Financial Agreement

I hereby give authorization for payment of insurance benefits to be made directly to Spectra Health for services rendered. I understand that I am financially responsible for all charges and accept responsibility for any fees for services not covered by my insurance or sliding fee scale assignment. I certify that the information I have reported regarding my insurance coverage is correct. I hereby authorize Spectra Health to release all information necessary to secure the payment of benefits from my insurance carrier. I further agree that a photocopy of this agreement shall be as valid as the original.

Outside Lab and X-Ray Processing

Spectra Heath partners with outside organizations, such as Altru, for processing certain labs and x-rays. When processing by an outside organization is required, I understand that I am subject to those agencies' separate Patient Financial Rights & Responsibilities and I may receive applicable billing from these sources. If you are uninsured and on the Spectra Plan, we may be able to assist with the cost of specific labs/x-rays processed at Altru.

Spectra Health No-Show Policy

DENTAL CLINIC - I understand that after two (2) broken dental appointments in a six (6) month period, I will be ineligible for treatment for six (6) months.

MEDICAL CLINIC - I understand that if I am late by ten (10) or more minutes to a medical appointment, I will be asked to reschedule my appointment.

BEHAVIORAL HEALTH - I understand that two (2) consecutive broken specialty mental health appointments or chemical dependency evaluations will result in the cancellation of any outstanding appointments after the second missed appointment.

Electronic Medical Records Affiliation Agreement

Your health records with Spectra Health will be stored in the same Electronic Medical Record as Altru Health Systems. While your information could be visible to certain health care providers at Altru, providers only access charts of their patients for provided care. Altru and Spectra Health have methods of monitoring for inappropriate employee access to patient charts and employ disciplinary policies related to inappropriate chart access.

Sharing of Relevant Information Among my Spectra Health Care Team

As an integrated care setting, Spectra Health providers work as a team. This may require sharing relevant information among your Spectra Health care team.

Substance Use Disorder and Mental Health Treatment

I understand that my substance use disorder and mental health treatment records are protected under the federal regulations governing Confidentiality and Drug Abuse Patient Records, 42 C.F.R. Part 2, and the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 45 C.F.R. pts 160 & 164, and cannot be disclosed without my written authorization unless otherwise provided for by the regulations.

Behavioral Health and Primary Care Telehealth Consent

I consent to receive primary care and behavioral health services through telehealth. I understand that the provider of my visit will be in an alternate approved location. A telehealth service means that my visit with a practitioner at the distant site will happen by using special audiovisual equipment. Spectra Health telehealth service uses a secure web-based system for transmitting audio and video data. To ensure privacy, the data is encrypted at the highest level available for telehealth.

I understand that telehealth services are considered a proxy for direct face-to-face treatment, but certain risks exist. I understand that risks for using telehealth services can include - but are not limited to - technology interruptions, unauthorized information access, technology difficulties, or the need to have a visit performed in-person.

I understand that I can decline telehealth services at any time with no impact to future care, treatment, or program benefits. I understand that the same confidentiality laws and protections for face-to-face visits apply to telehealth visits including the expectation of privacy, confidentiality, and to be informed of all people who will be present during my visit. I understand that I can access information from a telehealth visit or request records from a telehealth visit by submitting a written request to Spectra Health. I acknowledge that information related to my telehealth visit will not be released without my written consent. I acknowledge that billing will occur from my practitioner and may include a facility fee from the site from which I am presented.

Informed Consent and Authorization to Treat

I understand I have the right to be told the reason for the treatment/procedure(s), the benefits or risks associated with it, and other treatment options. I understand that services provided at Spectra Health are voluntary and I can refuse service(s) at any time.

I also authorize Spectra Health to complete exams (including ocular dilation), treatments, order diagnostic tests, and to provide medications that my provider thinks are necessary to stay healthy. If I choose to participate in telehealth services, I acknowledge that my provider will explain to me how the video conferencing technology will be used.

I have read the authorization terms laid out in the above statements.

By signing below, I am authorizing Spectra Health to provide me and/or my family with care.