PATIENT CONSENT, PRIVACY & FINANCIAL RESPONSIBILITY AGREEMENT
This Agreement is acknowledged and agreed to through the Patient Intake Acknowledgment
Consent for Care and Treatment
I voluntarily consent to receive medical, psychiatric, and behavioral health services provided by Elira Health, LLC, including services rendered by its clinicians, staff, and authorized personnel, as determined to be clinically appropriate based on my needs and preferences. I understand that this general consent applies to evaluations, assessments, examinations, diagnostic services, treatment planning, medication administration and prescribing, minor office-based procedures, care coordination, telehealth services, and, when applicable, photography for medical, scientific, or educational purposes, as well as other services deemed advisable for my health and well-being under the general or specific instructions of my healthcare provider.
I understand that telehealth services require that I be physically located in a state in which my clinician is licensed to practice at the time services are provided. I understand that telehealth services are not appropriate for medical or psychiatric emergencies. In the event of an emergency, I agree to call 911 or go to the nearest emergency department.
I acknowledge that the practice of medicine and behavioral health is not an exact science and that individual responses to treatment vary. I understand that no guarantees have been made regarding the outcome of any evaluation, treatment, or service.
For behavioral and mental health services, I understand that participation may involve discussing personal experiences, thoughts, emotions, and behaviors. While these services may lead to meaningful benefits, they may also involve temporary discomfort, emotional distress, or the experience of difficult emotions. I understand that I am encouraged to communicate openly with my clinician about any concerns, reactions, or changes in symptoms during treatment.
I understand that recommended treatments, the material risks and benefits, and reasonable alternatives may be discussed with me as appropriate, and that I have the right to ask questions, decline any recommended service, or withdraw my consent for care at any time, except to the extent that action has already been taken in reliance upon my consent.
I understand that my participation and engagement in care is an important factor in treatment outcomes, and that outcomes may depend on my active involvement in services. I acknowledge that referrals to other providers or levels of care may be recommended if clinically indicated.
Unless revoked in writing, this consent for care will remain valid for one (1) year from the date of my signature below, or, if no date is present, from the date this document becomes part of my medical record. Any revocation of consent must be submitted in writing to Elira Health, LLC.
Authorization for Release of Information (Payment & Healthcare Operations)
I authorize Elira Health, LLC to release information from my medical and non-medical records, including current and prior encounters, as necessary for treatment, payment, and healthcare operations, including billing and reimbursement, Medicare, Medicaid, and commercial insurance claims, prior authorizations, utilization review, employers or third-party payers when applicable, and any entity responsible for payment of benefits, as permitted by applicable federal and Indiana law.
Financial Responsibility, Assignment of Benefits, and Billing Protections
I affirm that all demographic and insurance information I have provided is accurate, complete, and up to date. I authorize Elira Health, LLC to bill my health plan(s) and act on my behalf in submitting claims for services rendered. I assign to Elira Health, LLC any insurance or third-party payments otherwise payable to me for covered services, including Medicare, Medicaid, commercial insurers, employee benefit plans, or other payers.
I understand that coverage and payment are subject to the terms of my health plan, including any network status, benefit limitations, exclusions, medical necessity rules, and the insurer’s final determination of benefits. I am responsible for any portion of charges that my insurer determines are not covered, subject to applicable protections under state and federal law.
State and Federal Billing Protections
I acknowledge that:
Under Indiana law and the federal No Surprises Act, I cannot be balance billed in certain situations when services are covered by a health plan, such as:
Emergency care from an out-of-network provider or facility;
Certain ancillary services (e.g., anesthesiology, radiology) provided by out-of-network professionals at an in-network facility, unless permitted consent is obtained.
In these cases, my financial responsibility will be limited to in-network cost-sharing amounts (copayment, coinsurance, deductible) required by my plan.
These protections do not apply if I knowingly receive services from out-of-network providers in non-emergency settings and sign an appropriate consent form waiving balance billing protections, where permitted by law.
Good Faith Estimates
If I am uninsured, self-pay, or choose not to use insurance, I understand that I have the right to receive a Good Faith Estimate of expected charges for scheduled non-emergency care, and that I can request this estimate prior to receiving services. If the billed amount is at least $400 more than a required good faith estimate, I may dispute the charges under federal law.
Billing, Disputes, and Collection
I accept responsibility for payment of any portion of charges not covered by my insurer, to the extent permitted by my plan and applicable state or federal law, including the No Surprises Act and other billing protections. I understand that coverage determinations are made by my health plan and that Elira Health, LLC is not responsible for benefit determinations made by my insurer.
Payment for patient-responsible balances is due within forty-five (45) days of the billing date. I understand that I may contact Elira Health, LLC to request clarification of charges, submit updated insurance information, or discuss billing questions or disputes.
If my account becomes delinquent and is referred for collection, I may be responsible for reasonable collection-related costs, including attorney’s fees, to the extent permitted by Indiana and federal law. Elira Health, LLC will comply with all applicable laws regarding billing, collections, and patient financial protections.
Information regarding billing protections and Good Faith Estimates is available on Elira Health, LLC’s website and upon request.
Notice of Privacy Practices (HIPAA)
I acknowledge that Elira Health, LLC uses and discloses my protected health information for treatment, payment, and healthcare operations in accordance with HIPAA and applicable Indiana law. I acknowledge that I have been offered the opportunity to review the Elira Health Notice of Privacy Practices, which is available in the office, on the website, and upon request.
