Consent to Treatment
Welcome to Octave Behavioral Health. This document contains important information about our policies and professional services. Please read it carefully and discuss any questions you have with your provider.
Our providers are affiliated with one or more of the following professional entities: Octave Behavioral, P.A (FL); Octave Behavioral Health, PC (CA); Octave Behavioral, P.C. (NJ); and Octave Psychiatry Behavioral Health, P.C. (NY) (collectively, “Octave Health Professional Entities”). In this document, the terms “we,” “us,” or “our” refers to the Octave Health Professional Entities. The terms “you” and “yours” refer to the individual(s) receiving the services from our providers.
Our Notice of Privacy Practices, the policies in this document, as well as applicable federal and state laws, apply to both in-office and teletherapy services, regardless of modality.
By signing this document, you, or the person authorized to act for you, affirm your agreement to the policies contained in this document and your consent to receive the professional services. Your consent to treatment is valid until your patient relationship with Octave Behavioral Health is terminated.
Psychotherapy Services
Psychotherapy, often called talk therapy, is a form of treatment that can be helpful to individuals. There are many different definitions and philosophies of psychotherapy, and each of our providers will offer their own unique approach to treatment in unison with your goals, desires, and preferences. Therapy is offered as individual therapy and relationship therapy for couples or for adult family members.
Therapy has both benefits and risks. Benefits can include improved mood, improved relationships, and resolution of specific problems. However, therapy is not guaranteed to work for everybody. Therapy may also require exploring unpleasant aspects of your life and can, at times, lead to feelings of distress (e.g., guilt, anxiety, frustration, etc.) or a temporary increase in symptoms. These unpleasant aspects are generally temporary but are important to discuss with your provider.
Your course of treatment will be individualized depending on the intensity and duration of your presenting concerns, your level of engagement and active participation in the treatment plan, and the specific nature of your concerns. If you have questions about any of the treatments used during your therapy, their possible risks, alternative treatments, your provider’s credentials, or about the treatment plan in general, please ask your provider at any time.
You may withdraw from treatment at any time. However, it is recommended that you discuss your plan to end treatment with your provider before acting, so that they have an opportunity to offer further recommendations or referral options. If at any point your provider assesses that the sessions are not effective in helping you reach your goals, they will discuss this with you and, if appropriate, end treatment and offer referrals that may be of help to you.
If you commit violence to, verbally or physically threaten or harass your provider, the provider’s colleagues or family, Octave Behavioral Health or anyone affiliated with Octave Behavioral Health, your provider reserves the right to terminate your treatment unilaterally and immediately. Failure or refusal to pay for services after a reasonable time is another condition for termination of services.
Confidentiality
Your privacy is important. In general, the privacy of all communications between a patient and a provider is protected by law, and providers can only release information about their work with a patient with the patient’s written permission. But there are a few exceptions.
In certain circumstances, your provider is required by law to inform legal authorities, or potentially impacted individuals, regarding the following situations:
- If there is suspected abuse or neglect of an elder, incapacitated, or dependent adult, or child.
- If, in your provider’s judgment, you are in danger of harming yourself or another person, or are unable to care for yourself.
- If you communicate to your provider a serious threat of physical violence against another person.
Additional limits to confidentiality include:
- If your provider is ordered by a court to release information as part of a legal proceeding, your provider may be required to share details of your care.
- Your provider may, on occasion, consult with other professionals in their areas of expertise to provide the best treatment for you. Information about you may be shared in this context without using your name.
- If your provider reasonably believes you are experiencing a psychiatric emergency, they may request a welfare check or contact your emergency contact.
- As otherwise required by law and/or detailed in our Notice of Privacy Practices.
It is important that you know that your provider adheres to a “no-secrets” policy for relationship therapy. Your provider will review this policy with you during your initial session. If you have any questions about the “no secrets” policy, please ask your provider at any time.
- No one is permitted to record a session.
While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that you raise to your provider any questions or concerns that you may have.
Attendance and Cancellation
Consistency is essential for the overall progress and effectiveness of therapy. Please be on time for your scheduled appointment. Appointments must be canceled or rescheduled at least 24 hours in advance of the session to avoid any charges. You will be considered a no-show if you are more than 15 minutes late to your scheduled appointment. To reschedule or cancel an appointment, please contact [email protected].
