Informed Consent and Participation Agreement
I acknowledge by participating in the free group session sponsored by the Boris L. Henson Foundation, I authorize sharing my registration and its contents (referral) with my chosen provider and/or company. Questions regarding your HIPAA patient rights, responsibilities, and/or release of information must be sent to your treating provider if desired.
I acknowledge and give permission for any and all information associated with my registration to be used by the Boris L. Henson Foundation strictly for billing, statistics, and quality assurance.
I acknowledge that service fees for special exceptions, insurance copay's, no-shows, and referrals to alternate providers agreed upon between me and my provider are NOT covered by the campaign.
I will ensure the mandated Quality of Service Survey is submitted online after EVERY session. I acknowledge that a lack of completion may delay provider reimbursement, scheduling, and lead to removal from the campaign.
Break the silence, Break the cycle!
BLHF Senior Initiatives Team