Outpatient Intake Packet

Patient Personal Data

Patient First Name * Patient Last Name *

Patient DOB(MM/DD/YYYY): *

Guardian First and Last name, if applicable:

Address: * City: * State: *

Primary Phone Number: *

Email Address: *

Insurance Carrier: * Policy Number: *

Practice Policies

Attendance:

– If you miss or cancel 3 appointments for medication management and/or therapy without giving 24 hours notice, you will be discharged from Dominion Outpatient Services (DOS). This will also mean we are not able to fulfill refills on medication. ALL CANCELATIONS MUST BE MADE 24 HOURS PRIOR TO SCHEDULED APPOINTMENT TIME. If you cancel without 24 hours notice, you can be charged a 50.00 late cancellation fee.
– Dominion Care reserves the right to cancel and/or request to reschedule should you arrive 10 minutes late for your scheduled appointment.
– For psychological testing if No Show or Cancellation without 24 hour notice, will only be rescheduled on one more occasion.
– Calls received outside business hours will be returned the next business day. If you are having suicidal ideations or are concerned for you or your childs safety, please contact the nearest ER or dial 911.

What to Expect:

Depending on your reasons for coming into Dominion Outpatient Services, you may receive several different types of services. The following are the different services that are provided:
– Outpatient Therapy Services-Services can be provided on an individual, family, couples, or group basis. These sessions can last 45-60 min.
– Psychiatric Services-Medication evaluation and medication management. These appointments can be 15-60 minutes.
– Psychological Testing These appointments can be 1-3 Hours per session. These can require multiple sessions depending on reason for referral and testing being completed.
– If you disclose a serious harm to yourself or someone else and there is a safety concern. Steps must be taken to inform your parent or guardian/emergency can contact in order to keep you safe.
– If you disclose a plan or plans to cause serious harm to yourself and/or someone else and there is a safety concern, steps will be taken to inform your parent/guardian/emergency contact and the person who you intend to harm.
– If you disclose abuse and/or neglect, as a court ordered mandated reporter, mental health providers must report suspected child abuse or neglect to the Department of Social Services by State Law.
– If you are involved in a court case and a request is made for information regarding your services. If this occurs, mental health providers will not provide any information about you without you and your parent/guardians written agreement. However, in some instances, mental health providers can be subpoenaed and may have to comply with the courts request regardless of the clients wishes.
If you have any questions regarding confidentiality and outpatient services, please ask your provider. We are here to support you and to make sure that you understand your rights as a client.

Insurance:

– Please make sure that your provider is informed of any changes in your insurance plan to ensure that you or your child can continue with treatment. If we are not updated, then it is possible that you could have balance due to insurance denying your claims.
– Your Insurance card must be available at every appointment. You may not be able to keep your appointment if we cannot verify your insurance.

Clinical Documentation:

For clients that have commercial insurance, all requested clinical documentation needed will be charged $20 per page . Clinical documentation requires 2 weeks preparation time (IE: Letters for school, court, or attorneys). This does not include doctors notes for attending appointments at DOS.

Prior Authorizations:

Dominion Outpatient understands the importance of clients receiving their medication in a timely manner.
– We will complete prior authorizations in a minimum of 72 hours (3 business days). Please understand that this process requires clinical documentation and collaboration with your insurance provider and your pharmacy. Please have your pharmacy fax the prior authorization request to our office at (804) 272-2030.
– Dominion Outpatient will then contact your insurance company to complete the prior authorization. Insurance companies can take anywhere from 24 hours to 30 days to review and approve one individual medication prior authorization.
– Dominion Outpatient cannot control what the outcome of the prior authorization request will be, as it is the insurance provider’s ultimate decision. Most of the time, is a prior authorization is not being approved, it is because of the insurance company, not Dominion Outpatient.

Medication Specific Policies:

– Refills will not be granted after 5pm, on weekends, or holidays.
– Refill requests can take a minimum of 3 business days.
– In order to ensure you do not run out of medications, you will need to submit a refill request at least one week prior to their due date. Your pharmacy should be contacting the office at least a week ahead of when you will need your medication to ensure you do not run out. Many pharmacies also allow you to subscribe to automatic refill reminders.
– If you miss or cancel 3 appointments without giving 24 hours notice, you will be discharged from Dominion Outpatient Services (DOS). This will also mean we are not able to fulfill refills on medication.

