Services 4 — Eglen Psychological Services, LLC

Please download, print and fill out all forms, and mail originals to

Dr. Eglen

EPS Consent Telehealth Consultation

Jan Eglen, Ph.D.

12455 Glendurgan Drive

Carmel, Indiana 46032

1. I understand that Dr. Jan Eglen (Psychologist) recommends engaging in telehealth services with me to provide treatment.

2. I understand this is out of necessity and an abundance of caution and has originated due to the Coronavirus (Covid-19) pandemic. This will continue until such time that we are able to meet in person, or could continue, depending on the particular circumstance.

3. I understand that telehealth treatment has potential benefits including, but not limited to, easier access to care.

4. I understand that telehealth has been found to be effective in treating a wide range of disorders, and there are potential benefits including, but not limited to easier access to care. I understand; however, there is no guarantee that all treatment of all patients will be effective.

5. I understand that it is my obligation to notify Dr. Eglen of my location at the beginning of each treatment session. If for some reason, I change locations during the session, it is my obligation to notify Dr. Eglen of any change in location.

6. I understand that it is my obligation to notify Dr. Eglen of any other persons in the location, either on or off camera and who can hear or see the session. I understand that I am responsible to ensure privacy at my location. I will notify my Dr. Eglen at the outset of each session and am aware that confidential information may be discussed.

7. I understand that it is my obligation to ensure that any virtual assistant artificial intelligence devices, including but not limited to Alexa or Echo, will be disabled or will not be in the location where information can be heard.

8. I agree that I will not record either through audio or video any of the session, unless I notify Dr. Eglen and this is agreed upon.

9. I understand there are potential risks to using telehealth technology, including but not limited to, interruptions, unauthorized access, and technical difficulties. I understand some of these technological challenges include issues with software, hardware, and internet connection which may result in interruption.

10. I understand that Dr. Eglen is not responsible for any technological problems of which Dr. Eglen has no control over. I further understand that Dr. Eglen does not guarantee that technology will be available or work as expected.

11. I understand that I am responsible for information security on my device, including but not limited to, computer, tablet, or phone, and in my own location.

12. I understand that Dr. Eglen or I (or, if applicable, my guardian or conservator), can discontinue the telehealth consult/visit if it is determined by either me or Dr. Eglen that the videoconferencing connections or protections are not adequate for the situation.

13. I have had a conversation with Dr. Eglen , during which time I have had the opportunity to ask questions concerning services via telehealth. My questions have been answered, and the risks, benefits, and any practical alternatives have been discussed with me.

14. Doxy.me is the technology service we will use to conduct telehealth videoconferencing appointments. Dr. Eglen has discussed the use of this platform. Prior to each session, I will receive an email link to enter the “waiting room” until the session begins. There are no passwords or log in required.

By signing this document, I acknowledge:

1. Doxy.me is NOT an emergency service. In the event of an emergency, I will use a phone to call 9-1-1 and/or other appropriate emergency contact.

2. I recognize Dr. Eglen may need to notify emergency personnel in the event he/she feels there is a safety concern, including but not limited to, a risk to self/others or Dr. Eglen is concerned that immediate medical attention is needed.

3. Though Dr. Eglen and I may be in virtual contact through telehealth services, neither Doxy.me or my Psychologist provides any medical or emergency or urgent healthcare services or advice. I understand should medical services be required, I will contact my physician. If emergency services are needed, I understand I should call 9-1-1.

4. The Doxy.me facilitates videoconferencing and this technology platform is not, itself, a source of healthcare, medical advice, or care.

5. I understand that the same fee rates apply for telehealth as apply for in-person treatment. Some insurers are waiving co-pays during this time. It is my obligation to contact my insurer before engaging in telehealth to determine if there are applicable co-pays or fees for which I am responsible. Insurance or other managed care providers may not cover telehealth sessions. I understand that if my insurance, HMO, third-party payor, or other managed care provider do not cover the telehealth sessions, I will be solely responsible for the entire fee of the session.

6. During these times of the impact of Coronavirus (Covid-19) my Psychologist may not have access to all of my medical/treatment records. Dr Eglen has made reasonable efforts to obtain records, but I understand and agree this may not be reasonably possible.

7. To maintain confidentiality, I will not share my telehealth appointment link or information with anyone not authorized to attend the session.

8. I understand that either I or Dr. Eglen can discontinue the telehealth services if those services do not appear to benefit me therapeutically or for other reasons which will be explained to me. I understand there may be no other treatment alternative available.

I have read and understand the information provided above regarding telehealth, have discussed it with Dr. Jan Eglen, and I hereby give informed consent to the use of telehealth.

______________________________

Signature of patient (or guardian/conservator)

_______________________________

Printed name

________________________________

Date







This confidential information is provided to you in accord with State and Federal laws and regulations including but not limited to applicable Welfare and Institutions Code, Civil Code and HIPPA Privacy Standards.  Duplication of this information for further disclosure is prohibited without prior written authorization of the client/ authorized representative to who it pertains unless other permitted by law.

Methods of Contact

I would like to be contacted for appointment reminders and other correspondence via the following ways (check all that apply):

Telephone (please provide preferred number): ______________________________

Voicemail Message _______________________

Text Message (if different than above):____________________________

Email: ___________________________________

Postal Mail (include address if other than provided): _______________________________

________________________________ __________________

Patient Signature Date

________________________________ __________________

Printed Name Date

________________________________ __________________

Witness Signature Date

________________________________ __________________

Witness Printed Name Date

Consent to Treatment

Adult Individual Treatment

I have fully discussed with Dr. Jan Eglen the various aspects of the patient agreement. This has included a discussion of my evaluation/intake as well as the method of treatment. The nature of the treatment has been described, including the extent, its possible side effects, and possible alternative forms of treatment. My Psychologist has discussed with me scheduling, the nature of the fee and policies regarding missed appointments. My clinician has explained to me the limitations of confidentiality. I understand I may withdraw from treatment at any time, but if I decide to do this, I will discuss my plan with Dr. Eglen before acting on it. My only financial obligation, should I decide to stop treatment, is to pay for the services I have already received.

