Consent to Treatment

Last Updated: February 1, 2024

Your school is partnering with Cartwheel (“Cartwheel Care”) and Cartwheel Health Services P.C. (“Cartwheel Health Services”) and collectively, “Cartwheel”, to provide access to virtual mental health care services to students over video calls with licensed therapists and medical providers. This is also known as telehealth.

The purpose of this form is to obtain consent for the student’s participation in a telehealth consultation and see potential treatment. By signing this form, you acknowledge that you understand and agree to the following:

Informed Consent for Telehealth Services

Telehealth involves the use of electronic communications to enable healthcare providers at different locations to share individual patient medical information for the purpose of improving patient care. Telehealth services offered by Cartwheel may include, without limitation, diagnostic assessment, therapy services, chart review, remote prescribing, medication management, laboratory services, appointment scheduling, health information sharing (including care coordination with other treating providers), and non-clinical services, such as patient education. Health information may be used for diagnosis, therapy, medication management, follow-up care and/or patient education.

By signing this form, you acknowledge that you understand and agree with the following:

• I consent for me and/or the student to receive Cartwheel’s services via telehealth. I understand that these services do not replace the relationship between the student and their primary care doctor or other healthcare providers.
• I understand that I and/or the student will be initially assigned a provider, but that I may submit a request to change providers by sending an email to office@cartwheelcare.org. I acknowledge that all reasonable effort will be made to honor my request. If my request cannot be honored I understand I have the right to seek services for me and/or the student elsewhere.
• I understand that Cartwheel will rely on all information I provide to Cartwheel as accurate and complete and will use such information in its delivery of services to me and/or the student. I further understand that the inaccuracy of any such information I provide to Cartwheel may impact the efficacy of such services.
• I understand that telehealth services include potential benefits, such as easier access to care and the convenience of meeting from home or another location of my choosing.
• I understand that telehealth services also include potential risks, such as technical failures resulting in delays in evaluation and treatment and, in rare events, failure of security protocols causing a breach of privacy of personal medical information. I understand that reasonable and appropriate efforts have been made to eliminate any confidentiality risk associated with the telehealth consultation, and confidentiality protections under federal and state law apply to information disclosed during this telehealth consultation. I understand there is a risk of technical failures during the telehealth encounter beyond the control of Cartwheel.
• I understand that I may suspend or terminate use of the telehealth services at any time for any reason or for no reason.
• I understand that alternatives to telehealth consultation, such as in-person services, are available, and in choosing to authorize the student to participate in a telehealth consultation, I understand that some parts of the services involving tests may be conducted by individuals at my location, or at a testing facility, at the direction of the Cartwheel provider (e.g., labs or vital sign monitoring).
• I understand there may be side effects from certain medications prescribed, and that my provider will specifically address these risks when prescribing such medication.
• I understand Cartwheel is a telehealth-based service that may use other technology vendors. I understand that Cartwheel and its vendors are not equipped to handle psychiatric or medical emergencies. If the student has an emergency that needs immediate response, I will call 911 or take the student to the nearest emergency room. I understand that Cartwheel providers are not able to connect me or the student directly to any local emergency services.
• I have read or had this form read and/or had this form explained to me. I fully understand the form’s contents including the risks and benefits of the procedure(s). I have had an opportunity to ask questions about this information and all of my questions have been answered to my satisfaction.

Informed Consent for Teens

The following is only for students aged 13+ and their parents and/or legal guardians. By signing this form, you acknowledge that you understand and agree to the following:

Meeting with a Cartwheel therapist and/or medical provider is an opportunity for you to share challenges and problems that may be impacting important areas of your life. We want you to feel comfortable sharing with whomever is on your Cartwheel team about what is going on, and we understand that privacy is an important part of building that comfort and trust. Cartwheel will keep what you share in all sessions confidential, unless your parent or guardian is present or we have your consent to disclose certain details. 

