New Patient Form

Patient or patient's legal representative agree to the following terms for encounters with Brain Solutions PLLC (BS):

1. Treatment: The patient consents to the treatment and services provided by Brain Solutions which may include but are not limited to: psychotherapy, psychiatric services, evaluating patients before prescribing medications, refilling existing prescriptions, regular monitoring of medication use, behavioral healthcare, and any necessary periodic laboratory tests.
2. Release of Information: The patient acknowledges and agrees that any health and/or financial information (including information regarding alcohol or drug abuse, HIV related or to other communicable disease related information) may be released to the following:
   1. Healthcare providers or their agents who are providing or have provided healthcare to the patient; any individual or entity responsible for payment of BS's charges; to health care providers or organizations.
   2. All BS staff members, contractors, business associates, service locations, facilities and services and associated staff, and contractors.
   3. Individuals and entities as specified by law, ethical standards, and per insurance billing requirements.
   4. Patients covered under Arizona Medicaid System benefits waive the right to confidential disclosure with their Primary Care Physician.
3. Contraband: Drugs, alcohol, weapons, and other articles specified as contraband by BS may not be brought onto BS premises. Any illegal substance will be confiscated and turned over to law enforcement authorities.
4. Dismissal From Provider Services or BS: Patient may be dismissed from provider care or BS for: 1. Excessive no-shows/late arrivals, 2. Inappropriate or disruptive behavior, 3. Failure to follow treatment recommendations, 4. Medication dishonesty, 5. Failure to meet financial obligations, 6. Providing false or inadequate information, 7. Failing to authorize the release of records to BS or, 8. Being a difficult patient.
5. Teaching Program: BS participates in training programs for therapists and health care personnel. Some patient services may be provided by persons in training, under the supervision and instruction of therapists or other BS providers and/or contractors. These persons in training may also observe care given to the patient by therapists and BS providers and/or contractors. Patient will be notified if treatment is being provided by an unlicensed provider who is directly supervised by a licensed provider. With consent, any observation (e.g. video-taped or audio-taped) by a provider supervisor will be used strictly for educational purposes. Any questions regarding supervision will go to the Clinical Director, Jonathan C. Mackey, LCSW.