If you cancel with less than 24 hours’ notice or miss your scheduled appointment, you will be charged a cancellation fee. The cancellation fee is not eligible for insurance reimbursement.
Your provider is often not immediately available by telephone. If you need to contact your provider between sessions for non-urgent issues, please contact [email protected].
Billing and Payments
We require payment at the time of service. This includes your copay, coinsurance, or deductible. This consent authorizes us to charge your credit card on file for services rendered and to send billing claims to your insurance company, health plan, or a third party administrator for reimbursement.
We may update our fees as needed, or at the start of each calendar year. Fees are subject to change with 30 days written notice at any time. If you have any questions, please reach
contact [email protected].
Teletherapy
The services may be provided to you in-person or through teletherapy technologies, as deemed clinically appropriate. This consent provides you with important information about teletherapy. By signing this consent, you agree to participate in teletherapy and receive the services from your provider via synchronous and/ or asynchronous technologies, as appropriate.
Teletherapy is the provision of psychotherapy services provided digitally, typically via secure video conference but in some circumstances via telephone. Teletherapy offers an effective option for continuity of care when in-person services are not possible or not preferred. Of course, you are not required to receive services via teletherapy and may withdraw your consent at any time.
Your provider will be licensed in the state where you are located when the services are provided, or otherwise meet a professional licensure exception under applicable state law, and will establish a provider-patient relationship in accordance with the laws and rules in the applicable state. Please let your provider know if you will be traveling to another state or if you move to another state. In some cases, providers may not be able to provide services to you while you are located in another state, even temporarily.
The benefits of teletherapy are:
- Easier access to care and continuity of care
- Convenience of meeting from your desired location (restrictions may apply based on federal, state, or local laws).
The potential risks of teletherapy are:
- Interruptions, background noise, or technical difficulties.
- Unauthorized access to your health information if you are not in a private room or location.
- In the event of a crisis during session, your provider will not be in the same location as you.
In the event you are unable to communicate with your provider due to a technological or equipment failure, please contact [email protected].
It may be also useful during the course of treatment to communicate by email, text message, or other electronic methods of communication. By signing this consent, you agree to receive periodic electronic communications (e.g., email, call, or text) from us about the services you have received or will receive. You may opt out at any time. Although your provider will make reasonable efforts to protect the privacy and security of all electronic communication with you, including teletherapy, we cannot guarantee confidentiality when communications are made through these channels.
Death or Incapacity of Provider
If your provider is incapacitated or dies, it will be necessary for another provider to take possession of your file and records. By signing this form, you consent to allow another licensed professional whom your provider or Octave Behavioral Health designates to take possession of your file and records, provide you with copies upon request, or to deliver them to a provider of your choice.
Research, Writing, Teaching
Your provider and others at Octave Behavioral Health conduct internal research and training, or publish information for professional and/or lay audiences. De-identified information about you and your treatment may be used to support these initiatives. Any use of information about your treatment would be only in an anonymized and/or de-identified way for these purposes.
Emergencies
IF YOU ARE IN A STATE OF CRISIS OR EMERGENCY, PLEASE DIAL 911 OR GO TO THE LOCAL EMERGENCY ROOM. IN THE EVENT YOU ARE EXPERIENCING EMOTIONAL DISTRESS, PLEASE CALL OR TEXT 988, THE SUICIDE AND CRISIS LIFELINE.
Minors
You must be at least 18 years old to receive the services. We do not provide treatment to individuals under the age of 18.
If you have any questions or concerns regarding this document, please speak to your provider or contact [email protected].
Additional State Disclosures
Depending on the state where you reside, we may provide additional information to you. These additional disclosures and consents are incorporated into this document.
California — for all California patients — The Board of Behavioral Sciences receives and responds to complaints regarding services provided within the scope of practice of (marriage and family therapists, licensed educational psychologists, clinical social workers, or professional clinical counselors). You may contact the board online at www.bbs.ca.gov, or by calling (916) 574-7830.
Connecticut — for all Connecticut patients — You understand that each telehealth provider shall, at the time of the initial telehealth interaction, ask you whether you consent to that provider’s disclosure of records concerting the telehealth interaction to your primary care provider. You further understand that your primary care provider may obtain a copy of your records of your telehealth encounter, upon your consent.
