General Consent for Services
Circle Health Services provides healthcare services to individuals. After you have read each section of this form, and have had the opportunity to ask questions, please sign and date it to indicate your agreement and consent to receive services. If at any time you need help completing this form or do not understand any section of this form, please notify a staff member who is available to read this form and answer questions. Service will not be provided to anyone who changes or alters the terms or language of this consent form.
Authorization for Treatment
I agree to permit Circle Health Services authorized personnel to perform such services, diagnostic, and therapeutic procedures that my treating provider(s) deem necessary for care. I understand that services may include primary care, dental care, assessment services, psychiatric treatment, individual and group counseling, case management, substance use crisis intervention, substance use intensive outpatient services, and other medical care deemed necessary by my provider(s). I understand that HIV testing is included with an annual physical examination, and I can request that HIV testing not be done.
I agree to permit x-rays, laboratory tests, breathalyzer tests, photographs for treatment purposes, routine medical treatment (for example, medications, injections, drawing blood for tests), emergency procedures as necessary and other services performed at the request of the provider(s) involved in my care.
I understand that, except in an emergency, any further treatment or procedures will be performed only after I have been informed of the benefits, material risks and complications associated with such treatment or procedures and I have given my consent.
I further understand that physicians, nurses, and other healthcare personnel in training, as well as physician, nurse, and other healthcare personnel acting as volunteers, may assist, be present and participate in providing my care.
I understand that my medical records will be accessible to authorized personnel and that Circle Health Services will comply with certain safeguards established by federal, state, and local law as well as by Circle Health Services’ policies. Medical records are retained in accordance with applicable law and pursuant to Circle Health Services’ record retention policies.
I understand that I can call the Mobile Crisis Team for psychiatric crises after hours and the Circle Health Services after hours line when Circle Health Services is closed.
I understand that for after-hours emergency care, I will go to the nearest emergency room or call 911.
Outcome of Treatment
I understand that participating in services may not produce a satisfactory or successful outcome. I also realize that, by not participating in services, my problem or concern may become more serious. I acknowledge that no guarantees have been made to me with respect to the results of my care or treatment. I understand that, in some cases, Circle Health Services may work with me to develop alternative treatment programs. I recognize that referrals may be made for services that Circle Health Services does not provide. However, I understand that I am not obligated to accept such referrals.
Right to Terminate Service
I understand that I can determine, within reason, what services I need and/or want, and that I may terminate or withdraw from these services at any time. I understand that I have the right to decline services, including medication, except in an emergency. I understand that I have the right to decline, refuse or terminate a service, and that this will not prevent me from continuing to receive services that I request. I understand that no right extends so far as to supersede health and safety considerations, I understand that, if I terminate or withdraw from service, I may lose the benefit that continued treatment could provide. If I refuse treatment that is suggested to me, I will not hold Circle Health Services responsible for any consequences resulting from my decision to refuse treatment.
Client Rights and Responsibilities
I have received and read the Client Rights and Responsibilities. I agree to carry out my responsibilities found in the Client Rights and Responsibilities.
Notice of Privacy Practices
I have received and read the Circle Health Services’ Notice Regarding the Use and Disclosure of Protected Health Information (Notice of Privacy Practices).
Financial Responsibility and Assignment of Benefits
In consideration of the services received or to be received, I assign to Circle Health Services all benefits, and I direct insurers to pay such benefits directly to Circle Health Services. I understand that I am financially responsible for any service billed that is not covered by my insurance. I understand that I can meet with a benefits representative regarding my insurance benefits, and if I am uninsured that I can apply for benefits. I understand that I am responsible for co-payments at the time of service. The sliding fee scale has been reviewed with me. I will not be denied service because of an inability to pay for service.
Copies of Documents
I understand that I may receive a copy of this form, and copies of the Client Rights and Responsibilities and Notice of Privacy Practices, at any time.
Consent for Johnson & Johnson, Moderna or Pfizer COVID-19 Vaccine
Circle Health Services provides healthcare services to individuals. After you have read this form, and have had the opportunity to ask questions, please sign and date it to indicate your agreement and consent to receive the Johnson & Johnson, Moderna or Pfizer COVID-19 vaccine. If at any time you do not understand any section of this form, please notify a staff member who is available to read this form and answer questions. Service will not be provided to anyone who changes or alters the terms or language of this consent form. I have read or have had read to me the information in the Fact Sheet for Recipients and Caregivers: Emergency Use Authorization (EUA) of the Johnson & Johnson, Moderna or Pfizer COVID-19 vaccine. I have had a chance to ask questions that were answered to my satisfaction. I understand the benefits and risks of the vaccine being administered and ask that the vaccine be given to me or to the person named below for whom I am authorized to make this request. I hereby give my consent to Circle Health Services to bill my insurance for the vaccine, if applicable. I authorize the release of this record to the Ohio Department of Health Immunization Program. I hereby acknowledge that I have received and read the Circle Health Services’ Notice Regarding the Use and Disclosure of Protected Health Information (Notice of Privacy Practices).