Treatment Consent Form

I hereby give my consent to care performed by the physician/APRN at Solace Center (henceforth referred to as "the practice"). I consent to being treated by the practice using psychotropic medications, non-psychotropic medications, psychotherapy, and other forms of treatment deemed necessary and appropriate by the provider and within the provider's scope of practice.

I understand, and I am informed that, as with all healthcare treatments, results are not guaranteed and there is no promise of cure. I have had the opportunity to discuss with my provider the nature and purpose of treatments and procedures. I am aware that all existing methods of diagnosis and treatment pose some level of risk. I do not expect the provider to be able to anticipate and explain all risks and complications, and I wish to rely on the provider to exercise judgment during the course of the treatment which the provider feels, at the time, based upon the facts then known, is in my best interests.

Solace Center providers are only in the office during limited, posted hours. We do not provide out-of-office call coverage and refer to the emergency department (ED) if there are ever any concerns about health or safety. I will immediately inform the provider if I experience any unanticipated or unpleasant effects associated with treatment or prescription(s)/supplement(s) prescribed/recommended. I understand that if an emergency medical condition or mental health crisis arises, I am expected to call 9-1-1 / 988 or go to the nearest emergency room.

I, the undersigned patient, hereby authorize Solace Center, in accordance with Massachusetts state law, to request and obtain my medication history from my pharmacies, other healthcare providers, and through the Massachusetts Prescription Awareness Tool (MassPAT), a nationwide health information network that electronically exchanges medication history of scheduled medications prescribed.

This consent includes, but is not limited to: (1) prescribed medications, (2) dosage and frequency, (3) prescribing physicians, and (4) pharmacy information.

I understand this information will be used by Solace Center for the purpose of ensuring continuity of care, preventing medication errors, and providing the best possible medical treatment. I acknowledge that I have the right to revoke this consent at any time, except to the extent that action has been taken in reliance on this consent, and that Solace Center will maintain the confidentiality of my medication history in accordance with federal and state law.

I understand that the practice may recommend blood, saliva, stool, urine, hair, or skin testing within their scope of practice. In addition to conventional testing, specific tests may be ordered through specialized laboratories to assess structural and/or functional deficiencies. I agree to the use of such tests and will always have the opportunity to discuss their applicability and limitations with my provider prior to sample collection. I agree to pay the laboratory any fees due for sample collection and processing.

I consent to voluntarily engaging in a telemedicine consultation with the practice. I understand that video conferencing technology is not the same as a direct in-person visit — it has potential benefits (easier access to care, lower costs, visits from home) and potential risks (interruptions, unauthorized access, technical difficulties). My provider or I can discontinue a telehealth visit if the connection is not adequate. I understand telemedicine has limitations regarding physical examination, and that telehealth is not an emergency service — in an emergency I will call 911 or go to the nearest emergency department. I will not share my telemedicine login or video link with anyone unauthorized to attend the appointment.

An Artificial Intelligence (AI) scribe may be used to assist in documenting and transcribing sessions accurately, to enhance quality of care and streamline record-keeping. It transcribes spoken words into written text and does not interpret or analyze the content beyond transcription. I understand information recorded by the AI scribe is subject to the same confidentiality standards as our sessions, that access to transcriptions is restricted to authorized personnel, and that I have the right to opt out of its use at any time.

I understand the practice may, on rare occasions, offer telephone consultations (verbal only, no video), and that these have considerable limitations, including no physical exam or visual assessment. My provider may determine that adequate care is not possible via telephone alone, in which case I agree to follow through with any required in-person or video telehealth visits.

The preferred method of communication is a secure patient portal. The practice also permits communication by email, which carries risk — email can be forwarded, intercepted, or otherwise disclosed without full control. Email concerning diagnosis or treatment becomes part of my protected health information. Email must never be used in a medical or mental health emergency. I understand I may withdraw consent to email communication at any time in writing, and I agree to assume the risks associated with its use.

I authorize the practice to use my name, address, phone number, and clinical records to contact me with appointment reminders and related health information, by phone, voicemail, text message, or other messaging platforms, including leaving a message with someone else who answers if I am unavailable.