District of Columbia — for all D.C. patients — You have been informed of alternate forms of communication between you and a physician for urgent matters. Relevant communications
with the physician, including those done via electronic methods shall be documented and filed in your medical record.
New Jersey — for all New Jersey patients — You acknowledge that the telehealth encounter may be with a health care provider who is not a physician. You have the right to request a copy of your medical information and you understand your medical information may be forwarded directly to your primary care provider or health care provider of record, or upon your request, to other health care providers.
Tennessee — for all Tennessee patients — The information you share in psychotherapy is protected health information and is generally considered confidential by both Tennessee state law and federal regulations, with some limited exceptions (e.g., may be shared with another healthcare provider, required by subpoena). Your mental health provider may also disclose information without consent: (1) if disclosure is necessary for other duties that the mental health provider is bound by, (2) if it is necessary to assure service or care is the least drastic means, (3) due to a court order, (4) if it is solely information to a residential service recipient, (5) to facilitate continuity of service to another health care provider, (6) if a custodial agent for another state agency that has legal custody of the service cannot perform the agent’s duties, or (7) it is necessary for the preparation of a post-mortem examination.
Notice of Privacy Practices
OUR PRIVACY COMMITMENT
Thank you for giving us the opportunity to serve you. In the normal course of doing business, Octave Health Group, Inc., on behalf of Octave Behavioral, P.A., Octave Behavioral Health, PC, Octave Behavioral Michigan, PC, Octave Behavioral, P.C., and Octave Psychiatry Behavioral Health, P.C., creates, obtains, and/or maintains records about you and the services we provide to you. The information we collect is called protected health information (“PHI”). We take our obligation to keep your PHI secure and confidential very seriously.
We are required by federal and state law to protect the privacy of your PHI and to provide you with this Notice of Privacy Practices (“Notice”) about how we safeguard and use it, and notify you following a breach of your unsecured PHI.
When we use or give out (“disclose”) your PHI, we are bound by the terms of this Notice. This Notice applies to all electronic or paper records we create, obtain, and/or maintain that contain your PHI.
THIS NOTICE DESCRIBES:
∙ How we may use and disclose your PHI
∙ Your rights to access and amend your PHI
We are required by law to:
∙ Maintain the privacy of your PHI
∙ Provide you with notice of our legal duties and privacy practices with respect to PHI
∙ Abide by the terms of the Notice
HOW WE PROTECT YOUR PRIVACY
We understand the importance of protecting your PHI. We maintain technical, physical and administrative safeguards to ensure the privacy of your PHI.
PERMITTED USES AND DISCLOSURES OF YOUR PHI
HOW WE MAY USE PHI WITHOUT YOUR AUTHORIZATION
Treatment – We may use and disclose your PHI to health care professionals or other third parties to provide, coordinate and manage the delivery of health care. For example, behavioral health assessments and other PHI may be disclosed to your health insurer and your primary care physician in order to facilitate the provision of behavioral health services.
Payment – We may use and disclose PHI about you to receive payment for our services or premiums for your coverage, determine your insurance coverage for certain services, manage your account, fulfill our responsibilities under your benefit plan, and process your claims for drugs you have received. For example, we may give PHI to your health plan (or its designee) so we can confirm your eligibility or coverage, or we may submit claims to your health plan, employer or other third party for payment.
Health Care Operations – We may use and disclose your PHI to carry on our own business planning and administrative operations. We need to do this so we can provide you with high-quality services. For example, we may share your claims information with your doctor if you have a medical need that requires attention. We may use and disclose PHI about you to assess the use or effectiveness of certain drugs, develop and monitor medical protocols, and to provide information regarding helpful health-management services.
Disclosures to Your Employer as Sponsor of Your Health Plan – Where permitted by law, we may disclose your PHI to your employer or to a company acting on your employer’s behalf, so that entity can monitor, audit and otherwise administer the employee health plan in which you participate. Your employer is not permitted to use the PHI we disclose for any purpose other than administration of your benefits. See your employer’s health plan documents for information on whether your employer receives PHI and, if so, the identity of the employees who are authorized to receive your PHI.
Information That May Be of Interest to You – We may use or disclose your PHI to contact you about treatment options or alternatives that may be of interest to you.
