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 Youth Initiatives Team
Overall, how would you rate your experience in the group
Please let us know how we can do better.