Consent to Treatment

I, the undersigned, hereby give my permission for Beal Wellness and its providers to administer medical treatment as deemed necessary. I authorize the Practice to file for insurance benefits to cover the costs of my care.

Understanding of Treatment and Financial Responsibilities

• I understand that Beal Wellness will need to send my medical record information to my insurance provider.

• I am responsible for paying my share of the costs.

• In cases where my insurance does not cover the costs or if I am uninsured, I am responsible for the full payment of these services.

• I acknowledge my right to refuse any procedure or treatment.

• I am aware of my right to discuss all medical treatments with my provider.

Consent for Use and Disclosure of Protected Health Information (PHI)

I give consent for Beal Wellness to use and disclose my PHI for the purposes of treatment, payment, and healthcare operations (TPO). This includes but is not limited to:

• Contacting me via phone, text, email, patient portal at my provided numbers and addresses, including leaving messages, for matters related to TPO such as appointment reminders and insurance matters.

• Sharing my PHI as necessary for the execution of TPO.

• I understand that while Beal Wellness takes privacy and confidentiality seriously, electronic communication has inherent risks. These include, but are not limited to, potential interception, misdirection, or loss of privacy.

Beal Wellness partners with research organizations that securely review limited information from our electronic health record (such as diagnosis, demographics, and relevant clinical data) to identify potential clinical research opportunities. If you qualify, SiteRx may contact you directly to discuss participation. This is optional and does not affect your care.

Receipt of Privacy Practices

I acknowledge that I have received and reviewed a copy of Beal Wellness' Notice of Privacy Practices.

Revocation of Consent

I understand that I can revoke this consent in writing at any time, except where actions have already been taken based on this consent.

Non-Consent Consequence

If I do not provide consent, or if I later revoke this consent, Beal Wellness may decline to provide treatment.

Medical Records Policy

HIPAA Compliance and Mental Health Records

In accordance with The Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule, Beal Wellness exercises special considerations for Mental Health records.

• Mental health records, as part of the overall medical record, and psychotherapy notes are treated differently under the HIPAA Privacy Rule.

• Psychotherapy notes, containing sensitive information and personal therapist notes, are generally not required for treatment, payment, or healthcare operations and are thus given special protections.

• Our office will not release psychotherapy notes or charts directly to patients.

Release of Medical Records

• Upon a signed release form, our office will transfer complete records to other healthcare providers, insurance companies, or attorneys.

• Medical records, including service dates, diagnoses, test results, treatment plans, and medication information, can be released to patients upon request.