Fees and Payments. The practice files for insurance reimbursement; co-pays, deductibles, and fees not covered by insurance are the patient's responsibility. I authorize the practice to file claims and assign benefits payable for services rendered. All outstanding balances must be paid in full prior to the next office visit.

Missed Appointment Policy. Please provide at least 48 hours' notice to cancel or reschedule a new/initial visit, and 24 hours' notice for a follow-up visit. A missed appointment or insufficient notice may incur a $50.00 fee, due before further treatment. Repeated no-shows may result in the practice declining future appointments or requiring prepayment.

Phone Calls. Calls requiring 10 minutes or more of provider time may be billed as a minimum visit ($25 / 15 minutes).

Returned Checks. A $25.00 fee applies to any check returned by the bank.

Past Due Accounts. Accounts more than 25 days past due may be charged to the card on file, referred to a collection agency, and are subject to associated fees, interest, and legal costs as permitted by law.

Copies of Records. Paper copies of medical records may incur a fee of up to $1.00 per page for the first 25 pages and $0.25 per additional page; electronic copies are capped at $2.00 per page.

Special Letters, Forms, and Documents. Completing insurance forms, workplace documentation, or letters of medical necessity requires significant provider time and may incur an administrative fee, disclosed to you in advance. The practice does not write Emotional Support Animal letters or complete Social Security/Long-Term Disability forms (short-term disability may be considered case-by-case). School accommodation and course-withdrawal letters are supported, with a nominal administrative fee and up to 5–7 days for completion; none of these are completed at a first visit. The practice does not complete court/legal documents or assessments.

My provider's role is focused on treatment and does not extend to legal or court-related proceedings, mediation, or custody evaluations. My provider may offer opinions on general medical decision-making capacity, but is not qualified to determine financial decision-making capacity, the relationship between mental illness and criminality, or competency to stand trial, and does not serve as an expert witness or forensic provider. Services are limited to letters of attendance (dates of service and a basic summary of treatment) without recommendations, extrapolations, or judgments.

Many supplements, vitamins, medical-grade foods, nutritional powders, botanicals, and homeopathic remedies have not been evaluated by the FDA and are not intended to diagnose, treat, cure, or prevent any disease.

I authorize the practice to maintain my credit/debit card number on file (including with its billing platform) and to use it to process payment for services rendered, including any balance past 25 days. I understand a receipt/superbill will be sent to me within 30 days of each visit, and it is my responsibility to notify the office of any change to my card information.

Charge-Backs and Disputes. An administrative fee may apply to any credit card charge-back or dispute. Payments for services already rendered are final and non-refundable.

I agree to indemnify, defend, and hold harmless the medical providers employed by Solace Center — and their respective officers, directors, employees, and affiliates — from liabilities, losses, claims, damages, and costs arising out of the rendering of medical care, my failure to disclose relevant medical/physical information, or harm resulting from care or medications provided by the practice. I am aware of potential side effects associated with treatment, accept the associated risks, and will not seek indemnification from the practice.

I acknowledge that I have been given the opportunity to review Solace Center's Notice of Privacy Practices, which describes how my protected health information (PHI) may be used and disclosed, and my rights regarding that information.

In accordance with HIPAA, I authorize Solace Center to release medical records concerning my care to any physician, hospital, or other healthcare professional providing care to me, for purposes of treatment, payment, and healthcare operations. I understand I may request in writing how my PHI is used or disclosed, and that the practice is not required to agree to a requested restriction but is bound to any restriction it does agree to.

You have the right to be treated with respect and dignity; to know the name and professional status of those serving you; to privacy and confidentiality; to receive accurate information about your health; to know the effectiveness and side effects of treatment; to participate in choosing your treatment; to receive education and counseling about treatment; to review and request amendment of your medical record; and to receive information about related services.

You have the responsibility to seek medical attention promptly and provide useful feedback; to be honest about your medical, social, and lifestyle history; to ask questions about anything you don't understand; to follow health advice and instructions; to report significant changes in your health; to respect clinic policies; and to show up for appointments or cancel at least 48 hours in advance.