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By signing below, I acknowledge that I understand and agree to the following:

As part of the Oklahoma Child and Adolescent Psychiatry and Mental Health Access Program (OKCAPMAP), child and adolescent psychiatrist and licensed mental health professionals engage with primary care providers (PCPs) to help strengthen their ability to manage behavioral health needs of their pediatric patients. Through telephone and video consultations with PCPs who care for children and adolescents, OKCAPMAP child and adolescent psychiatrists and licensed mental health professionals can assist, educate, and train registered PCPs in the care of their patients. OKCAPMAP child and adolescent psychiatrists and licensed mental health professionals do not establish provider-patient relationships with or prescribe medications for the patients of registered PCPs, but rather, provide services solely and directly to PCPs (provider-to-provider). Accordingly, PCPs will be exclusively responsible for providing clinical services in the exercise of their professional medical judgment.

As a participant in OKCAPMAP, PCP collaboration holds a critical role in maximizing the benefits of the child and adolescent psychiatry and mental health access program. As such, OKCAPMAP expects PCPs will participate in meaningful ways, including periodically participating in data collection related to the outputs and outcomes of the program. This includes basic demographic data about the PCP and practice information as it relates to OKCAPMAP. As part of the program, data about patients may be communicated with OKCAPMAP staff and PCPs agree to inform patients of this consultative effort and de-identify private health information prior to requesting and throughout consultation with OKCAPMAP consultants. If a patient declines to have provider-to-provider consultation on their behalf or their child or adolescent’s behalf, it is expected that the PCP will not seek consultation with regard to that specific patient. No patient private health information will be reported in this study. Patient demographic data, provider demographic data, provider needs data, and program outcomes, outputs, and impacts data will be collected and reported.

Risks in participating in this program are minimal and limited to typical daily medical personnel experiences (e.g., identification of child abuse, sensitive topics). Participation in this program can provide benefits such as increased knowledge and competency, specialty consultation for specific patient care, patient referral assistance, and provider wellness. Individual patients, by proxy, can benefit by improved access to mental health care and mental health wellness via increased and improved mental health screening, diagnosis, treatment, and referral.

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