I have read the above and fully understand the diagnosis, the nature of treatment, the alternatives to this treatment, the limits of confidentiality in this relationship, and the circumstances in which confidential communications may need to be breached.

Please initial after the following statements:

I authorize the release of any information acquired in the course of examination or treatment necessary to process an insurance claim. I also assign payment of insurance benefits to the provider for services rendered for in-network benefits.

Initial _______

I understand and agree that I am ultimately responsible for the balance on my account for any professional services rendered, regardless of my insurance status. I understand that if collection proceedings are necessary, I will pay all fees associated with collecting this bill.

Initial _______

(For out-of-network patients) I understand that Dr. Jan Eglen is not an in-network provider with my insurance company, _____________________________________. As a result, I understand that I am responsible for payment up front, and EPS will provide me with the necessary documentation for me to file a claim with my health insurance company if I choose to do so. The cost of the session is _________________________.

Initial _______

(If applicable) I authorize communication between Dr. Eglen and my referring physician/clinician _________________________ to inform that I have initiated services (separate release is required for further exchange of information).

Initial _______

Date:____________________________________________

Adult Patient Information Form

Name: _____________________________ Date of Birth: ___________________________ Today’s Date: ___________________________________

Gender: _______________ Gender Pronouns: ________ Sexual Orientation: __________________

Age: _______________________ Partner/Relationship Status:__________________________ Race/Ethnicity: __________________________

Other Important Demographic Information: _____________________________________________

Street Address: ________________________________________________________________________________

City: ________________ State: ________ Zip Code: ___________

Preferred Phone Number (home/work/cell): _______________________________________________________

Referring Provider: ____________________________________________________________________________

Current Medications: ___________________________________________________________________________

Previous Mental Health Services: _________________________________________________________________

Presenting Problems: __________________________________________________________________________

Contact Information in Case of Emergency

Name:______________________________________________ Relationship to Patient: ______________________________ Phone: __________________________________

Secondary Emergency Contact ________________________________ Relationship to Patient: ________________________ Phone: ________________

PRIMARY INSURANCE INFORMATION

Insurance Company Name:__________________________ Phone#:__________________________________

Policy Holder’s Name:________________________________Date of Birth:______________________________

Relationship to Patient:____________________________ Name of Policy Holder’s Employer:___________

ID#:__________________________________ Group#:_________________________________

SECONDARY INSURANCE INFORMATION

Insurance Company Name:__________________________ Phone#:__________________________________

Policy Holder’s Name:________________________________Date of Birth:______________________________

Relationship to Patient:______________________ Name of Policy Holder’s Employer: ___________

ID#:__________________________________ Group#:__________________________________

______________________________________________________________________________

CREDIT CARD AUTHORIZATION FORM

NAME OF PATIENT: __________________________________________________________

NAME ON CARD:______________________________________________________________

BILLING ADDRESS:____________________________________________________________________

______________________________________________________________________________

Circle one: VISA MASTERCARD DISCOVER AMERICAN EXPRESS

ACCOUNT #: _________________________________________________________________

EXPIRATION DATE: ________________________

CVC # (ON BACK OF CARD): _______________

By signing this form, I authorize EPS and Dr. Jan Eglen to charge this card. I may choose to use other forms of payment such as cash, check or an HSA account. I understand that, should my account be 30 days overdue, I authorize EPS and my clinician to automatically charge this card.

I hereby grant permission to charge my credit card after every ____ session(s) _______ (initials)

or

I hereby grant permission to charge my credit card if my balance reaches $100 without further authorization.

AUTHORIZED SIGNATURE:________________________________________________________________

DATE: __________________________

AUTHORIZED SIGNATURE:________________________________________________________________

DATE: __________________________

AUTHORIZATION FOR RELEASE OF INFORMATION

I, __________________________do hereby consent and authorize Dr. Jan Eglen and/or EPS

to disclose to: _____________________________________________________________________

Name/Address/Telephone Number

The following specific information regarding (self/child’s name): _________________________________

___ Admission ___ Discharge Summary ___ Progress Notes

___ Attendance in Treatment ___ Patient Demographic Information ___ Psychological Evaluation

___ Progress in Treatment ___ Treatment Plans

___ Prognosis/Diagnosis ___ Other: _______________________________________________

I understand that this information is to be used for the purpose of: ______________________________________________________________________________________

__________________________ ______________________________

Patient/Guardian Signature Witness Signature

__________________________ ______________________________

Printed Patient/Guardian Name Witness Printed Name

__________________________ ______________________________

Date Date

I, __________________________do hereby consent and authorize my provider and/or EPS, to disclose to:

_____________________________________________________________________________________________

Name/Address/Telephone Number

The following specific information regarding (self/child’s name): _________________________________

___ Admission ___ Discharge Summary ___ Progress Notes

___ Attendance in Treatment ___ Patient Demographic Information ___ Psychological Evaluation

___ Progress in Treatment ___ Treatment Plans

___ Prognosis/Diagnosis __ Other: _______________________________________________

I understand that this information is to be used for the purpose of: _________________________________________

__________________________ ______________________________

Patient/Guardian Signature Witness Signature

__________________________ ______________________________

Printed Patient/Guardian Name Witness Printed Name

__________________________ ______________________________

Date Date

Patients may revoke releases at any time by informing Dr. Eglen verbally or in writing. Unless otherwise specified by this patient, this release will remain valid for 1 year from the time of signing.