Privacy & Consent Rights Consent Forms Use tab below to switch the consent form HIPAA Form Telehealth Form Substance Control Agreement HIPAA Consent Form Name * Name First Name First Name Last Name Last Name Date of Birth * Today's Date * Notice of Privacy Practices This notice describes how your medical information may be used and disclosed and how you can access this information. Neurostry Behavioral Health is committed to protecting your privacy in accordance with HIPAA and applicable Washington State laws. HOW YOUR INFORMATION MAY BE USED Your Protected Health Information (PHI) may be used for the following purposes: Treatment: We may use your information to provide, coordinate, or manage your care, including communication between providers involved in your treatment. Payment: We may use your information to bill and collect payment for services, including sharing information with insurance companies when applicable. Healthcare Operations: We may use your information for quality improvement, compliance, training, and internal administrative operations. OTHER PERMITTED DISCLOSURES We may disclose your information without your written authorization in the following situations: If required by law To prevent serious harm to you or others Suspected abuse or neglect (mandatory reporting) Public health and safety reporting Court orders or legal proceedings CONFIDENTIALITY IN PSYCHIATRIC CARE Mental health records are treated with heightened confidentiality. Certain disclosures require explicit written authorization, except where required or permitted by law. TELEHEALTH PRIVACY As a telehealth provider, Neurostry uses secure, HIPAA-compliant platforms. While we take all reasonable steps to protect your privacy, there are inherent risks with electronic communication. YOUR RIGHTS You have the right to: Access and request a copy of your medical records Request corrections to your records Request restrictions on certain uses/disclosures Request confidential communications File a complaint if you believe your rights have been violated COMPLAINTS If you believe your privacy rights have been violated, you may file a complaint with: Neurostry Behavioral Health * Or the U.S. Department of Health and Human Services (HHS).You will not be penalized for filing a complaint. PATIENT CONSENT FOR USE & DISCLOSURE By signing below, I acknowledge that: * I have received and reviewed the Notice of Privacy Practices I understand how my information may be used and disclosed I consent to the use of my information for treatment, payment, and healthcare operations I understand I may revoke this consent in writing at any time Patient Signature * signature keyboard Clear Today's Date * Submit If you are human, leave this field blank. Telehealth Informed Consent Form Name * Name First Name First Name Last Name Last Name Date of Birth * Today's Date * Telehealth Consent ➤ I understand that telehealth involves the use of electronic communication to provide psychiatric services remotely. ➤ I acknowledge the potential risks and benefits of telehealth, including technical issues and confidentiality limitations. ➤ I understand that I must be physically located in Washington State during telehealth appointments. ➤ I understand that telehealth is not appropriate for emergencies and agree to call 911 or go to the nearest emergency room if needed. ➤ I understand that recording of telehealth sessions by either the patient or provider is strictly prohibited without prior written consent from all parties involved. ➤ I understand that I have the right to withdraw consent for telehealth treatment at any time without affecting my right to future care or treatment. Telehealth Consent: * I consent to video sessions I understand phone may be used if video fails Patient Signature * signature keyboard Clear Submit If you are human, leave this field blank. NEUROSTRY CONTROLLED SUBSTANCE AGREEMENT Name * Name First Name First Name Last Name Last Name Date of Birth * Today's Date * PURPOSE OF THIS AGREEMENT This agreement outlines the expectations and responsibilities for patients receiving controlled substances (such as stimulant medications or benzodiazepines) from Neurostry Behavioral Health. These medications require careful monitoring due to their potential for misuse, dependence, and regulatory oversight. PATIENT AGREEMENT By signing this form, I agree to the following: MEDICATION USE I will take medications only as prescribed. I will not change the dose without provider approval. I will not share, sell, or misuse my medication. ONE PROVIDER / ONE PHARMACY I will receive controlled substances only from Neurostry Behavioral Health I will use one designated pharmacy: Patient Name FOLLOW-UP REQUIREMENTS I agree to attend all scheduled appointments. I understand that missed appointments may result in medication delays or discontinuation. NO EARLY REFILLS Early refills will not be provided for lost, stolen, or overused medication. Repeated requests for early refills may result in discontinuation. MONITORING & COMPLIANCE I understand that: My prescription history may be reviewed through the Washington Prescription Monitoring Program (PMP). I may be required to complete random drug screening if clinically indicated. Compliance is required to continue treatment. MISUSE OR NON-COMPLIANCE Medication may be discontinued if: There is evidence of misuse or diversion. I do not follow treatment recommendations. I fail to attend follow-up appointments. RISKS OF CONTROLLED SUBSTANCES I understand risks may include the following: Dependence or addiction. Increased heart rate or blood pressure. Anxiety or sleep disturbances. Withdrawal symptoms if stopped abruptly. SAFE STORAGE: I agree to store medications in a secure location. I understand I am responsible for preventing loss or theft. IMPAIRMENT WARNING: I understand medications may affect my ability to drive or operate machinery. CONSENT & ACKNOWLEDGMENT By signing below, I acknowledge that: I understand the risks and responsibilities of controlled substance treatment. I agree to follow all guidelines outlined in this agreement. I understand that failure to comply may result in discontinuation of medication. Neurostry Behavioral Health * Patient Signature * signature keyboard Clear Today's Date * Submit If you are human, leave this field blank.