If you need to contact your provider:

You provider can be reached by phone (804) 272-2000, Monday through Friday from 8am to 5pm. Calls received outside normal business hours will be returned the next business day.
If you have an emergency or a crisis, please call 911 or head to your nearest emergency room. Please be advised that Dominion Outpatient services does not provide CRISIS coverage. If you are seeking those services, we can help you find a provider.
Clinicians are not available outside your scheduled appointment time due to the nature of their role. For example, you come to the office and see your therapist once per week. If you have a significant issue before your next scheduled appointment, please call our office and ask for another appointment sooner. If you have any questions about your services, please call our office and DOS staff will help you find the information that you are looking for.
If you have any questions regarding confidentiality and outpatient services, please ask your provider. We are here to support you and to make sure that you understand your rights as a client.

I understand, and agree to, the above information. I give me permission for any therapy, testing, or diagnostic evaluation seen as helpful by my therapist to treat me, my family, or other relationship (minor child). Progress toward treatment goals will be documented in case notes as well as individual treatment plans. I request that payment of Medicare, Medicaid and other Insurance benefits be made on my behalf to the mental health provider. I authorize my provider to release medical information necessary to process my claims. I agree to pay insurance Co-payments and any insurance deductible AT THE TIME SERVICES ARE RENDERED. If I have any questions or concerns, I will discuss these with my provider. *

Rights and Responsibilities

You are entitled to certain rights under Federal and State Laws. No person shall be denied any of their legal rights while you are receiving services from Dominion Care. Such rights include, but are not limited to, the following:
1. The right to be treated with dignity and respect and to use your preferred or legal name.
2. The right to privacy.
3. The right to equal access to treatment or services regardless of race, religion, sex or handicap.
4. The right to inquire and be told about your rights.
5. The right to a fair and objective grievance process.
6. The right to participate in the development of your treatment/service plan.
7. The right not to be the subject of experimental or investigational research without written and informed consent.
8. The right to be fully informed of treatment involving significant risks.
9. The right to receive confidential services and your record to be kept in a confidential manner within the limits of the law, and have appropriate access to those records.
10. The right to receive services in the least restrictive environment.
11. The right to have a copy of the rules of conduct applicable to services in which you are participating.
12. The right to receive services in a manner that is responsive to your age, gender, family, friends, cultural/ethnic background, sexual orientation, mental/physical disability, and spiritual beliefs.
13. The right to know that your Clinician may be a Supervisee registered with the Board of Health Professions. If so, their name and credentials and supervisor will be given to you separately.
Any complaints should be addressed to the Dominion Care Human Rights Contact (Program Manager/Director): Name: Lauren Sowers, phone number: 540.419.3958
IF YOU FEEL THAT YOU NEED OUTSIDE ASSISTANCE, PLEASE CONTACT THE REGIONAL ADVOCATE: Ann Pascoe (NOVA) 804-297-1503; Reginald Daye (Tidewater) 804-253-7061; Cassie Purtlebaugh (Fredericksburg/ Lynchburg/ Caroline Area) 804-382-3889; Andrea Milhouse (Richmond/ Tri Cities Area) 434-390-0116; Mandy Crowder (Roanoke and Franklin Area) 434-713-1621. The Regional Advocate’s role is to help you with the grievance process.
Responsibilities of the primary caregiver or legal guardian and Individual:
1. To keep all scheduled appointments with Dominion Care staff or to inform staff in advance if you are unable to keep the appointment.
2. To work on your service goals as agreed upon in your Individualized Service Plan.
3. To provide staff with accurate and complete information as it pertains to your treatment and care at Dominion Care. To treat all others with respect.
4. To adhere to the Dominion Care rules prohibiting smoking and drug use and banning weapons on the Dominion Care premises.
INQUIRY, APPEAL AND GRIEVANCE PROCEDURES: There is always the potential that the treatment received by an individual may not be perceived by that individual as fair or appropriate. To safeguard against any mistreatment of an individual, or any failure to provide quality care, or inaccurate accounting regarding individual charges, Dominion Care has established a grievance procedure whereby the individual can make their concern known. The basic procedure if you have a complaint or concern is as follows: Individuals who express dissatisfaction will be instructed to talk to clinical or administrative staff regarding their complaint or grievance. Individuals will be asked if they wish to write a formal grievance and they will be assisted by the Program Director or designee. Complaints and grievances will be investigated and resolved within 10 calendar days.
I hereby acknowledge that: (select all that apply) *

Client Rights

Policy
A patient/client has the right to impose restrictions on the use or disclosure of PHI in some circumstances in which use or disclosure would otherwise be permitted under HIPAA.

