Patient-Centered Care in University Place, Washington

T001: Release of Information (ROI) & Disclosure of Protected Health Information

This form allows us to share your health information for treatment, payment, and healthcare operations as necessary. By signing, you consent to these uses and disclosures.

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T002: Controlled Substance Contract

If you are prescribed a controlled substance, this contract outlines essential guidelines for safe and responsible usage. Signing indicates your agreement to these terms.

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T003: HIPAA Disclosure Notice

At University Place TMS Clinic & General Psychiatry, we prioritize the protection of your health information. This notice provides an overview of how your health information will be utilized and disclosed in relation to Transcranial Magnetic Stimulation (TMS) Therapy, as well as your rights under the Health Insurance Portability and Accountability Act (HIPAA).

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T004: Disclosure Statement

This document contains vital information about our services, policies, and your rights as a patient. Signing confirms that you understand and agree to our practices and policies.

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T005: Surprise Medical Bill Disclosure

This document explains your rights under the No Surprises Act, detailing protections against unexpected medical bills. By signing, you acknowledge that you have read and understood these protections.

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T006: TMS Consent Form

This form offers comprehensive information about TMS (Transcranial Magnetic Stimulation) therapy, including its benefits, procedures, and potential risks. By signing, you confirm your understanding and consent to this treatment.

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MH001: Release of Information & Disclosure of Protected Health Information

This form permits us to share your health information for necessary purposes such as treatment, payment, and healthcare operations. By signing, you confirm your consent to these uses and disclosures.

Download Form

MH002: Controlled Substance Contract

If you are prescribed a controlled substance, this contract outlines essential guidelines to ensure safe and responsible usage. By signing, you indicate your agreement to these terms.

Download Form

MH003: HIPAA Disclosure Notice

This document explains how your personal health information (PHI) is utilized and protected under the Health Insurance Portability and Accountability Act (HIPAA). It details your rights, including:

• Accessing your health records.
• Requesting changes to your information.
• Restricting the disclosure of your information for specific purposes.

It also outlines circumstances in which we may need to disclose your information without your consent, such as in public health emergencies or legal requirements. By signing this form, you acknowledge that you have been informed about how your health information is handled and protected.

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MH004: Disclosure Statement

This document provides a comprehensive overview of our services, policies, and your rights as a client. It includes:

• The qualifications and approach of your provider.
• The types of services available, such as assessments, medication management, and therapy.
• Office policies, including cancellation procedures, telehealth practices, and payment methods.
• Your rights concerning confidentiality, privacy, and termination of care.

By signing this statement, you confirm that you have read and agree to adhere to these policies while receiving care at our clinic.

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MH005: Surprise Medical Bill Disclosure

This document outlines your protections under the No Surprises Act, which safeguards you from unexpected medical bills in certain situations, including:

• Receiving emergency care from an out-of-network provider.
• Treatment is received at an in-network facility but is billed by out-of-network specialists.

It also clarifies your right to:
• Pay only in-network cost-sharing amounts for specific out-of-network services.
• Avoid being balance billed for emergency services.

By signing this form, you acknowledge that you understand your rights and protections against surprise medical bills.

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