CONSENT FOR TREATMENT, PAYMENT, AND HEALTHCARE OPERATIONS/PRIVACY PRACTICES

ADULT

Please correct the errors described below.

Professional Disclosure: I understand that my counselor is a Master’s level mental health clinician, practicing with a license issued from the State of Arkansas and not a medical doctor, or a doctor of Psychology. My counselor’s primary role is to provide professional counseling services. If I have questions, I am welcome to ask for clarification of my counselor’s credentials, specializations, and training.

Risks and Benefits: I am aware that there are both risks and benefits to counseling. While most people experience some level of distress that leads them to seek counseling, it should be understood that when a counselor and client are working towards the goals of counseling, distress, problems in relationships, and other unforeseen circumstances may arise. It is also understood that a goal of counseling will be to alleviate or manage these potential stressors, but an exacerbation of problems may occur. The benefits of therapy may include, but are not limited to, the diminishing of symptoms, distress, relationship growth and a general sense of well-being. However, individual results are not predictable and may vary.

Limits of Confidentiality: I understand that confidentiality is not absolute, that in some circumstances my counselor may be required by law or by the ethical standards of the American Counseling Association to share information about my case. Information may be released without my consent in situations where there is reason to believe I might harm myself or others, in the case of actual or suspected abuse of a child, elder or handicapped person. For the purpose of case consultation, my information may also be discussed with others associated with Still Waters Family Counseling and/or with supervisors/other supervisee.

Emergency Notification: My counselor can be called in the case of psychological emergencies. However, he will not always be available by phone or in the evenings. If I cannot reach my counselor I can call 911 or go to the nearest emergency room.

I have read and understand the above information and agree to receive counseling for myself or for my child. I also give consent for my mental health clinician to leave a voicemail, text my phone, or contact me via email, as needed.

CLIENT DEMOGRAPHICS

EMERGENCY CONTACT

EMPLOYMENT INFORMATION (OPTIONAL)

CONSENT TO FILE INSURANCE ON YOUR BEHALF

Please provide copy of insurance card with paperwork

Primary Insurance Information:

If you know…

Secondary Insurance Information (If applicable)

If you know…

I consent to have Still Waters Family Counseling file insurance on my behalf.

Please Note: Any insurance coverage quoted by our staff is not a guarantee until your insurance company reviews the claim to determine actual coverage.

FEE SCHEDULE AND AGREEMENT

  • Initial Intake Session: $165.00 (60 minutes)
  • Individual/Family Counseling: $165.00 (60 minutes)
  • Professional Consultation $110.00 (45 minutes)
  • Paper Work for 3rd Party: $50.00
  • Court Appearance: $2,500.00 (per day includes all prep work)
  • Document Creation: $50.00
  • Coping/ Mailing/ Faxing of Records: $20.00
  • Late Cancellation/ No Show Fee: $75.00
  • Assessment: $15.00 (per assessment)

Prices subject to change. Clients are responsible for payment of all fees. We will be happy to submit an insurance claim for you or provide you with a receipt for submitting your insurance claim. However, clients are ultimately responsible for payment of their bill. Fees are payable at the time of service.

Your appointment time is reserved for you alone. Due to the nature of the services provided filling an appointment time on short notice is nearly impossible. So, we ask that (expect in cases of actual emergencies) you give us at least 24-hour notice for appointment cancelation or rescheduling. The missed appointment fee will be charged for any appointment canceled or rescheduled without a 24-hour notice or if the appointment is missed without notice. Habitual canceling, rescheduling or not keeping of appointments may result in loss of services.

If payment becomes problematic for you, we are willing to work with you on an individualized payment agreement.

I have read and agree to the terms of the above fee policy.

I would like to use the following credit/debit cared for the purposes of making automatic payments. (optional)

Miscellaneous Information

A reminder does not replace your responsibility to keep your appointment. Our cancellation policy still applies. Since your appoint time is for you alone we ask that you give us 24-hour notice for cancellation or rescheduling. Chronic canceling or rescheduling, even with 24-hour notice, may result in application of the missed appointment fee or loss of future service. Please make every effort to keep your appointment.

INCLEMENT WEATHER POLICY

We understand that weather my affect your ability to make your appointment. Still Waters Family Counseling will not be opened when Fayetteville Public Schools are closed for inclement weather. Every effort will be made to give rescheduling priority if the clinic needs to close. If inclement weather affects you differently, please contact us. You will not be charged the broken appointment fee.

CHILDREN IN THE LOBBY

We understand that childcare may not be available or may fall through at the last minute. If needed infants and toddlers may stay in the session with you. We asked that you keep in mind that our staff members have duties they need to perform and may not be able to give your child supervision. We do offer a Lego table and books for older children.

PERSONAL INFORMATION

Marriage Information:

List all others living in your home:

History of the Presenting Problem or Complaint

Medical History

Recent Weight Changes:

Medication(s) taken for anxiety, nervousness, depression, or related types of problems

Primary Care Physician

Consent:

I give my counselor Consent to Release Information to my Primary Care Physician.

Crisis Information:

Religious Background

NOTICE OF PRIVACY PRACTICES

This notice describes how medical, mental health, and substance abuse information about you may be used or disclosed as well as how you can obtain access to this information. Please review it carefully.

Still Waters Family Counseling is committed to protecting the privacy of your medical, mental health and substance abuse information. We create a record of the care and services that you receive from us. This information is needed to provide you with quality care and to comply with legal and ethical standards. We are required by law to maintain the privacy of your protected health information and to provide you with this Notice of Privacy Practices. We are also required to comply with the terms of this notice.