Procedures

1. Types of Request
A patient/client may request that the Covered Entity restrict use or disclosure of PHI for purposes of treatment, payment and health care operations, and may request a restriction on information given to family members, friends, and others involved in his or her care. [Disclosures to family members for patients/clients receiving treatment in federally funded drug and alcohol treatment programs require patient authorization under 42 C.F.R. Part 2, so those patients/clients would have no need to impose a restriction in this area.]
2. Making Requests
2.1. Requests for restrictions on the use of PHI for treatment, payment and health care operations must be made in writing on a Request for Restriction on Use and Disclosure of Health Information. If a patient/client informs any staff member that he/she wants to request a restriction on the use of the patients/clients PHI, the staff member should provide the patient/client with the proper form. The staff member should not ask the patient/client the reason for his/her request. All requests shall be forwarded to the Privacy Officer, who will make the decision on all requests. The Privacy Officer may accept or reject the request, in his/her discretion (consistent with other applicable law and ethical requirements), for any reason, except as provided in 2.2 below.
2.2. The Covered Entity must comply with the request if:
2.2.1. A patient/client requests a restriction on the disclosure of PHI to a health plan for purposes of carrying out payment or health care operations, 2.2.2The disclosure is not otherwise required by law, and
2.2.3.The disclosure concerns PHI which pertains solely to a health care item or service for which the Covered Entity has been paid out of pocket by the patient/client in full.
3. Accepted Requests
3.1. The patient/client will be notified in writing whether or not the Covered Entity will agree to restrict use of the patients/clients PHI as requested. A copy of the letter will be filed in the patients/clients record. If the Covered Entity agrees to restrict use of the patients/clients PHI or is required to restrict use of the patients/clients PHI as provided in 2.2 above, a copy of the letter will be sent to each department/program that has access to the patients/clients PHI. The restrictions must be followed by each staff member, unless the PHI is needed to provide emergency treatment to the patient.
3.2. Once a request for restriction has been accepted, the Covered Entity will flag or make some other notation in the patients/clients record with respect to the PHI that has been restricted to ensure that such information is not inadvertently disclosed.
3.3. If PHI subject to a restriction is provided to another health care provider in an emergency, the staff member must request that the health care provider receiving the information not redisclose the PHI.
4. Termination of Restriction
4.1. Any restriction on the use or disclosure of PHI may be terminated only under one of the following circumstances: 4.1.1The patient/client requests or agrees, in writing, to terminate the restriction;
4.1.2. The patient/client orally agrees to terminate the restriction, and the oral agreement is documented by a staff member; or
4.1.3. The patient/client is given written notice that the Covered Entity no longer agrees to be bound by the restriction. In this case, the Covered Entity will still be obliged to honor the restriction for PHI created or received before the written notice.
4.2. Any staff member who receives, either orally or in writing, a notice of termination from a patient/client must document the termination in the patients/clients record and inform the Program Director.
References
45 C.F.R. 164.522(a) 45 C.F.R. 164.530(j)
Acknowledgement
I have read the above Request for Restrictions and understand that I may request a copy of this notice at anytime. *

Provider Choice

If you are an individual or an individuals legal guardian seeking the service listed below, you are entitled to a choice of provider. This means you may select Dominion Care as your provider or you may choose from another provider within the community. In addition, any action taken by this agency may be appealed to the Department of Medical Assistance Services (DMAS) by following the procedure listed below.

The freedom of choice has been discussed with me. I understand that I have the option to receive services from other providers. I am choosing Dominion Care as my provider for the following Services:
Please select all services below: *

Any action taken by this agency that affects the services of this Individual may be appealed to DMAS. Your notification must be in writing and submitted to the Appeals Division, Department of Medical Assistance Services, 600 East Broad Street, Suite 1300, Richmond, Virginia 23219. The written request for an appeal must be filed within thirty (30) day of this notification. If you file an appeal before the effective date of this action, (date), services may continue during the appeal process. However, if this decision is upheld by the Appeals Division, you will be required to reimburse the Medical Assistance Program for services provided after (date). For further information on recipient rights, you may call 804-786-7933 or visit them on the website at www.dmas.virginia.gov/.

