HIPAA NOTICE, INFORMED CONSENT, AND SERVICE AGREEMENT
ON POINT 4 VETERANS (OP4V)

(Electronic Agreement & Online Payment Authorization)

Provider:
On Point 4 Veterans (OP4V)
Michael F. Coonan, LMSW, ACSW, BCD
1889 E River Rd
Traverse City, MI 49696
Email: mikecoonan3@gmail.com
Website: onpoint4veterans.net

 

1. PURPOSE OF SERVICES

On Point 4 Veterans (OP4V) provides independent, community-based mental health services for veterans. Services include:

  • Military History Psychosocial Assessments (MH-PSA)

  • Mental health evaluations and clinical documentation

  • Education regarding PTSD, depression, anxiety, insomnia, and related conditions

  • Preparation for VA mental health treatment and disability evaluations

  • Clinical referrals and care coordination when appropriate

Important: OP4V is a private organization and is not affiliated with the Department of Veterans Affairs (VA).

 

2. INFORMED CONSENT FOR TREATMENT

By proceeding with services, I voluntarily consent to receive mental health evaluation services from OP4V.

I understand that:

  • Services may include interviews, clinical assessments, and written reports

  • I may be asked to discuss difficult or traumatic experiences

  • I may withdraw consent at any time in writing

  • No specific VA outcome, rating, or benefit is promised or guaranteed

3. HIPAA NOTICE OF PRIVACY PRACTICES

OP4V complies with the Health Insurance Portability and Accountability Act (HIPAA).

My Protected Health Information (PHI) may be used or disclosed only as necessary to:

  • Provide clinical services

  • Document findings and professional opinions

  • Coordinate care or referrals (with my authorization)

  • Meet legal, ethical, or regulatory requirements

I understand I have the right to:

  • Access and obtain copies of my records

  • Request corrections to my records

  • Request limits on how my information is shared

  • Receive a copy of this privacy notice

4. AUTHORIZATION TO RELEASE INFORMATION (OPTIONAL & REVOCABLE)

I authorize OP4V to release relevant clinical information when appropriate to:

☐ VA clinicians or VA systems
☐ Private healthcare providers
☐ Veteran Service Officers (VSOs)
☐ Legal representatives
☐ My spouse/partner (when clinically appropriate)

This authorization is voluntary and may be revoked at any time in writing.

5. LIMITS OF CONFIDENTIALITY

Confidentiality may be broken only when required by law, including:

  • Risk of serious harm to myself or others

  • Suspected abuse or neglect of a child, elder, or vulnerable adult

  • Court order or other legal requirement

When possible, OP4V will make reasonable efforts to inform me before any required disclosure.

 

6. VA-RELATED DISCLOSURES

I understand that:

  • OP4V does not control VA decisions, disability ratings, or access to care

  • The VA independently determines how any submitted evaluation is used

  • OP4V does not fabricate information or coach false claims

  • All documentation reflects my reported history, clinical findings, and professional judgment

7. FEES AND PAYMENT

Service Fee: $600 (Flat Fee)

I understand and agree that:

  • The fee is for professional clinical services, not outcomes

  • Services are private-pay only and are not billed to insurance or the VA

  • Full payment is required prior to the start of services

 

8. ELECTRONIC CONSENT & PAYMENT AUTHORIZATION

By submitting payment online, I acknowledge and agree that:

  • My payment serves as my electronic signature

  • I am providing informed consent for services

  • I accept the HIPAA Notice of Privacy Practices

  • I authorize OP4V to begin services immediately

  • This agreement is legally binding and equivalent to a handwritten signature

 

9. SERVICE TIMELINE & RECORD DELIVERY

I understand that:

  • Completing payment allows services to begin without delay

  • Scheduling and evaluation may be expedited

  • A copy of this agreement will be emailed to me for my records

10. ACKNOWLEDGEMENT OF AGREEMENT

By completing payment, I confirm that:

  • I have read and understand this agreement

  • I agree to all terms and conditions

  • I am voluntarily consenting to services

Electronic Acceptance Date: Automatically recorded
Transaction Record/IP Address: Securely maintained

Provider:
Michael F. Coonan, LMSW, ACSW, BCD
On Point 4 Veterans (OP4V)