This Notice of Privacy Practices contains an outline of your rights regarding the information that we maintain about you and a description of how you may exercise these rights. This notice also describes how we may use or disclose your Protected Health Information to carry out treatment, obtain payment or for healthcare operations, and for other purposes that are permitted or required by law.

The Health Information Portability and Accountability Act (HIPAA) defines ‘Protected Health Information’ as medical, mental health, and substance abuse information, including identifying information about you that we have collected from you or received from others.

This Notice of Privacy Practices applies to all Still Waters Family Counseling providers, staff members, and student interns.

YOUR RIGHTS

You have the following rights regarding your Protected Health Information (PHI). You have a right to:

  • ❖ Confidential Communications. To maintain your confidentiality, you may ask that we communicate with you in a particular way, or at a certain location, such as calling you at work rather than at home.
  • ❖ Inspection and Copy. You have the right review and/ or receive a copy of the information in your record. Under certain limited circumstances, we may have to deny your request. If we deny your request you may request a free 30 minute session to discuss the reason(s) for the denial with your counselor.
  • ❖ Make Addendums. You may ask us to add an addendum to the information in your records if you feel that the information is incorrect or incomplete. Your request may be denied if we did not create the information. You may prepare a statement that will be included in our clinical record if you do not agree with the information in your record.
  • ❖ An Accounting of Disclosures. You may request a list of disclosures that we have made of your PHI with the exceptions of treatment, payment or healthcare operations described in this notice, or information released with your with your authorization.
  • ❖ Request Restrictions. You may ask us to limit our use or disclosure of you PHI. We are not required to agree with your request but if we do, we will honor your request unless the information is needed to provide emergency treatment for you.
  • ❖ Receive a Copy of this Notice. You may receive a paper copy of the Notice of Privacy Practices at any time.

HOW WE WILL USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION

Still Waters Family may use or disclose your Protected Health Information (PHI) for treatment, payment or healthcare operations.

  • ❖ For Treatment. We may use and disclose your PHI to provide, coordinate, and manage your care and services. Information about you may be shared with Still Waters Family Counseling staff, or student interns who are involved in your care or services. This information will be shared on a “need to know” basis.
  • We also may use your PHI in order to remind you about an appointment at Still Waters Family Counseling or to provide information about treatment alternatives or other health-related benefits and services that may be of interest to you.
  • ❖ For Payment. Your PHI will be used and disclosed, as needed, to obtain payment for your services. For example, a bill for services sent to you or to a third-party payer such as Blue Cross and Blue Shield, might include identifying information about you such as your name, your diagnosis, and services received.
  • ❖ For Health Care Operations. We will use or disclose, as needed, your PHI to support and improve the activities at Still Waters Family Counseling. For example, Still Waters staff may use information in your clinical record to evaluate the care you received. This information would then be used in efforts to improve the quality and effectiveness of services provided by Still Waters Family Counseling.

Uses and Disclosures of your Protected Health Information (PHI) That May Be Made Only with Your Specific Authorization

  • Other uses and disclosures of your PHI will be made only with your specific written authorization, unless otherwise permitted or required by law as described below. For example, your authorization would be required for us to share your confidential information with a member of your family. You may revoke authorization at any time, except to the extent that we have already taken an action to use or disclose your information, relying upon your authorization.

Uses and Disclosures of your Protected Health Information (PHI) That May Be Made Without Your Authorization

  • ❖ As Required by Law. We may be required by federal, state, or local law to disclose your PHI. For example, if you have threatened to harm another person, we may be required to notify the local police department and the threatened person.
  • ❖ For Public Health Activities. We may need to disclose your PHI to a public health authority that is required by law to receive information. Such disclosures would be made for the purpose of controlling disease, injury, or disability. For example, a disclosure regarding HIV/AIDS status would be made to the local Department of Public Health if necessary to protect health of an individual, diagnosis and care for the mental health consumer or to prevent further transmission of the virus.
  • ❖ Abuse or Neglect. We may be required to disclose your PHI if we suspect that you or another person has been abused or neglected.
  • ❖ Health Oversight. We may be required to disclose your PHI for an audit, inspection, investigation or other health care oversight activity.
  • ❖ Judicial and Administrative Proceedings. We may have to disclose your PHI if we receive a court order or subpoena or for risk management purposes.
  • ❖ Law Enforcement. We may have to disclose your PHI in connection with a criminal investigation by a federal, state, or local law enforcement agency.
  • ❖ Serious Threat to Health or Safety. We may be required to disclose information about you when it is necessary to prevent serious threat to your health and safety or that of another person or of the public.

If you believe that your rights have been violated, contact our office to discuss the issue or contact the Office of Civil rights. Your services will not be affected in way if you file a complaint.

To file a complaint with the Office of Civil Rights, call or write:

Office of Civil Rights US Dept. of Health and Human Services 200 Independence AVE, S.W. Washington DC 20201 1-877-696-6775

OCRPrivacy@hhs.gov

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I,

acknowledge that I have received a copy of Still Waters Family Counseling’s Notice of Privacy Practices.

My signature below indicates that I have received the Notice of Privacy Practices and that I have been provided an opportunity to ask questions about office’s privacy practices as they pertain to my Protected Health Information.

Still Waters Family Counseling
3313 W Mt Comfort Rd, Fayetteville, AR 72704
Phone (479) 263-7602
stillwatersfamilycounseling@gmail.com
Fax (479) 443-2892

Your information will be encrypted.

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