Rights to Confidentiality

We take confidentiality very seriously. We follow very strict rules from the United States and State Governments about when we can release your medical record your protected health information.
The Federal Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule establishes a foundation of Federal protection for personal health information, carefully balanced to avoid creating unnecessary barriers to the delivery of quality health care. The Rule generally prohibits this program from using or disclosing your protected health information unless authorized by you, except as follows:
First, we are required by law to disclose your protected health information in certain circumstances, for example, to report abuse and neglect, and to warn about dangerous behavior. Second, we are authorized to disclose your protected health information without your consent when we use the information for treatment, payment or the health care operations of the program. Treatment generally means the provision, coordination, or management of health care and related services among health care providers or by a health care provider with a third party, consultation between health care providers regarding a patient, or the referral of a patient from one health care provider to another.
Payment encompasses the various activities of health care providers to obtain payment or be reimbursed for their services. Health care operations are certain administrative, financial, legal, and quality improvement activities of a program that are necessary to run its business and to support the core functions of treatment and payment.
The program will, without your authorization:
Use or disclose your protected health information for its own treatment, payment, and health care operations activities.
We may disclose your protected health information for the treatment activities of any health care provider (including providers not covered by the Privacy Rule).
We may disclose your protected health information to another health care provider (including providers not covered by the Privacy Rule) for the payment activities of the entity that receives the information
We may disclose your protected health information to another provider for certain health care operation activities of the provider that receives the information if: Each provider either has or had a relationship with you, and protected health information pertains to the relationship; and the disclosure is for a quality-related health care operations activity or for the purpose of health care fraud and abuse detection or compliance.
Security. Your medical record (your protected health information) is kept in a secure location and only those employees or clinicians who need access to your medical record for treatment, payment or health care operations have access to your medical record unless you sign an authorization.
It is our policy to reasonably limit disclosures of, and requests for, protected health information for payment and health care operations to the minimum necessary. We also limit which members of our workforce may have access to protected health information for treatment, payment, and health care operations, based on those who need access to the information to do their jobs.
We may also disclose information in order to contact you, for example to make appointments, to check with you about how you are doing, and to evaluate the services that we provide to you. We may also contact you for our fund-raising efforts.
Your right to see your record.
You have the right to see your record, or to receive a summary of your record. To do this, please contact your Service Provider. You also have the right to ask us for an accounting of the persons or programs to whom we have disclosed your protected health information. (This does not include disclosures for treatment, payment or health care operations, or to persons authorized by you.) To receive this accounting, please contact your Care Provider.
If you disagree with the contents of your medical record, you may also request an amendment to your record. We will place that amendment in the medical records unless we did not create that part of the record or we believe the existing record is accurate and complete. If we grant the amendment, we will notify you and you may request that we provide the amendment to other programs and to programs that you identify to us as having already received your medical record. If we deny the amendment, we will give you specific reasons for the denial. You may then submit a statement of disagreement and we may submit a rebuttal. If you notify us in writing, we will attach your request for amendment and our denial to future disclosures of that part of your medical record. Also, if you continue to disagree, you may file a complaint with the Complaint Officer at (Agency Info) and the Office of Civil Rights at HHS.gov
How to file a complaint. If you believe that your protected health information has been released in violation of the law, you have the right to file a complaint. You may file a complaint with our program by contacting or submitted a letter to: Complaint Officer (Agency Info). You may also file a complaint with the Office of Civil Rights at HHS.gov. You have our promise that our program will not retaliate against you if you choose to file a complaint.
If you want to send your protected health information to someone, you must sign an authorization. Authorizations may be obtained from your Service Provider.
Notification of Breach. In an event there has been an breach in releasing personal health information (PHI), Dominion Care will provide notice to you by telephone or verbally by Dominion Care. Such conversation shall be documented by Dominion Care.
Acknowledgement I have read the above Notice of Privacy Practices and Notification of Breach of the Agency and understand that I may request a copy of this notice at anytime. *

Confidentiality Part 2

Dominion Outpatient Services, LLC (‘Dominion,’ ‘we’ or ‘us’) provides outpatient substance use disorder treatment services through its qualified treatment staff. All patient records of Dominion that relate to the diagnosis, treatment, or referral for treatment for a substance use disorder are subject to stringent privacy and security standards under federal confidentiality laws and regulations, the Health Insurance Portability and Accountability Act of 1996 (‘HIPAA’), 42 U.S.C. 1320d et seq., 45
C.F.R. Parts 160 & 164, and the Confidentiality of Substance Use Disorder Patient Records, 42 U.S.C. 290dd, 42 C.F.R. Part 2 (‘Part 2’)

HIPAA protects all patient-identifying medical and health information maintained by Dominion as a health care provider, including any substance use disorder- related information. Part 2 is narrower and only governs our use and disclosure of a patient’s substance use disorder records. Protections under Part 2 go above and beyond the requires HIPAA protections, as described in our Notice of Privacy Practices.

