Consent to Services Agreement
Last updated: Aug 6, 2025
Last updated: Aug 6, 2025
Marigold peer specialists and recovery coaches work closely with you on personal matters to do with your mental health, substance use, and wellness. It is important that we have a clear understanding of how our relationship works and what is expected of each of us. This consent outlines this framework. Please ask questions at any point during your participation with Marigold’s Recovery Support.
1. We agree to provide services that are recovery oriented, person-centered, and trauma-informed to all members.
I voluntarily agree to receive services provided by Marigold Health (“Marigold”) and its team members.
2. We agree to provide services through your health plan.
I give Marigold permission to verify my eligibility to receive services with my insurance plan and to bill my insurance plan for services. I can stop my permission at any time by telling Marigold in writing, in-person, or verbally by phone or voicemail.
3. We agree to abide by the Health Insurance Portability and Accountability Act (HIPAA) when using and disclosing your medical information.
I allow the release of my medical information when needed for treatment, payment, healthcare operations, and for state/federal agencies. I received and read Marigold Health’s Notice of Privacy Practices, which can be found on Marigold’s website link. I understand and accept the conditions.
4. We respect your rights as a patient. We want to make sure you know and understand them.
I received and read Marigold Health’s Patient Rights and Responsibilities, which can be found on Marigold’s website link. I understand and accept the conditions.
5. Marigold strives to ensure confidentiality for all protected health information (PHI) created via phone calls, texts, groups, emails, interactions on the app, and face-to-face. Communication via text and email is fast and efficient, but it is NOT completely secure. It is possible to address messages to the wrong person. It is also possible that the text/email could be improperly accessed during transmission and storage.
By providing my cell, landline, or any other numbers(s) and/or my email address, I expressly consent to receiving communications from Marigold, its staff, its contractors, and others, at any number or email I provide. I understand that depending on my cell phone plan I could be charged for these calls or text messages. I agree to provide new number(s) if my number(s) change. I further understand that communications sent via unencrypted email or via text messages over an open network are inherently unsecure, and there is no assurance of confidentiality of information communicated in this manner. Nevertheless, I want Marigold or its staff, its contractors, or others, to communicate with me via email and/or text message. I understand that this Consent to Services is in effect while services are provided to me by Marigold unless I tell Marigold verbally or in writing that I no longer want to participate. I acknowledge that Marigold has offered me a copy of its Consent to Treat, and that I have the right to obtain a paper copy of this Consent to Services, upon request, even if I have agreed to accept this notice electronically. I understand this acknowledgement in no way affects the care I shall receive from Marigold.