Informed Treatment Consent for Override Services
- Override provides specific services via telehealth that are designed to help relieve pain conditions.
- All visits with Override providers will be via telehealth. This means that I will be able to consult with Override pain medicine physicians, physical therapists, behavioral health specialists, and health and wellness coaches through an interactive audio-visual connection, and that I will be able to exchange secure messages with Override providers.
- I authorize Override providers to disclose to each other, and share for the coordination of my care, any and all medical records, including but not limited to, Assessments, Diagnoses, Psychosocial, Psychological and Psychiatric Evaluations, Treatment Plans, Summaries, Current Treatment Update, Medication Management Information, Presence/Participation in Treatment, Nursing/Medical Information, Educational Information, Discharge/Transfer Summary, Continuing Care Plan, Progress in Treatment, Demographic Information, and Psychotherapy Notes, that each may have.
- Claims for treatment will be filed with my insurance carrier (if applicable) to pay for the telehealth treatment that I receive from Override.
- If telehealth services provided by Override are subject to deductible, co-insurance or co-pay in accordance with my insurance plan benefits, I will be responsible for payment of such deductible, co-insurance and co-pay.
- If I do not have insurance, or if my insurance does not cover/denies payment for the telehealth services provided by Override, I will pay for the services myself. I allow Override to charge my method of payment on file to pay any dues. I understand that Override reserves the right to discontinue treatment if I have an unpaid invoice that is past due.
- I have the right to refuse any telehealth service and have the right to discuss all medical treatments with my providers.
- I have read this form in its entirety or have had it read to me. I have had a chance to have all my questions regarding telehealth treatment answered to my satisfaction. I sign this form voluntarily, and in doing so acknowledge my understanding of the contents of this form and give my consent for telehealth treatment by Overrider providers.
Last Updated: September 2, 2022