Part 2 requires your written consent for most uses and disclosures of your substance use treatment disorder records. You must consent to Dominion’s identifying you as a patient that utilizes substance user disorder treatment services, except as permitted by the regulations. You must consent for Dominion to disclose your information to insurance companies and third-party payers, or to other treating providers. In order to facilitate treatment among other providers and our receipt of payment for the services we provide to you, Dominion requests that you consent to these disclosures.

Under federal law, we may disclose personally identifiable substance use disorder treatment information without you written consent when:
-The disclosure is allowed by court order;
-The disclosure is made to medical personnel in a medical emergency;
-The disclosure is made to state or local authorities to report suspected child abuse or neglect;
-The disclosure is made to a qualified service organization that assists us in certain administrative functions;
-The disclosure is made to qualified individuals, entities or authorities for research purpose or for audit or program evaluation; or
-The disclosure relates to a crime committed on the premises or a crime or threat of a crime against our staff members.
Violation of Part 2 is a crime and suspected violations may be reported to appropriate authorities in the location where the violation occurs: US Attorney’s Office for the Eastern District of Virginia (Richmond): 804-819-5400; 919 East Main Street, Suite 1900, Richmond, Virginia 23219.

If you have any questions about how Dominion Protects the privacy and security of your information in accordance with HIPAA and Part 2, you can contact Lauren Sowers and 804-272-2000.
Acknowledgement of Receipt of Notice of Federal Confidentiality Requirements

I acknowledge that I have received and reviewed Dominion Outpatient Services’ Notice of Federal Confidentiality Requirements, which describes how Dominion must protect the privacy and security of my substance use disorder treatment records and information. *

Prnt/Guard Partic. Consen

Parent/Guardian Participation Consent

Dominion Care believes that family participation is fundamental in helping each child that we serve. It is crucial that parents/guardians be invested in his/her child’s progress at Dominion Care and also make the necessary changes needed to provide each child with a healthy and encouraging environment that helps facilitate change.
Parents/Guardians are required to engage in services with their child which may include individualized meetings to address the child’s progress. If you feel that your child is not making the progress you expected or you have other concerns about your child’s placement with Dominion Care, we encourage you to contact your child’s QMHP to schedule a meeting.
If you choose not to engage in services or meetings with your child, this may affect your child’s enrollment in services with Dominion Care. It is vital that you be an active participant in your child’s services.
By signing below, you are indicating that you understand that you are expected to participate in services and individualized meetings held for your child. We look forward to working with you and your child from a family approach.
If Not Applicable Please Check Below:

Finance Agreement

First Name:

Last Name:

By signing below, you, the parent/guardian, and client are indicating that you understand that connecting with DYS staff on social media platforms is prohibited and could have negative repercussions on the therapeutic relationship. You also understand that connecting with your counselor after services have closed constitutes a dual relationship which violates company policy and code of ethics. If you have any questions or concerns about the information, please contact the program manager/coordinator.

In accordance with the services that will be provided by Dominion Outpatient LLC, I hereby authorize any insurance company to pay this agency in full for outpatient services rendered in accordance with my insurance policy benefits. All applicable co-payments, co-insurance, deductibles, or other out of pocket expenses for outpatient services are expected to be paid at time of service. Co-payments, co-insurance, and deductibles are the client’s responsibility. Payment is accepted via credit card or check, not in cash.

Your insurance may require prior authorization for outpatient services. It is the client’s responsibility to monitor insurance benefits, deductibles, and effective/termination dates of coverage. It is also the client’s responsibility to communicate this to their provider at Dominion Outpatient. If insurance lapses and client attend services, there could be a fee that insurance does not pay. The responsibility would then fall on the client for payment of services rendered.