Electronic Records & Patient Portal Use
I understand that Elira Health, LLC utilizes electronic health records and secure electronic communication systems, including patient portals, to support care delivery and administrative functions. I understand that electronic communications are intended for non-urgent matters only and may not be reviewed immediately. I agree not to use electronic messaging for emergencies and understand that response times may vary based on clinical availability. I acknowledge that while reasonable safeguards are in place, no electronic system can be guaranteed to be completely secure.
AI-Assisted Documentation & Transcription
Elira Health, LLC may use secure technology tools, including artificial intelligence–assisted documentation or transcription services, to support accurate and timely clinical documentation. When used, these tools may assist in converting spoken clinical information into written clinical notes or summaries within the electronic health record.
I understand that:
• These tools are used solely to assist with documentation and administrative functions.
• Clinical judgment, decision-making, diagnosis, and treatment decisions are made exclusively by licensed clinicians, not by artificial intelligence.
• Any audio data, if used, is processed securely and in accordance with HIPAA and applicable Indiana law.
• Vendors providing these services are required to maintain appropriate safeguards for protected health information and are subject to applicable privacy and security agreements.
• The final clinical record is reviewed, edited, and approved by my clinician.
I understand that I may request additional information about these tools or may decline the use of AI-assisted documentation by notifying my clinician, which will not affect my access to care.
Billing for Electronic and Telephone-Based Clinical Services
I understand that certain patient-initiated electronic or telephone communications that require clinical evaluation, medical decision-making, and provider time may be considered billable services and may be submitted to my insurance or billed to me when applicable. I understand that these services are separate from routine administrative communications and that coverage and patient responsibility vary by insurance plan.
Telephone, Text, Email & TCPA Consent
I consent to Elira Health, LLC, and its agents, contacting me regarding appointments, care coordination, billing, account servicing, and collections using telephone calls (including wireless numbers), text messages, emails, and automated or prerecorded messages when applicable. I understand message frequency may vary, message and data rates may apply, and I can reply HELP for assistance or STOP to opt-out at any time.
Substance Use Information
I acknowledge that Elira Health, LLC complies with 42 CFR Part 2 regarding the confidentiality of substance use disorder records. I authorize Elira Health, LLC to disclose substance use treatment information as necessary for insurance billing, payment, prior authorization, and healthcare operations, as permitted by law.
Medication Data & Prescription History Authorization
I understand that information regarding medications I am currently taking or have taken in the past may assist my providers in delivering safe and effective care and reducing the risk of medication interactions or adverse reactions.
As an exercise of my right of access, I authorize Elira Health, LLC to access, obtain, and import into my electronic medical record available information regarding prescription medications dispensed to me at any time in the past, including information from pharmacies, prescription monitoring programs, pharmacy benefit managers, or other legally authorized sources.
I understand that this information will become part of my legal medical record and will be used or disclosed only as permitted by the Notice of Privacy Practices or applicable law.
Controlled Substances & Safety Monitoring
I understand that certain medications, including controlled substances, may require additional safety measures as part of appropriate medical care. These measures may include review of prescription monitoring program data, laboratory testing, urine drug screening, pill counts, treatment agreements, or other monitoring activities as determined by my clinician based on clinical judgment, regulatory requirements, and patient safety considerations. I understand that failure to comply with required monitoring may result in changes to my treatment plan or discontinuation of certain medications.
Health Information Exchange (HIE)
I understand that my medical information may be accessed, used, and shared electronically through one or more health information exchange networks in which Elira Health, LLC participates for purposes of treatment, care coordination, patient safety, and healthcare operations.
I understand that I may opt out of HIE participation by submitting a written request and may opt back in at any time. I understand that opting out may limit providers’ timely access to important health information.
Minors, Confidentiality, and Legal Proceedings
I understand that children and adolescents deserve a safe and private space for mental health care. To the extent permitted by law, Elira Health, LLC may limit parental access to a minor’s mental health records if, in the clinician’s good-faith judgment, disclosure could be harmful or is otherwise restricted by law.
I understand that Elira Health, LLC does not participate in custody evaluations or forensic proceedings and that involvement in legal proceedings may require termination of services or referral elsewhere.
Elira Health, LLC does not provide custody evaluations, forensic opinions, or legal recommendations. I understand that I am financially responsible for time and expenses related to legal requests, as permitted by law.
Patient Discharge or Termination of Services
I understand that my clinician or Elira Health, LLC may discharge or terminate services if treatment is no longer clinically appropriate, goals have been met, I fail to engage in care, licensing or legal limitations apply, my conduct interferes with care or safety, or my involvement in legal proceedings creates a conflict of interest.
Upon written request, Elira Health, LLC may coordinate with a new provider to support continuity of care when appropriate.
Active Patient Status and Attendance Policy
I understand that I will be considered an inactive patient if I have not been seen within the past ninety (90) days, have no future appointment scheduled, and have not expressed a desire to continue services.
I understand that arriving more than seven (7) minutes late may be considered a no-show. I understand that twenty-four (24) hours’ notice is required to cancel or reschedule an appointment.
If proper notice is not provided, I agree to pay a late cancellation or no-show fee of $75, which is not covered by insurance. I understand that two (2) missed appointments may result in termination of services.
Health Patient Rights & Responsibilities
I acknowledge that I have been given the opportunity to review Elira Health, LLC’s Patient Rights and Responsibilities, Financial Policy, and Notice of Privacy Practices. I understand these documents are posted and available upon request.