Eclipse Mental Health Services

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Compliance Policy

The following is required to fulfill your compliance requirements. Please initial after each statement demonstrating that you read and understand the requirement:

The Following NON-compliance may result in immediate dismissal or tapering/discontinuation of current medication regimen:

If any compliance requirement is violated you will be required to review and sign a compliance violation log. If you refuse to do this you will be dismissed immediately.

CONSENT TO RELEASE

PSYCHIATRIC / MEDICAL and/or ALCOHOL / DRUG ABUSE records

under the conditions listed below:

4. An additional consent must be obtained for any other transfer or disclosure of this information.

5. I understand that I may receive a copy of this release.

CONSENT FOR AUDIO/VIDEO RECORDING

I give my consent to be AUDIO/VIDEO recorded during any in office or telemedicine

TOTAL ECLIPSE CONSENT FOR TREATMENT FORM

I am an independently practicing professional. I am completely independent in providing you with clinical services and I alone am fully responsible for those services. My professional records are electronically maintained, in accordance with HIPAA and no one else can have access to them without your specific, written permission.

The undersigned patient or responsible party (parent, legal guardian or conservator) consents to, and authorizes services, by Total Eclipse DMH. These services may include psychotherapy, medication therapy, laboratory tests, diagnostic procedures and other appropriate alternative therapies via telemedicine or face to face. You will be billed monthly for these services regardless if you use your allotted scheduled time per month.

The undersigned understands that he/she has the right to:

Be informed of and participate in the selection of treatment modalities.

Receive a copy of this consent.

Withdraw this consent at any time.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Your information will be encrypted.

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