Read and Check: *

Updated Fee Schedule:

– Psychiatric Evaluation: $225.00
– Medication Management: $75.00
– Initial Diagnositic Assessment: $150.00
– Individual Outpatient Therapy session: $100.00
– Family and Couples Outpatient Therapy Session: $125.00
– Group Therapy: $40.00
– IOP Assessment: $165.00
– IOP Group: $281.25
– ADOS Assessment Self-Pay: $1,100
– Preparation of reports, letters, telephone or other conferences: $20 page
I acknowledge that myself or parent/guardian have reviewed the financial policies and agree to the above: *

Informed Consent

I agree and consent to participate in outpatient mental health services offered and provided by Dominion Outpatient Services, LLC. I understand that I am agreeing only to those services that the provider is qualified to provide within:
1. The scope of the provider’s license, certification, and training.
2. The scope of the license, certification, and training, of the outpatient mental health providers directly supervising the services received by the client.

If the client is under the age 18 or is unable to consent to treatment, I attest that I have legal custody of this individual and I am authorized to initiate and consent to treatment on behalf of this client.

* Indicates required field

Social Networking Policy

Dominion Care believes in providing the best quality services to children, families, and clients. In providing quality services one of the most important parts of the therapeutic relationship between a client and the counselor is maintaining confidentiality. It is important that the client understands the importance of the counselor- client relationship and know it is a therapeutic process and not a ‘friendship’ connection but a relationship that adheres to assisting the client and family members with obtaining self-sufficiency, good mental health, and a good quality of life long after the therapeutic relationship has ended.
It is important that clients and family members understand that counselors absolutely cannot connect with them on social networking sites such as Facebook or Twitter. Doing so violates many policies and practices including the social work code of the ethics, counselor code of ethics, and of course confidentiality. Dominion Care wants clients to know that refusal to connect with them on social networking sites is not a form of rejection but goes against company policy and other laws that mandate social work and counselor practices. It is also important that clients understand that counselors will not be allowed to connect with them in any way after the therapeutic process has ended.

Photo/Media Consent

Written consent by the individual served or their substitute decision maker (custodial parent/authorized representative/legal guardian) will be obtained prior to Dominion Care staff or agents engaging in photography, recording videos or audio tapes at/or for any agency sponsored events.

Recorded or printed images belong to Dominion Care and when practicable, may be retained in the individuals medical record. Once information or images are made and disclosed, the service recipients privacy may not be protected by federal privacy regulations.

All service recipients or substitute decision makers may revoke this authorization at any time, by notifying Dominion Care staff, of their wish to do so.The individual or substitute decision maker will be notified of the receipt of their request.

My authorization (or the person receiving services, for whom I am giving consent) and voluntary consent to participate in a promotional story or image (photograph, audio, video or media) made by Dominion Care staff indicates my understanding that I have been told that this story and/or image (photograph, audio or videotape) may appear in the public media, including print or broadcast media and used for informational, educational or training purposes. I agree that all such pictures, photographs, video or audio recordings and any reproductions thereof, including digital files shall remain the property of Dominion Care, unless otherwise noted. I may ask to review all final productions.

This Consent Form terminates one year from the date of signature, unless revoked prior to that date.
I hearby *

Consent for Camera Surveillance
Individual/guardian consents to audio and visual surveillance to protect the health, welfare, and safety of individuals while on Dominion Care premises. Utilizing audio and visual surveillance does not replace the services of Dominion Care staff. Placement of audio and visual surveillance are restricted to public areas and do not record where individuals have a reasonable expectation of privacy (e.g., restroom). The audio and visual surveillance are in operation 365 days per year, 24 hours per day and records in real time continuously. It is the policy of Dominion Care that the surveillance is for therapeutic purposes only and will be conducted upon consent of the individual/guardian.

Individual/guardian have been given the opportunity to ask any questions regarding audio and visual surveillance.

By signing below, you are indicating that you understand that the Fredericksburg Dominion Care location utilizes audio and visual survelliance to protect the health,welfare, and safety of individuals while on premises.

Not Applicable – Individual does not receive services in Fredericksburg.

Emergency Contact Release

AUTHORIZATION FOR RELEASE/EXCHANGE INFORMATION

First Name:

Last Name:

DOB:

Address:

I Hereby authorize the staff at Dominion Outpatient Services or anyone designated in writing to this agency, to furnish to:
Emergency Contact:
Name:

Phone Number:

Address:

I do not want to share information with my Emergency Contact
To disclose the following: *

Purpose or Need for information: Coordination of Care
**This release of information will expire:
I Hereby authorize the information requested above from my record. I understand that the information to be released from my record is confidential and protected from disclosure without my signing the written authorization. I also understand that I have the right to cancel my permission to release information at any time before it is released.
* Indicates required field

Use previous signature

Treat ProvRelease (Prt2)

CONSENT TO RELEASE TO TREATING PROVIDER (Part 2)

A ‘treating provider relationship’ exists when a patient receives, agrees to receive, or is legally required to receive diagnosis, evaluation, treatment, or consultation, for any condition. An in-person encounter is not required for a treating provider relationship to exist.

