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EMERGENCY CONTACT

INSURANCE INFORMATION:

PAYMENT INFORMATION

I verify, by signing below, that the income noted is my verifiable household income and number of dependents. I may be asked to provide proof of income or benefits. I authorize my insurance benefits to be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Solvista Health or insurance company to release any information required to process my claims. Falsification of information may result in disqualification of assistance.

Consent to Services: I voluntarily consent that I will participate in healthcare services (which may include, but is not limited to, behavioral health, medical care, psychiatric, and/or substance use treatment) at Solvista Health. All services will be provided by appropriately qualified staff and may include a care team to provide individualized services by a coordinated group of integrated professionals. This consent remains valid for the duration of services unless revoked.

Potential Benefits of Treatment: Solvista Health's goal is to provide best in class, quality care that utilizes evidence-based practices to guide individualized care decisions. Reaching goals and improving quality of life often requires change, which can be hard. Research shows that likelihood of success is more often achieved when I am an active participant. It is important to keep my care team informed of any changes, barriers, or difficulties that I am experiencing as it relates to my treatment.

Billing and Payment Obligation: Solvista Health does not believe anyone should be denied care because of their ability to pay. As a client/patient, I am required to maintain up to date, accurate information regarding my insurance or payment preference, and I agree to assist Solvista Health in submitting claims for payment and/or helping obtain payment. I agree to follow Solvista Health's Financial and Collections Policies. This includes, but is not limited to, paying any copays at the time of service and/or paying any deductibles in a timely manner. If I am unable to pay or am having difficulty making payment, I understand Solvista Health has financial assistance programs available that I can apply for.

Telehealth Services: I consent to receive services via telehealth, where I would interact with a provider in a live format but who is not physically present with me. I understand and agree neither party will record the service without consent of the other party and that the provider is only responsible for limited HIPAA protections at my location. I will let staff know if I prefer to receive services in person, Solvista Health will attempt to accommodate my request. I understand that I may change my preference to receive telehealth services at any time for any reason.

Limits of Participation in Custody and Court Proceedings: Solvista Health reserves the right to decline to participate in court proceedings. I agree not to subpoena Solvista Health in any proceeding that may jeopardize the therapeutic relationship between me and my provider. This includes, but is not limited to, requests to testify in court, write reports to the court, and/or make custody recommendations.

Acknowledgments: Information regarding Solvista Health's practices are provided as part of this informed consent. Please review these documents carefully and initial below. My initials indicate that I have read, understand, and agree to each of the following documents.

Duration of Consent To Treat: This consent is valid for the duration of time I receive services at Solvista Health or until I notify Solvista Health of my intent to discontinue services. I understand if I withdraw consent, my services with Solvista Health will end.

I understand that Solvista Health may disclose information related to my services to Rocky Mountain Health Plans (Medicaid) for payment, health care and care coordination purposes. I also understand that I may opt out and not consent to disclosure of information regarding care coordination purposes.

I have read and understand the above information, have had an opportunity to ask questions about this information, and I consent to receive healthcare services from Solvista Health. If applicable, I also attest that I am the legal guardian and have the right to consent for the treatment of this minor.

If you are the Parent/Guardian of the client/patient, please sign below