Conditions For Treatment

1. During the telehealth session, please be located in a safe and private area that ensures confidentiality. Please do not have anyone else in the room unless it has been discussed and agreed upon with your provider. Please do not conduct other activities while in session, such as:
   • Driving a vehicle
   • Shopping
   • And/or receiving other services

   You understand that your session may be discontinued if policy and procedures are not

2. Relieve Behavioral Health and Wellness Center, LLC does not accept walk-in appointments. Patients are seen by appointment only. Medications are filled during appointments only. If you fail to appear for your scheduled appointment, medication refills may not be available. It is your responsibility to call the office and discuss future appointment availability.
3. Sharing or selling medication is a crime. We do not tolerate individuals selling or sharing medications prescribed in this office or any other medical practice. This act is considered grounds for immediate discharge without the possibility of readmission.
4. Patients are expected to adhere to the treatment plan that has been designed and discussed with them. Each treatment plan is different. Failure to comply with your treatment plan could result in premature termination of your treatment. It is based on the provider's description of medication choices and dosing in compliance with evidence-based practice.

Privacy and Release of Information

Services you receive in this office are confidential, except in the circumstances listed below:

1. Threats of harm to self or others
2. Abuse of a child, vulnerable adult, or developmentally disabled person
3. A court order to release information
4. Subpoena of treatment records by an attorney. If you do not want this information released, you must obtain a protective order from the court within fourteen (14) days.
5. If you are applying for health insurance, we may be required to provide information to your health plan, including some or all of your treatment records, so that your carrier can cover the costs of services. By signing the Acknowledgement of Receipt of Office Policies and Procedures form, you consent to the release of that information to your health plan.
6. If you are party to child custody litigation at any time in the future, the court may order the release of information about your treatment in this office.
7. In some instances, as provided by the state law of Connecticut, information about your healthcare may be exchanged with other healthcare professionals involved in your treatment.
8. In all circumstances other than those specified above, I will not release information about your treatment without your prior authorization.

Ways the Practice May Use and Disclose your Information

Confidential information may be released for payment and healthcare operations purposes only to health insurance plans, their agents, and business associates of the practice. The definition of health insurance plan does not include life insurance companies, automobile insurance companies, or workers' compensation carriers. These are not covered under HIPAA. Therefore, if you would like information submitted to one of these companies, an authorization will be required unless otherwise required by state or federal law.

Communicating with You and Others Involved in Your Care. This practice may contact you to provide appointment reminders or information about treatment alternatives, other health-related benefits, and services that may be of interest to you. In certain situations, we may share information about you with a friend or family member who is involved in your care or payment for your care unless you have requested that such disclosures not occur and we have agreed. The information disclosed will be directly relevant to such person's involvement with your care or payment related to your care. Whenever possible, this person will be identified by you. However, in emergencies or other situations where you are unable to express your preference, we may need to share information about you with other individuals or organizations to coordinate your care or notify your family.

1. As Required by Law: This office will disclose information about you when required to do so by federal, state, or local law. For example, we may release information about you in response to a valid court subpoena.
2. Health Oversight Activities: This office may disclose information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the healthcare system, government programs, and compliance with civil rights laws.
3. For Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made for information about the professional services that you have received within my practice and the records thereof, such information may be privileged under state law. We will not release information without the written authorization of you or your legal representative, or in the instance of issuance. This may also be the case in the example of a court subpoena requiring provision of such information of which you have been appropriately notified and in response to which you have not opposed the court subpoena within the legally specified format and timeframe, or in the instance of the issuance of a court order compelling me to provide Protected Health Information (PHI). This privilege does not apply when you are being evaluated for a third party or where the evaluation is court-ordered. You will be informed in advance if this is the case.
4. To Avert Serious Threat to Health or Safety: This office may disclose your confidential mental health information to any person without authorization if we reasonably believe that disclosure will avoid or minimize imminent danger to your health or safety or the health or safety of any other individual. These disclosures may be made to law enforcement officials in response to a violent crime or to protect the target of a violent crime. For example, the threat of harming another individual may be reported to the appropriate authorities.
5. Law Enforcement: This office may release information about you if asked to do so by a law enforcement official:
   • In response to a court order, subpoena, warrant, summons, or similar process
   • To identify or locate a suspect, fugitive, material witness, or missing person
   • If you are suspected to be a victim of a crime, generally with your permission
   • About a death we believe may be the result of criminal conduct at the hospital, in private practices, or outside the healthcare system
   • In emergency circumstances, to report a crime; the location of the crime or victims, or the identity, description, or location of the person who committed the crime

Cancellation

Although we accept several insurance companies, individual policies have different coverage. This is especially true of policies purchased by companies outside the state of Connecticut. We cannot verify your coverage as we are not the policyholder. Please make sure your insurance covers telehealth services. You can verify your coverage online or by contacting your insurance company directly. You are required to sign forms in our office, acknowledging that you are responsible for any fees that your insurance company denies. Please verify coverage before your first appointment. All copays, co-insurance, deductibles, and outstanding balances are due upon arrival. You may contact our office with any questions or concerns.

As a reminder, if you do not cancel at least 24 hours before your appointment time, all commercial insurance plans will be charged a $100 fee.