This consent form is for when a patient wishes to authorize the disclosure for their substance use disorder information to an individual or entity with which the patient has a treating provider relationship.

First Name:

Last Name:

Authorize: Dominion Outpatient Services, LLC
To disclose the following: *

to:

For the purpose of: Coordination of Care
I understand that my substance use disorder records are protected under the Federal regulations governing Confidentiality and Substance Use Disorder Patient Records. 42 C.F.R Part 2, and the Health Insurance Portability and Accountability Act of 1996 (‘HIPAA’), 45 C.F.R pts 160 & 164, and cannot be disclosed or re- disclosed without my without my written consent unless otherwise provided for by the regulations.

I understand that I revoke this authorization at any time except to the extent that action has been taken in reliance on it. Unless I revoke my consent earlier, this consent will expire automatically on:
I understand that I might be denied services if I refuse to consent to a disclosure for purposes of treatment, payment, or health care operations, if permitted by state law. I will not be denied services if I refuse to consent to a disclosure for other purposes. I HAVE NOT BEEN PROVIDED A COPY OF THIS FORM.
Release not applicable:
 Yes
* Indicates required field

Use previous signature

PCP Release

AUTHORIZATION FOR RELEASE/EXCHANGE INFORMATION

First Name:

Last Name:

DOB:

Address:

I Hereby authorize the staff at Dominion Outpatient Services or anyone designated in writing to this agency, to furnish to:
Primary Care Physician:
Name:

Phone Number:

Address:

I do not have a Primary Care Physician
I do not want to share information with my Primary Care Physician
To disclose the following: *

Purpose or Need for information: Coordination of Care
**This release of information will expire:
I Hereby authorize the information requested above from my record. I understand that the information to be released from my record is confidential and protected from disclosure without my signing the written authorization. I also understand that I have the right to cancel my permission to release information at any time before it is released.
* Indicates required field

Use previous signature

Payer (Prt2) Release

CONSENT TO RELEASE INSURANCE COMPANY (Part 2)

First Name:

Last Name:

Authorize: Dominion Outpatient Services, LLC
To disclose the following: *

To Insurance Plan:

For the purpose of: Coordination of Care
I understand that my substance use disorder records are protected under the Federal regulations governing Confidentiality and Substance Use Disorder Patient Records. 42 C.F.R Part 2, and the Health Insurance Portability and Accountability Act of 1996 (‘HIPAA’), 45 C.F.R pts 160 & 164, and cannot be disclosed or re- disclosed without my without my written consent unless otherwise provided for by the regulations.

I understand that I may revoke this authorization at any time except to the extent that action has been taken in reliance on it. Unless I revoke my consent earlier, this consent will expire automatically as follows:
This release is good through:
I understand that I might be denied services if I refuse to consent to a disclosure for purposes of treatment, payment, or health care operations, if permitted by state law. I will not be denied services if I refuse to consent to a disclosure for other purposes. I HAVE NOT BEEN PROVIDED A COPY OF THIS FORM
Release not applicable:
 Yes

Use previous signature

IndividualRelease (Prt2)

CONSENT TO INDIVIDUAL RECIPIENT (Part 2)

First Name:

Last Name:

Authorize: Dominion Outpatient Services, LLC
To disclose the following: *

to:

For the purpose of: Coordination of Care
I understand that my substance use disorder records are protected under the Federal regulations governing Confidentiality and Substance Use Disorder Patient Records. 42 C.F.R Part 2, and the Health Insurance Portability and Accountability Act of 1996 (‘HIPAA’), 45 C.F.R pts 160 & 164, and cannot be disclosed or re- disclosed without my without my written consent unless otherwise provided for by the regulations.