However, you should know that by law in many states, your parent or guardian may have the right to see any written records. Please also keep in mind that under certain circumstances, our providers are required by law, or by clinical guidelines, to disclose information whether or not you have given permission. Examples of these exceptions to confidentiality are listed below:

• You share with your provider that you plan to cause serious harm or death to yourself, and our providers believe you have the intent and ability to carry this out in the near future.
• You share with your provider that you plan to cause serious harm or death to someone else who can be identified, and our providers believe you have the intent and ability to carry this out in the near future.
• You are doing things that could cause serious harm to yourself or someone else, even if you do not intend to harm yourself or another person.
• You tell your provider you are being abused, either physically, sexually, or emotionally, or that you have been abused in the past. 
• You are involved in a court case and your information is requested. If this happens, our providers will not disclose information without your written agreement unless required by the court. Our providers will do what they can within the law to protect your confidentiality, and they will inform you if they are legally required to disclose information about your care.

Informed Consent for Medication Management

The following is only for clients who opt in for medication management services. By signing this form, you acknowledge that you understand and agree to the following:

• I understand our medical provider has recommended that medication(s) and/or adjustments to medication(s) may assist in the student’s treatment. 
• I understand medication(s) being prescribed have both potential risks and benefits. Our medical provider and/or team has explained to me the potential risks and benefits, the risk of drug interactions, and the potential short and long term side effects. I accept these risks.
• I agree the student will take this medication only as prescribed by the medical provider and will not make dose adjustments and/or discontinue the medication unless directed.
• I agree the student and/or at least one legal guardian will attend all scheduled appointments as directed.
• I understand that prescribed medications are for the student’s use only and should not be given or sold to others.
• I have reviewed this Informed Consent. I understand that failure to do so may result in my discharge from this medical practice.

Consent for Minors with Divorced or Separated Parents (if applicable)

The following is only for clients with divorced or separated parents. By signing this form, you acknowledge that you understand and agree to the following:

• I warrant that I am a legal guardian of the student and have authority to consent to behavioral and medical treatment of the student. 
• I understand that Cartwheel is not responsible for ensuring that either of the parents follows a legally binding divorce decree.
• I have legal custody and will provide evidence of legal custody if requested by Cartwheel.
• Cartwheel will not act as messengers between separated or divorced parents, and it is expected that parents will communicate with each other in whatever ways available to them regarding the care of the student.
• I understand that Cartwheel will not provide legal testimony regarding custody of the child. I agree that I will not ask Cartwheel providers to give testimony through subpoenas, legal summons, or in-person testimony.

Disclosure of Medical Information

You authorize Cartwheel Health Services to disclose health information and education records about the student, including personally-identifiable medical information, to Cartwheel Care, medical professionals, administrative staff, and employees of Cartwheel in accordance with applicable law for the purposes of treatment or general administration. Information covered under this release includes the student’s medical record, ongoing communications regarding psychiatric or mental health care, developmental and/or social history, and educational records. You also authorize the use of written or recorded information containing the student’s personally-identifiable medical information for the development and improvement of software, hardware, and related tools designed to improve services provided by medical professionals, administrative staff, contractors, and employees of Cartwheel. You also authorize the disclosure of information and records containing or related to the student’s personally-identifiable medical information for the purpose of billing commercial and insured healthcare payers, state and/or federal healthcare payers, including but not limited to state Medicaid plans. The purpose of the disclosure is to obtain information and/or renumeration for reimbursable medical services.

Provider Licenses

Cartwheel employs therapists and medical providers with a range of licenses and areas of expertise. All of our providers are licensed to provide clinical services in the state in which the student is receiving those services. 

You and/or the student may be offered treatment from a licensed therapist working under the direct supervision of an independently licensed therapist (typically a Licensed Certified Social Worker supervised by a Licensed Independent Clinical Social Worker). In some cases, the therapist working under supervision may not be credentialed with your health insurance plan. By signing this form, you acknowledge and agree that you and/or the student may receive treatment from a licensed therapist working under supervision. If you would prefer that you and/or the student wait to be seen by an independently licensed therapist, you may contact our office at 888-500-2067 or office@cartwheelcare.org.

