients/your-choices.

9. ACKNOWLEDGEMENTS. I acknowledge that I have been given/offered a copy of the following information: