Consent Forms

Consent to Treat

I hereby consent and authorize 180 Mental Health and Wellness to furnish me or the above registered patient with necessary medical care.

This care may include ancillary care including but not limited to laboratory testing, radiologic examinations and other diagnostic procedures as deemed necessary by the professional staff at 180 Mental Health and Wellness.

I understand that the services recommended to, or provided to me are in my, or the registered patient’s best interest.

I understand that I have and reserve the right to revoke this consent at any time and for any reason during my treatment at 180 Mental Health and Wellness.

I consent to be contacted by mail, email, and telephone regarding matters related to my treatment or patient account 180 Mental Health and Wellness and entities formally associated with 180 Mental Health and Wellness.

Consent To Treat Signature *

Printed Name: *
Signed Date: *
06/02/2026
 
Date of Birth: *
mm/dd/yyyy
 
Assignment of Benefits

I authorize payment directly to 180 Mental Health and Wellness for all medical benefits otherwise payable to me under terms of my insurance.

I understand that I am financially responsible for all co-payments, co-insurance, deductibles, and non-covered services. Overpayments on my account at 180 Mental Health and Wellness account may be applied to my patient balance. 

Assignment of Benefits Signature: *

Printed Name: *
Signed Date: *
06/02/2026
 
Date of Birth: *
mm/dd/yyyy
 
Patient Rights and Responsibilities

I will treat the staff and clients of 180 Mental Health and Wellness with dignity and respect. Verbally expressed profanities and vulgarities toward any staff or other patients of 180 Mental Health and Wellness will not be tolerated and could be grounds for service termination.

I will make every attempt to arrive to my appointment on time.

I will make every attempt to cancel appointments at least 2 hours before or it will be considered a No Show. Repeat no shows could result in you losing privileges to schedule future appointments.

I have been given the opportunity to ask any questions I have about my care through 180 Mental Health and Wellness.

I can request a copy of all authorization documents such as Notice of Privacy Practices (HIPAA), Patient responsibilities, and 180 Mental Health and Wellness Responsibilities and Duties.

I understand that I am expected to make every attempt to pay any payment due, copayment, or coinsurance amount at the time of service, but understand that an inability to pay will never prevent me from being treated at 180 Mental Health and Wellness.

Patient Rights and Responsibilities Signature: *

Printed Name: *
Signed Date: *
06/02/2026
 
Date of Birth: *
mm/dd/yyyy
 
Notice of Privacy Practices (HIPAA)

I authorize 180 Mental Health and Wellness to release protected health information to persons or entities directly associated with and engaged in carrying out a treatment plan for the patient.

180 Mental Health and Wellness may use and release any part of my medical records, including substance abuse,  mental/behavioral health, and medical, necessary to the process of billing third party payers for services rendered on my behalf.

I clearly understand that all my information will be kept confidential.

I consent for 180 Mental Health and Wellness to use technology, including automated technology such as auto-dialing or pre-recorded messages, to contact me at the address, e-mail address, or telephone number, including any cell phone/wireless number that I have provided;

I understand that this information will be used to review, investigate, make payment of a claim, to review records for quality improvement initiatives, audit compliance, utilization management, or complaint resolution.

Notice of Privacy Practices Signature: *

Printed Name: *
Signed Date: *
06/02/2026
 
Date of Birth: *
mm/dd/yyyy
 
No Show Policy

Appointment No-Shows

We understand that you may sometimes need to reschedule appointments. When we make your appointment, please understand we are reserving time for you and for your provider. This courtesy makes it possible to give both you and other patients the best service here at 180 Mental Health and Wellness. If you need to reschedule an appointment, please call the clinic as soon as possible or call at least 24 hours in advance.

If you no show your appointment or cancel your appointment less than 24 hours of your scheduled time, you will be charged a $50 no show fee.  This fee must be paid prior to being rescheduled with your provider.  If you have more than 3 no shows or late cancellations in a 6 month period, you will be discharged from services here at 180 Mental Health and Wellness.

We thank you for your trust in us here at 180 Mental Health and Wellness.

Notice of No Show Policy Patient/Legal Guardian Signature: *

Patient/Legal Guardian Printed Name: *
Signed Date: *
06/02/2026
 
Date of Birth: *
mm/dd/yyyy
 
Protected Health Information Disclosure Form

I give permission for my Protected Health Information to be disclosed for purposes of communicating results and care decisions to the family members and others selected for PHI disclosure.

I understand that I may revoke access at any time by submitting revocation form to 9855 E Southern Ave #50729, Mesa, AZ 85209. By signing below, I authorize the clinic to provide PHI information to the following individuals:

Contact 1:
Name: *
Phone Number: *
( ___ ) ___ - ____
Relationship: *
Contact 2:
Name: *
Phone Number: *
( ___ ) ___ - ____
Relationship: *
Contact 3:
Name: *
Phone Number: *
( ___ ) ___ - ____
Relationship: *
Protected Health Information Disclosure Signature: *
clear
Printed Name: *
Date of Birth: *
mm/dd/yyyy
 
Signed Date: *
06/02/2026
 
Controlled Substance Medication Contract

Purpose: This agreement outlines the terms and conditions for the use of controlled substances as established by 180 Mental Health and Wellness to promote safe and responsible medication use and to minimize the risk of abuse, addiction, and diversion. By signing this agreement, the patient agrees to comply with the terms of the contract and understands the consequences of violation.

Terms:

1. Medication: The patient will take prescribed controlled medications as directed by the provider.

2. Refills: Refills will be provided in accordance with the treatment plan established by the healthcare provider. Early refills will not be granted unless authorized by the healthcare provider under exceptional circumstances.

3. Monitoring: The patient agrees to attend regular follow-up appointments, including a once per year in-person appointment with the healthcare provider to monitor the effectiveness of the medication, assess for any adverse effects or signs of misuse, and comply with DEA regulations.

4. Use as Prescribed: The patient agrees to use the medication only as prescribed by the healthcare provider and not to exceed the recommended dosage or frequency of administration.

5. No Sharing: The patient agrees not to share, sell, or give away their controlled medication to others.

6. No Other Providers: The patient agrees not to seek controlled medications from other healthcare providers without prior authorization from the prescribing healthcare provider. If the patient is on other controlled substances with outside providers, the patient agrees to both the prescribing provider at 180 Mental Health and Wellness and outside provider have a collaborative relationship to ensure safety of medication use.

7. Drug Testing: The patient agrees to submit random drug testing as requested by the healthcare provider to monitor medication compliance and detect any signs of misuse.

8. Storage: The patient agrees to store their medication securely to prevent theft or unauthorized access by others.

Consequences of Violation:
Violation of any of the terms outlined in this contract may result in:

-Discontinuation of controlled substances.
-Discharge from services provided by 180 Mental Health and Wellness.
-Reporting to relevant authorities if illegal activities are detected.

Notice of Controlled Substance Medication Contract Signature: *

Printed Name: *
Signed Date: *
06/02/2026
 
Date of Birth: *
mm/dd/yyyy
 
Please Note: Any information submitted using this form is transmitted securely and held in the strictest of confidence, protecting your privacy.
 
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