Your student may be offered treatment with a PMHNP-BC (Psychiatric-Mental Health Nurse Practitioner-Board Certified). A PMHNP-BC is an advanced practice registered nurse (APRN) who has received advanced education and training in providing a wide range of psychiatric and mental healthcare services to patients and families in a variety of settings. PMHNP-BCs diagnose, conduct therapy, and prescribe medications for patients who have psychiatric disorders. They are fully qualified and licensed to provide emergency psychiatric services, psychosocial and physical assessment of their patients, treatment plans, and manage patient care.

Cancellation Policy and Fees

Last Updated: February 1, 2024
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Cartwheel works hard to offer appointments without a waitlist and expect students and their family members to consistently attend sessions. Missed or canceled sessions can delay a student’s progress, prevent other families from accessing care, and be disruptive for therapists and school counselors.

24 hours notice required

If you need to reschedule a visit, we ask that you provide 24 hours’ notice by calling 1-888-500-2067 or emailing office@cartwheelcare.org.

$80 cancellation / no-show fee

If a session is missed or canceled with less than 24 hours’ notice, Cartwheel will charge $80. Fees are not charged when prohibited by law.

Exceptions

We recognize that serious illnesses, family emergencies, and other things come up from time to time. Some students working with us might find it hard to always show up for their sessions, and we get that. Cartwheel will collaborate with you on a case-by-case basis with these exceptions in mind. If a student’s therapist is not a good fit for any reason, please let us know and we will work with you to find a solution.

Discharge in case of repeatedly canceled, or missed sessions

Cartwheel may end treatment if the student is not consistently joining their therapy sessions. Irregular attendance, including two consecutive late cancellations or unannounced misses, will lead to a review of attendance patterns and could lead to discharge from care. If discharged from care, a student may be considered for re-referral by the student’s school counselor in the future.

Patient Financial Responsibility Agreement

Last Updated: February 1, 2024

This financial responsibility agreement forms a binding agreement between CARTWHEEL HEALTH SERVICES P.C. (“Cartwheel”) and the undersigned patient who is receiving medical services or the undersigned Responsible Party for patients under 18 years old holding other legal representative status (“Responsible Party”).

By signing this form, you acknowledge that you understand and agree to the following:

Explanation of the Cost of Our Services

Cartwheel is committed to being an affordable option for students and families. Each family’s individual circumstances may vary, and you can contact our Care Team at 1-888-500-2067 or office@cartwheelcare.org with any questions.
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For uninsured students or students insured through Medicaid:

• You should not expect to pay anything for visits with Cartwheel.
• Cartwheel will verify your insurance information and may bill your insurance.

For students with private insurance:

• Costs will vary depending on your school district and insurance plan.
• If Cartwheel is in network with your insurance plan, we will bill your insurance. You may be responsible for copayments, deductibles, and/or coinsurance. Please note that, while we can provide a cost estimate, it is your responsibility to confirm coverage and benefits with your insurance company.
• If Cartwheel is out of network, you will be charged a fee of $40 per therapy session and $100 per hour of psychiatry.
• Payments can be made with a credit/debit card (including an HSA or FSA card).
• Cartwheel has a standard fee schedule you can access at the following link, but note that the price listed does not usually reflect the cost with insurance: https://link.cartwheelcare.org/fees.

Good Faith Estimates

Please note: Good Faith Estimates only apply if you are uninsured or not using insurance to pay for services.

You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost. Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.

You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services.

Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.

If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. Make sure to save a copy or picture of your Good Faith Estimate.

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call HHS at 1-877-696-6775.

Insurance Authorization

By signing this form, you authorize Cartwheel to act as your agent and disclose your health information to your insurance company to obtain payment for services rendered. You understand you are financially responsible for all charges not covered by your insurance plan.

Accurate Insurance Information

By signing this form, you agree to provide Cartwheel with accurate and complete insurance information and to communicate any changes to your insurance information. You agree to pay for any costs that result from coverage lapses due to incomplete or inaccurate information.