I understand that I revoke this authorization at any time except to the extent that action has been taken in reliance on it. Unless I revoke my consent earlier, this consent will expire automatically on:
I understand that I might be denied services if I refuse to consent to a disclosure for purposes of treatment, payment, or health care operations, if permitted by state law. I will not be denied services if I refuse to consent to a disclosure for other purposes. I HAVE NOT BEEN PROVIDED A COPY OF THIS FORM
Release not applicable:
 Yes
* Indicates required field

Use previous signature

Orientation Checklist

Items/Areas Explained To and Acknowledged By Consumer

By providing my signature below, I have read and reviewed the included information in full.  I also understand that I can contact Dominion Care staff for any questions or concerns regarding the information included by contacting the office Monday-Friday, 8:30am-5:00pm at 804-272-2000.

Use previous signature

LMHP-E CONSENT FORM

Date:
First Name:

Last Name:

DOB:

Consent *

CARF

Dominion Care is accredited by The Commission on Accreditation of Rehabilitation Facilities (CARF). CARF assists service providers in improving the quality of their services, demonstrating value, and meeting internationally recognized organizational and program standards. Accreditation is an ongoing process, signaling to the public that a service provider is committed to continuously improving services, encouraging feedback, and serving the community. Accreditation also demonstrates a provider’s commitment to enhance its performance, manage its risk, and distinguish its service delivery.

During service delivery you may receive Quality Assurance Calls and/or Satisfaction Surveys from our management team in order to discuss how services are going. It would also be beneficial if we could contact you after discharge in order to collect information to enhance our quality management.

Can Dominion Care contact you after discharge from services? *

Telehealth Consent

Treatment Services
I agree to take part in Telehealth services offered by Dominion Outpatient Services. Telehealth potential risks and benefits were explained to me. Program staff also explained how the telehealth services work.
Use of Telehealth
I understand that I may be seen by a physician, psychiatrist, or a nurse practitioner in person or remotely at Dominion Care. For remote physician services, I hereby authorize Dominion Care to use Telehealth/telepsychiatry in the course of my assessment and treatment. I understand that the Telehealth involves the communication of my medical information, both orally and visually, to physicians and other healthcare practitioners who are not physically present at the programs site.
What is Telehealth and how do Telehealth Services work?
Telehealth services are used when the provider cannot be physically present with you to evaluate your needs and service plan. Telehealth allows you and the staff to talk with and/or see one another using video and computer equipment.
You will be in a private room with a staff person over video/phone. You may also request to have a friend or family member present. The staff will be in a private room at another location.
Client Choice
I understand that I have the option to withhold consent at this time or to withdraw this consent at any time, including any time during a session, without affecting the right future care, treatment or risking the loss or withdrawal of any program benefits to which I would otherwise be entitled.
If I choose not to consent to Telehealth services, the program may be unable to provide me with the convenient and readily available services and my services will be rescheduled for a later date and/or a different site.
Benefits & Risks of Telemedicine
I understand that I can expect benefits from Telehealth but that no results can be guaranteed or assured. Telehealth provides me access to behavioral health care that otherwise might not have been available in my community. Despite reasonable and appropriate efforts, there is the possibility that:
1 The transmission of medical information could be disrupted or distorted by technical failures in transmission;
2 The transmission of medical information could be interrupted by unauthorized persons;
3 The electronic storage of medical information generated by telemedicine consultation in one or more databases could be accessed by unauthorized persons;
4 Telemedicine sessions or care may not be as complete as face-to-face exams or care;
5 Telemedicine does not negate or minimize the risks that may be inherent in a medical/mental illness or condition.
Communication with Healthcare Practitioners
I understand that by consenting to Telehealth, my staff will communicate medical information concerning me to physicians and other healthcare practitioners as permitted by HIPAA regulations protecting my confidentiality and privacy (see Client Notice of Privacy Practices). All existing confidentiality protections apply. All existing laws regarding client access to mental health information and copies of mental health records apply. There is no permanent video or voice recording kept of the Telemedicine services session. Client identifiable images or information from the Telehealth interaction shall not occur without the consent of the client or as otherwise permitted by law.

I have read and agree to all conditions for treatment and Telehealth set forth herein. I consent to receive Telehealth Services: *

Interpreter/Language Serv

Dominion Care Consent Form for Interpreter/Language Services

Dominion Cares policy is to ensure equal access to all persons served. This may include the use of professional interpreters so that persons served and families who prefer to communicate their care in a language other than English and their provider can communicate effectively. I understand that the interpreter follows a professional code of conduct which means that all information discussed during services is confidential. Interpreter/Language are at no cost to the individual to utilize while in services.

Consent for Interpreter/Language Services *