Welcome to Kirstin Care OMHC. We hope that your experience with us will be positive and that our assistance will be beneficial to your mental health.
The purpose of KIRSTIN CARE mental health treatment is for our counselors to help you achieve your goals and overcome any obstacles that led you to seek services with KIRSTIN CARE . This treatment will include various mental health treatments and/or Medication Management. You are encouraged to work with your provider in the development of your treatment plan and you should be informed of the process of any new modes used within your treatment process. The associated risks of mental health treatment are limited; you may experience some emotional difficulty, which your counselor/Nurse Practitioner will do their best to help you work through. The benefits to be gained from your visits are vast; some potential benefits of counseling/ medication management are an improved outlook on life, more effective coping skills, greater understanding of self, and better communication tools that will not only have positive effects on your relationships, but through many spheres of your life.
As a client of KIRSTIN CARE , you are not required to accept treatment from KIRSTIN CARE at any time, and you have the right to decline part or all of your treatment, including withdrawal from our services should you not be willing to participate.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
I understand and consent to Kirstin Care OMHC (KIRSTIN CARE ) having one medical record for me. I understand that every counselor/Nurse Practitioner that provides treatment for me at KIRSTIN CARE will have access to all clinical notes in my clinical record.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
understand limits to confidentiality and have Parent/Guardian Child been provided with a copy of this statement.
For the Parent/Guardian: The right to confidentiality is maintained with two exceptions:
For the Child: The right to confidentiality is maintained with three exceptions:
Additional Disclosures at the Parent’s Request:
Welcome to Kirstin Care OMHC. Please read all documents thoroughly and complete them where necessary, so that you are prepared to discuss any questions with your counselor during your first session.
All information obtained/derived by the course of treatment is fully confidential. Exceptions to this guideline include instances when (a) the patient is a clear danger to themselves or others; (b) the patient is a minor (under the age of 18) and reports that he or she is or has been a victim of physical or sexual abuse; and (c) there is any suspected abuse to a child or elder abuse.
If you desire Kirstin Care OMHC to release or obtain information from a specific individual or agency, ask your counselor for an “Authorization to Release Information” form.
I understand that cases are occasionally discussed between Kirstin Care OMHC counselors and supervisors to provide the best clinical treatment possible.
Occasions may arise when you need to talk to your counselor in between normally scheduled sessions. If you leave a message with your counselor, they will make every effort to respond in a timely manner. Any consultation by telephone made between scheduled sessions will incur a charge to the patient. If there is a life-threatening emergency, call 911 or go immediately to your local Emergency Room.
Depending on what your insurance allows and authorizes, the psychotherapy session is 38 minutes in length or 53 minutes in length, beginning at your appointed time and concluding about 38 minutes or 53 minutes after. Therefore, it is to your benefit to arrive a few minutes in advance of the appointment time. Since your counselor has sessions scheduled after yours, the sessions must end 38/53 minutes after the appointment time regardless of your arrival time. If client’s lateness precludes the scheduled session length, a late fee may be assessed in addition to the copay.
*Does not apply to Medicaid clients
All payment is due at the time services are rendered. Payment may be made in the form of cash, check, or credit. If you choose to pay by check, please be prepared to supply a form of ID (e.g. driver’s license) and make the check payable to Kirstin Care OMHC. A $25.00 service charge will be levied on all checks returned by a bank for insufficient funds. If you choose to pay by credit card, please use the “Credit Card Authorization” form contained in this packet.
Our current fee per session (per a max of 55 minutes) is $100-$150 depending on the Current Procedural Terminology (CPT) code. If any or all outstanding balances are not paid, Kirstin Care OMHC reserves the right to release a client’s name and address to a collection agency. Also, a monthly interest fee of 2% will be charged for these balances until they are paid in full.
Kirstin Care OMHC will bill your insurance company for all sessions unless otherwise agreed upon. You are responsible for any balance that insurance does not cover and agree to pay any unpaid balance on your account in a prompt manner. *This does not apply to active Medicaid clients
All balances on accounts will be collected from clients 90 days after insurance has been billed. This means that Kirstin Care OMHC is giving your insurance company 90 days to pay the claim. The law states that it must be processed within 30 days of receipt. After 90 days, you are responsible to pay Kirstin Care OMHC directly. We will give you a receipt, which you can use to try to get your insurance company to reimburse you.
If your insurance changes or is terminated, please call the Kirstin Care OMHC administrative office as soon as possible to provide the office staff with your new information. Check the benefits as your coverage has likely changed from your old policy. If the insurance changes and you fail to notify us, this will result in the claim being denied from the insurance company and you will be held responsible for the entire fee.
No-show/No Call/Missed Appt: Anyone who either forgets or consciously chooses to forgo their appointment for whatever reason will be considered a “no-show" and recorded in your file. After the third rescheduled appt, we will be unable to put you on the schedule. Please keep in mind that it may be a few weeks before an appointment becomes available to see the Psychiatrist.