Consent for the Use and Disclosure of Health Information

By signing this form, you hereby authorize Cartwheel to release any information acquired in the course of your visit and treatment to any authorized agent for the purpose of healthcare, treatment, and payment. You authorize the release of behavioral health information to your insurers as necessary for determination and payment of benefits; to utilization review and professional standards review organizations, companies, and community resources that assist you with your healthcare needs.

Consent to Bill, Assignment of Benefits, and Payment

By signing this form, you authorize Cartwheel to file a claim with your insurance carrier for services rendered. You authorize payment of benefits directly to be paid to CARTWHEEL HEALTH SERVICES P.C., for services provided to your dependent or yourself. You understand that you are responsible for any part of the charges that are not covered/paid by your insurance and you will be billed directly for those services.

Payment authorization

By signing this form, you agree to provide Cartwheel with a valid credit card or debit card to be kept on file and authorize Cartwheel to charge your credit card for services rendered at the time of service. You certify that you are an authorized user of the credit card or debit card you provide to Cartwheel and will not dispute these scheduled transactions with your bank or credit card company as long as the transactions correspond to the terms indicated in this agreement. You acknowledge that credit card transactions could be linked to protected health information.

Outstanding balances

If your balance becomes past due, you agree to comply with a payment plan if offered. You understand your provider may terminate treatment for non-payment.

Authorization

You understand that this authorization will remain in effect until you cancel it in writing, and you agree to notify Cartwheel in writing of any changes in your account information or termination of this authorization.

Authorization to Allow Referral Coordination with School

Last Updated: February 1, 2024
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By signing this form, you provide authorization to allow Cartwheel to share limited details about the student’s enrollment in Cartwheel services with their school district. This does not include specific treatment details; it is limited to activities necessary to process the referral, including: Enrollment status, Information on scheduled appointments, Attendance patterns (attended or missed appointments).
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You understand that, unless withdrawn, this authorization will expire 365 days from the consent date.

Electronic Communication

Last Updated: February 1, 2024
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By signing this form, you acknowledge that you understand and agree to the following:

• You agree to receive text messages from Cartwheel to your phone number, and you are aware that mobile messages and data rates may apply. Cartwheel may contact you about your future appointments, including confirmation, failure to complete the appointment, cancellation, reminder notices, and insurance or billing related issues. 
• You agree to receive emails from Cartwheel to your email address. Cartwheel may contact you about your future appointments (including confirmation, failure to complete the appointment, cancellation, and reminder notices) and insurance or billing related issues. 
• Standard texting and email are not secure means of communication. Some protected health information that may be contained in our communications will not be encrypted. This means there is a risk the student’s protected health information in texts or emails could be intercepted and read by, or disclosed to, unauthorized third parties. You agree to accept the risks associated with non-secure, unencrypted text and email communications from Cartwheel that may contain protected health information.

Massachusetts Medicaid Consent (Optional)

Last updated: February 1, 2024

Permission for MassHealth to Get and Share Information in the Child Adolescent Needs and Strengths (CANS) System

The following is only for clients with MassHealth. If the student is not a MassHealth member, this does not apply to you.

If the student is a MassHealth member, we're required to ask if you would like to provide consent for MassHealth to access the student's behavioral health clinical information and share it with other providers and MassHealth managed care entities. You are not required to provide this consent, but if you want to do so, click on the link below to electronically sign the form: https://app.hellosign.com/s/KoAX9GCM

Signature

By signing this consent form, you represent and warrant that:

• You are an authorized legal representative of the student, or you are over the age of eighteen (18), or you are an emancipated minor. 
• You have read and agreed to the above policies, as well as the Terms and Conditions, Privacy Policy, and Notice of Privacy Practices.
• You agree to make every effort for the student to attend all scheduled sessions and to provide a minimum of 24 hours’ notice in the event of cancellation. Should a session be missed or canceled with less than 24 hours’ notice, you understand that a fee of $80, or the amount allowed by state and federal law, will be charged.