MediTelecare Resident Referral Form

Consent and Authorization to Screen, Evaluate and Treat

MediTelecare™ offers behavioral healthcare services via telehealth. Our neuropsychiatric team partners with the primary care physicians, families and patients to diagnose and improve neuropsychiatric symptoms such as depression, anxiety and memory problems.

By affixing my signature below, I consent to and authorize the MediTelecare™ team to screen me/my loved ones, medical chart. I understand that if the screen suggests that the undersigned will benefit from mental health services, and if the primary care provider is in agreement, I consent to and authorize an evaluation and treatment by MediTelecare™ including Behavioral Health Integration Services (BHI) and/or Chronic Care Management Services (CCM) as outlined in the "Notice To Patients Regarding Consent to Screen, Evaluate and Treat." Additionally, I am aware that I may revoke this consent at any time as long as I do so in writing.

By signing my name below, I agree to MediTelecare's™ "Telemedicine HIPAA Notice of Privacy Practices," "Notice To Patients Regarding Consent to Screen, Evaluate and Treat," and "License Agreement" Policies.