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Annual Patient Consent Update

This form is completed annually to confirm and update patient consents and acknowledgments previously provided at intake.

2026 yearly paperwork
Patient Name
Patient Name
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Do you have changes to demographics or contact information since last update

Insurance & Billing Status (Update)

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I understand that I am responsible for all charges not covered by insurance and that copayments or self-pay fees are due at the time of service.

Maximum file size: 20MB

Consent for Treatment & Communication

I consent to continued evaluation and treatment by Concordia Mind Health. I authorize communication by phone, voicemail, text message, email, and patient portal for healthcare operations, scheduling, and billing purposes, in accordance with HIPAA and South Dakota law.

Telehealth Consent

I consent to receive mental health services via telemedicine when clinically appropriate. I understand the risks and limitations of telehealth, including potential technical disruptions, and agree to participate from a private and safe location.

AI-Assisted Clinical Documentation Consent

I understand that Concordia Mind Health may use secure AI-assisted dictation technology to assist with documentation of my mental health visits. AI is used solely to support clinical note creation. All documentation is reviewed, edited, and approved by my licensed provider. AI does not provide diagnosis, therapy, or treatment decisions.

Financial, Refill, and No-Show Policy Acknowledgment

I acknowledge and agree to Concordia Mind Health’s current financial, prescription refill, and appointment cancellation/no-show policies, including applicable fees for missed appointments.

Controlled Substance Agreement

If I am prescribed controlled substances, I acknowledge that I remain bound by the clinic’s controlled substance agreement and understand that violations may result in discontinuation of prescribing or care.

HIPAA Acknowledgment

I acknowledge receipt of the Concordia Mind Health Notice of Privacy Practices and understand my rights regarding protected health information.

Release of Information (ROI) – Update

Concordia Mind Health is authorized to release information to the following individuals or entities involved in my care, payment, or coordination of services:
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Annual Consent Confirmation

By signing below, I confirm that the information above is accurate and that I consent to continued treatment and documentation practices as outlined.

Patient Name
Patient Name
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This annual consent update complies with HIPAA, South Dakota telehealth standards, and applicable federal regulations.

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