Individuals Involved in Your Care or Payment for Your Care – We may disclose PHI about you to someone who assists in or pays for your care.
Unless you write to us and specifically tell us not to, we may disclose your PHI to someone who has your permission to act on your behalf. We will require this person to provide adequate proof that he or she has your permission.
Legal Guardians – If you are under a legal guardianship, we may release your PHI to your legal guardians when we are permitted or required to do so under federal and applicable state law.
Business Associates – We arrange to provide some services through contracts with business associates so that they may help us operate more efficiently. We may disclose your PHI to business associates acting on our behalf. If any PHI is disclosed, we will protect your information from unauthorized use and disclosure using confidentiality agreements. Our business associates may, in turn, use vendors to assist them in providing services to us. If so, the business associates must enter into a confidentiality agreement with the vendor, which protects your information from unauthorized use and disclosure.
Research – Under certain circumstances, we may use and disclose PHI about you for research purposes. Before we use or disclose PHI about you, we will remove information that personally identifies you, obtain your written authorization or gain approval through a special approval process designed to protect the privacy of your PHI. In some circumstances, we may use your PHI to generate aggregate data (summarized data that does not identify you) to study outcomes, costs and provider profiles, and to suggest benefit designs for your employer or health plan. These studies generate aggregate data that we may sell or disclose to other companies or organizations. Aggregate data does not personally identify you.
Abuse, Neglect or Domestic Violence – We may disclose your PHI to a social service, protective agency or other government authority if we believe you are a victim of abuse, neglect or domestic violence. We will inform you of our disclosure unless informing you would place you at risk of serious harm.
Public Health – We may disclose your PHI for public health activities and purposes, such as regulatory reporting (e.g. reporting adverse events, vaccination efforts to avert the spread of communicable diseases) or for post-marketing surveillance in connection with FDA-mandates or product recalls.
We may receive payment from a third party for making disclosures for public health activities and purposes.
Judicial and Administrative Proceedings – We may disclose your PHI in the course of any judicial or administrative proceeding in response to a court order, subpoena or other lawful process, but only after we have been assured that efforts have been made to notify you of the request.
Law Enforcement – We may disclose your PHI, as required by law, in response to a subpoena, warrant, summons, or other appropriate process. In some circumstances, we may also disclose PHI to assist law enforcement with identification of relevant individuals, provide information about crime victims, provide information to law enforcement about decedents, and report a crime.
Coroners and Medical Examiners – We may disclose your PHI to a coroner or a medical examiner for the purpose of determining cause of death or other duties authorized by law.
Organ, Eye and Tissue Donation – We may disclose your PHI to organizations involved in organ transplantation to facilitate donation and transplantation.
Workers’ Compensation – We may disclose your PHI to comply with workers’ compensation laws and other similar programs.
Specialized Government Functions, Military and Veterans – We may disclose your PHI to authorized federal officials to perform intelligence, counterintelligence, medical suitability determinations, Presidential protection activities, and other national security activities authorized by law. If you are a member of the U.S. armed forces or of a foreign military, we may disclose your PHI as required by military command authorities or law.
If you are an inmate in a correctional institution or under the custody of a law enforcement official, we may disclose your PHI to those parties if disclosure is necessary for: the provision of your health care; maintaining the health or safety of yourself or other inmates or ensuring the safety and security of the correctional institution or its agents.
As Otherwise Required By Law – We will disclose PHI about you when required to do so by law. If federal, state or local law within your jurisdiction offers you additional protections against improper use or disclosure of PHI, we will follow such laws to the extent they apply.
Health Oversight – We may disclose PHI to a health oversight agency performing activities authorized by law, such as investigations and audits. These agencies include governmental agencies that oversee the health care system, government benefit programs, and organizations subject to government regulation and civil rights laws.
Creation of De-Identified Health Information – We may use your PHI to create data that cannot be linked to you by removing certain elements from your PHI, such as your name, address, telephone number, and member identification number. We may use this deidentified information to conduct certain business activities; for example, to create summary reports and to analyze and monitor industry trends.
To Avert Serious Threat to Health or Safety – We may disclose your PHI to prevent or lessen an imminent threat to the health or safety of another person or the public. Such disclosure will only be made to someone in a position to prevent or lessen the threat.