1. Late Arrivals: We provide you with a grace period of 15 minutes. If you arrive late for your appointment, it may be rescheduled on a case by case basis. Out of respect and consideration to the doctor and therapist, please plan accordingly and be on time.
2. Appointment Confirmation: We do provide courtesy calls but ultimately, it is your responsibility to remember your scheduled appointments. If we are unable to reach you to confirm your appointment, we have the right to cancel it and put another client in that time slot.
3. Therapy Services: If three consecutive "no-shows/missed appt" are documented in your file, an intent to discharge letter will be sent out. If we do not hear back from you in a stated time period, you will be discharged from the program.
The Mental Health Provider is responsible for determining if the weather is too hazardous to commute to your practice location. If your provider decides to hold the session as originally scheduled, you are expected to show and will be charged a cancellation fee for missed appointments. If your provider decides to cancel your session, they will contact you to inform you of the change.
We trust that your experience with Kirstin Care OMHC will be helpful and profitable to you. If you have any questions regarding these policies or other aspects of your relationship with us, please discuss them with your counselor or his/her clinical supervisor.
My signature certifies that I have read, understand, and have been given a copy of the Policies and Procedures document.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
THIS NOTICE DESCRIBES HOW MENTAL HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
THIS NOTICE GIVES YOU INFORMATION REQUIRED BY THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996 (HIPAA) that prescribes legal duties and privacy practices to protect the privacy of your individual identifiable health information; this is, Protected Health Information (PHI), as that term is defined in the HIPAA under Information.
THE EFFECTIVE DATE OF THIS NOTICE IS MAY 8th, 2018. KIRSTIN CARE OMHC is required to follow the terms of this Notice until it is replaced. KIRSTIN CARE OMHC may make changes to the terms of this Notice at any time. Upon your request, we will provide you with a copy of the current Notice. KIRSTIN CARE OMHC reserves the right to make the changes apply to your Information maintained in our files before, and after, the effective date of the new Notice. The following is a general description of how Federal and State law permits us to use and disclose your Information. Purposes for which KIRSTIN CARE OMHC May Use or Disclose Your Mental Health Information with your Consent to Treatment
KIRSTIN CARE OMHC may request your consent for the use and/or disclosure of your Information for treatment, payment, or health care operations as described below:
Your Information may be disclosed to a family member, friend, or other person selected by you or as designated by the law, if you verbally agree.
Except as provided below, your information will not be used for any non-routine purposes unless you give your written authorization to do so. If you give written authorization to use or disclose your Information for a purpose that is not described in this Notice, then, with certain exception, you may revoke it in writing at any time. Your revocation will be effective for the information KIRSTIN CARE OMHC maintains, unless KIRSTIN CARE OMHC has acted in reliance on your authorization.
You may make a written request to us to do one or more of the following concerning your Information:
If you want to exercise any of these rights or require further information about privacy practices, please contact us at the address below. In certain instances, KIRSTIN CARE OMHC is not required to agree to your request. KIRSTIN CARE OMHC will give you necessary information and forms for you to complete and return to request your Information. KIRSTIN CARE OMHC is permitted, by law, to charge you a fee for copying any documents requested in accordance with your rights as listed above. (Fee $1.00 per page.)
We have chosen to participate in the Chesapeake Regional Information System for our Patients (CRISP), a regional health information exchange serving Maryland and D.C. As permitted by law, your health information will be shared with this exchange in order to provide faster access, better coordination of care and assist providers and public health officials in making more informed decisions. You may “opt-out” and disable access to your health information available through CRISP by calling 1-877-952-7477 or completing and submitting an Opt-Out form to CRISP by mail, fax or through their website at www.crisphealth.org. Public health reporting and Controlled Dangerous Substances information, as part of the Maryland Prescription Drug Monitoring Program (PDMP), will still be available to providers.
If you believe that KIRSTIN CARE OMHC violated your privacy rights, you have the right to complain to us or to the Secretary of the U.S. Department of Health and Human Services (DHHS). You may file a written complaint with us at the address below. An individual must file a complaint within 180 days of when he/she knew or should have known that the act or omission occurred, unless the time limit is waived by the Secretary of DHHS. KIRSTIN CARE OMHC will not retaliate against you if you choose to file a complaint.
Contact Address:
Kirstin Care OMHC
5801 Allentown Road Suite 310, Camp Springs, Maryland, 20746
As a client of Kirstin Care OMHC, I acknowledge that I have been given the Privacy Notice required by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) that prescribes legal duties and privacy practices to protect the privacy of my individually identifiable health information, by Kirstin Care OMHC.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
Do you have a strong preference for:
Coordinate treatment across my healthcare team. I know that this authorization is voluntary, and will not affect my healthcare and payment if I refuse to sign it. I understand that I may review the requested information, request and keep upon receipt, a copy of this authorization after I sign it. I understand that the information provided by this request will be held in the strictest of confidence and is to be used only by the professionals on my healthcare team. This authorization can be cancelled by me at any time, unless a process has already started, and its completion depends of this authorization.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
Your information will be encrypted.