Health Psych Maine, LLC
Specializing in Health Psychology & Anxiety
2 Big Sky Lane, Waterville, ME 04901 | Phone: (207) 872-5800 | Fax: (207) 872-5888 | www.hpmaine.com
INFORMED CONSENT FOR IN-PERSON TESTING/VISIT DURING COVID-19 PUBLIC HEALTH CRISIS
This document contains important information about our decision to conduct testing/visits in Health Psych Maine’s office in light of the COVID-19 public health crisis. Please read this carefully and let us know if you have any questions. When you sign this document, it will be an official agreement between you and Health Psych Maine.
Risks of Opting for In-Person Services
You understand that by coming to the office, you are assuming the risk of exposure to the coronavirus (or other public health risk). This risk may increase if you travel by public transportation, cab, or ridesharing service.
Your Responsibility to Minimize Your Exposure
To complete testing/visits in person, you agree to take certain precautions which will help keep everyone (you, our staff, everyone’s families) safer from exposure, sickness, and possible death. If you do not adhere to these safeguards, you may not be allowed to complete your testing/visit and evaluation:
- Please keep your in-person appointment only if you are symptom free.
- Please take your temperature before coming to your appointment. If it is elevated (100 Fahrenheit or more), or if you have other symptoms of the coronavirus, you agree to cancel the appointment or proceed using telehealth or reschedule. If you wish to cancel for this reason, Health Psych Maine will not charge you our normal cancellation fee.
- Please wait in your car or outside until no earlier than 5 minutes before your appointment time.
- Please wash your hands or use alcohol-based hand sanitizer (provided in the office) when you enter the building.
- Please adhere to the safe distancing precautions we have set up at the reception desk and in the testing room.
- You will wear a mask when entering the office and all times you are interacting with staff (Health Psych Maine staff will too).
- Please keep a distance of 6 feet between yourself and others in the office, including staff.
- Please try not to touch your face or eyes with your hands. If you do, immediately wash or sanitize your hands.
- Please take steps before your appointment to minimize your exposure to COVID.
- If you have a job that exposes you to other people who are infected, let Health Psych Maine staff know.
- If a resident of your home tests positive for the infection, let Health Psych Maine staff know prior to your appointment and we will arrange for testing and evaluation via telehealth or reschedule.
Health Psych Maine may change the above precautions if additional local, state or federal orders or guidelines are published. If that happens, we will inform you of any necessary changes.
Health Psych Maine Commitment to Minimize Exposure
Health Psych Maine has taken steps to reduce the risk of spreading the coronavirus within the office and we have posted our efforts in the office. Please let us know if you have questions about these efforts.
If You or I Are Sick
You understand that we are committed to keeping you, our staff, and all of our families safe from the spread of this virus. If you show up for an appointment and our office staff believe that you have a fever or other symptoms, or believe you have been exposed, we will have to require you to leave the office immediately. We can follow up with services by telehealth as appropriate or reschedule.
If Health Psych Maine staff test positive for the coronavirus, we will notify you so that you can take appropriate precautions.
Your Confidentiality in the Case of Infection
If you have tested positive for the coronavirus, Health Psych Maine may be required to notify local health authorities that you have been in the office. If we have to report this, we will only provide the minimum information necessary for their data collection and will not go into any details about the reason(s) for our visits. By signing this form, you are agreeing that we may do so without an additional signed release.
This agreement supplements Health Psych Maine’s other policies and agreements.
Your signature below shows that you agree to these terms and conditions.