OTHER USES AND DISCLOSURES OF PHI
Uses of PHI That Require Your Authorization – Most uses and disclosures of psychotherapy notes (where appropriate), uses and disclosures for marketing purposes and disclosures that constitute a sale of PHI require an authorization. These activities and any other uses and disclosures of your PHI not listed in this Notice will be made only with your authorization unless we are permitted by applicable law to make such other use and disclosure, in which case, we shall comply with applicable law. You may revoke your authorization, in writing, at any time unless we have taken action in reliance upon it.
Written revocation of authorization must be sent to the address listed below.
Additional Protections for Certain Categories of PHI – For certain kinds of PHI, federal and state law may provide for enhanced privacy protection. Such protections may apply to PHI that is maintained in psychotherapy notes; PHI involving alcohol and drug abuse prevention, treatment, and referral; PHI concerning HIV/AIDS testing, diagnosis, or treatment; PHI involving venereal and/or communicable disease(s); and PHI related to genetic testing.
YOUR RIGHTS WITH RESPECT TO YOUR PHI
You have the following rights regarding the PHI we maintain about you:
Right to Inspect and Copy – Subject to some restrictions, you may inspect and copy PHI that may be used to make decisions about you, as well as records of enrollment, payment, claims adjudication and case or medical management. If we maintain such records electronically, you have the right to request such records in electronic format. You may also have the records sent to a third party, including requesting that we share your PHI with a Health Information Exchange (HIE). If you request copies, we may charge reasonable expenses incurred with copying and mailing the records. Under limited circumstances, we may deny you access to a portion of your records.
Right to Amend – If you believe PHI about you is incorrect or incomplete, you may ask us to amend the information. You must provide a reason supporting your request to amend. We may deny the request in some instances. If we determine that the PHI is inaccurate, we will correct it if permitted by law. If a healthcare facility or professional created the information that you want to change, you should ask them to amend the information.
Right to an Accounting of Disclosures – You have the right to request an accounting of disclosures of your PHI. This accounting identifies the disclosures we have made of your PHI other than for treatment, payment or health care operations. The provision of an accounting of disclosures is subject to certain restrictions. For example, the list will exclude the following, among others:
∙ Disclosures to you as well as disclosures you have authorized.
∙ Disclosures made earlier than six years before the date of your request (in the case of disclosures made from an electronic health record, this period may be limited to three years before the date of your request).
∙ Certain other disclosures that are excepted by law.
If you request an accounting more than once during any 12-month period, we may charge you a reasonable fee for each accounting report after the first one.
Right to Request Restrictions – You have the right to request a restriction or limitation on the PHI we use and disclose about you for treatment, payment or health care operations. You may also request your PHI not be disclosed to family members or friends who may be involved in your care or paying for your care. Your request must be in writing; state the restrictions you are requesting and state to whom the restriction applies. We are not required to agree to your request. If we do agree, we will comply with your request unless the restricted information is needed to provide you with emergency treatment. We will agree to your request to restrict PHI disclosed to a health plan for payment or health care operations (that is, non treatment) purposes if the information is about a medication for which you paid us, out-of-pocket, in full.
Confidential Communications – You may ask that we communicate with you in an alternate way or at an alternate location to protect the confidentiality of your PHI. Your request must state an alternate method or location you would like us to use to communicate your PHI to you.
Right to be Notified – You have the right to be notified following a breach of unsecured PHI if your PHI is affected.
Right to a Paper Copy of This Notice – You have the right to request a paper copy of this Notice at any time. For information about how to obtain a copy of this Notice and answers to
frequently asked questions, please call the Customer Service line for our agent at 877.279.6391. Even if we have agreed to provide this Notice electronically, you are still entitled to a paper copy.
Right to File a Complaint – If you believe we have violated your privacy rights, you may file a written complaint to us via our agent at the address listed below. You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services. You will not face retaliation for filing a complaint.
Written complaints, written revocation of authorization to use or disclose PHI, written requests for a copy of your PHI, amendment to your PHI, an accounting of disclosures, restrictions on your PHI or confidential communications may be mailed or emailed to our agent at the following address:
Octave Health Group, Inc.
625 Market Street, 15th Floor
San Francisco, California 94105
ATTN: Privacy Office
Email:
Please include your name, address and Customer ID number, as applicable.
ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES