Consent to Treat & Guarantee of Payment

Consent to Treat

I hereby give my consent as a (client/authorized representative of client) to receive behavioral health services, including, without limitation, counseling, psychotherapy, psychological assessment, medication management and/or psychiatric care from the health care provider contracted with a professional corporation or other professional legal entity associated with Therapymatch, Inc. d/b/a Headway (“Headway”). The Headway provider responsible for my care has explained to me the proposed treatment plan, the general nature and extent of any risks involved in the treatment, and alternative treatment options, if any.

I understand that confidentiality is an important aspect of the delivery of behavioral health services, and that Headway providers are bound by law and ethics to safeguard such patient-provider communications. I also understand that, although the law may allow me the right to examine treatment records, a Headway provider, in their reasonable professional discretion, may elect not to share certain information with me, but only as permitted or required by applicable federal and state privacy laws.

Guarantee of Payment

I understand that Headway renders services on the basis that insurance companies may or may not pay for all or a portion of its charges. I understand that I am personally responsible for knowing and understanding the coverage and eligibility conditions of my own insurance policy, including co-payment deductible, eligibility and coverage for all charges not paid by my insurance plan (Exception: services paid by a third party; EAP, Employer sponsored benefit). If I wish to self-pay for services provided by Headway, I have read and signed the Acknowledgment of Financial Responsibility. I understand that my obligation is subject to the Supplemental Headway Payment Terms (available at https://headway.co/legal/payment ) and, if I do not pay for the charges for which I am responsible, Headway may turn my account over to a collection agency.