Services Contract Consent Form

Please correct the errors described below.

By signing this form below, I acknowledge that I have read and fully understand the policies and procedures at Mindful Healing LLC provided in the Services Contract. I understand that before signing this document, I am free to ask questions and receive clarification from the clinician with whom I am first meeting either before or during the first appointment. If I develop new questions after having signed and submitted the document, I am free to continue the discussion with my clinician. I consent and agree to comply with the policies listed in the Services Contract, notably the following:

  • I consent to treatment with this clinician and understand I am able to terminate the services at any time for any reason, though payment is still due for any services rendered.
  • I understand treatment is an interactive process and requires my investment in order for progress to be made. Undergoing treatment is not a guarantee of improvement of condition and my condition may worsen during the course of treatment.
  • I understand the limits of confidentiality and in addition to the stated limits, agree to allow my clinician to speak to colleagues for the purpose of consultation and supervision, acknowledging that these colleagues are also responsible for maintaining confidentiality. For the purpose of discussion with colleagues, my information will be de-identified.
  • I acknowledge the social media policy and understand the privacy protections.
  • I consent to my clinician using a secure platform for electronic record keeping and billing.
  • If I provided my insurance information: (1) I agree to authorize Mindful Healing to submit insurance claims on my behalf, receive payment directly from my insurer, and realize I am responsible for paying any non-covered services; (2) I agree to pay for any and all medical services that my insurance company refuses to pay for, regardless of the reason; (3) If my insurance company denies payment for any reason, I will be responsible for the unpaid balance including co-pays, co-insurance, deductibles, and any non-covered expense. For the purpose of this agreement, failure of the insurance company to pay within 60 days of filing is a refusal to pay.
  • I agree to pay all fees as listed in the fee schedule.
  • I acknowledge that any balance more than 120 days overdue will be sent to a collection agency along with any personal information needed for the agency to contact me and secure payment.
  • I agree to have my credit card charged for any cancellation fees on the day of the missed session or late cancellation unless I have made other arrangements with my clinician.
  • I agree to have my credit card charged for any unpaid fees, including co-pays, co-insurances, etc., that I have not made arrangement to pay and are 30 days past due.
  • If I consent to have my sessions recorded via audio or video, I understand that I am able to retract that consent at any time, with no penalty.

Optional Clauses

Insurance Information

If you are the policy holder, you may indicate "Self"

Signature

My electronic signature indicates I have read the Services Contract, agree to the policies listed, agree to the optional clauses I indicated, allow Mindful Healing to use my insurance to pay for treatment when I have submitted it above, and recognize a credit card is kept on file for securing payment.

By typing and submitting this form, you agree that your intention is to provide a legally binding signature.
By typing and submitting this form, you agree that your intention is to provide a legally binding signature.

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