Patient Consent for Treatment and Services
Authorization for Treatment
I hereby authorize Nebraska Peace of Mind Behavioral Health contractors to provide care, support, and behavioral health services or treatment as may be necessary or advisable for myself or the individual for whom I am legally authorized to provide consent. I understand that outcomes cannot be guaranteed and that referrals for additional services may be recommended. This consent remains valid until withdrawn in writing.
Acknowledgment of Patient Rights and Responsibilities
I acknowledge that I have received and read the Nebraska Peace of Mind Behavioral Health Patient Rights and Responsibilities. My consent is given with full understanding of these rights and responsibilities.
Acknowledgment of Privacy Practices (HIPAA)
I have been given the opportunity to read the Nebraska Peace of Mind Behavioral Health Notice of Privacy Practices and to ask questions about anything I do not understand. I have been offered a copy of these Privacy Practices.
Emergency Medical Treatment
I understand that Nebraska Peace of Mind Behavioral Health staff will call 911 in the event of a medical or emotional emergency occurring at the office or during face-to-face services provided outside of the office.
Authorization for Transportation
I authorize Nebraska Peace of Mind Behavioral Health to provide transportation to myself and the family members listed on this consent form if transportation is offered as part of the program or service in which I am participating.
Consent for the Use of AI Scribe and Documentation Tools
By receiving care at Nebraska Peace of Mind Behavioral Health, I acknowledge and agree that HIPAA-compliant AI tools, including DeepScribe Inc. and other approved vendors, may be used to assist in creating and maintaining clinical documentation. These tools may collect, process, or store information in accordance with HIPAA and applicable confidentiality laws. I authorize the sharing of my information with these vendors solely for documentation purposes.
DeepScribe Privacy Policy: www.deepscribe.ai/privacy
Withdrawal of Consent: I may withdraw consent at any time by notifying my healthcare provider in writing.
Medication Management Agreement – Benzodiazepines
By signing this agreement, I commit to following the guidelines for safe benzodiazepine use as established by my healthcare provider.
Conditions for Use
- I understand the purpose, risks, and benefits of benzodiazepines and will report concerning side effects.
- I understand the risk of dependence and will follow instructions to prevent withdrawal symptoms.
- I confirm that I am not pregnant and will avoid alcohol and substance interactions.
- I will only obtain benzodiazepines from Nebraska Peace of Mind providers and fill prescriptions at the designated pharmacy.
Responsibilities
- I will not misuse or share medication and will disclose other substances I take.
- I agree to take medication as prescribed and participate in recommended therapies.
- I agree to random drug screening when requested.
- I understand therapy is part of a comprehensive treatment plan.
- I understand benzodiazepine therapy may be discontinued if I do not follow this agreement.
This agreement is permanent and becomes part of my medical record. I acknowledge that I understand and agree to all conditions described above.
Representative Authorization
I authorize Nebraska Peace of Mind Behavioral Health and its representatives to act on my behalf to recover benefit claims, appeal adverse determinations, and take necessary actions to obtain payment for services. I understand I am responsible for all co-pays, deductibles, and co-insurance amounts unless other arrangements are in place.
Acknowledgment of Contact Information
I agree to notify Nebraska Peace of Mind Behavioral Health of any changes to my contact information.
I acknowledge that Nebraska Peace of Mind Behavioral Health staff may collaborate regarding my case for referral, treatment, and coordination of care when appropriate.