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Terms and Policy

Health Insurance Portability Accountability Act (HIPAA) Client Rights & Therapist Duties

This document contains important information about federal law, the Health Insurance Portability and Accountability Act (HIPAA), that provides privacy protections and patient rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations.


HIPAA requires that The Hope Connection Therapy Company, PLLC provides you with a Notice of Privacy Practices (the Notice) for use and disclosure of PHI for treatment, payment and health care operations. The Notice, which is attached to this Agreement, explains HIPAA and its application to your PHI in greater detail. The law requires that The Hope Connection Therapy Company, PLLC obtains your signature acknowledging that we have provided you with this. If you have any questions, it is your right and obligation to ask so we can have a further discussion prior to signing this document. When you sign this document, it will also represent an agreement between us. You may revoke this Agreement in writing at any time. That revocation will be binding unless The Hope Connection Therapy Company, PLLC has taken action in reliance on it.


LIMITS ON CONFIDENTIALITY


The law protects the privacy of all communication between a patient and a therapist. In most situations, we can only release information about your treatment to others if you sign a written authorization form that meets certain legal requirements imposed by HIPAA. There are some situations where we are permitted or required to disclose information without either your consent or authorization. If such a situation arises, we will limit my disclosure to what is necessary. Reasons we may have to release your information without authorization:


1. If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the psychologist-patient privilege law. We cannot provide any information without your (or your legal representative's) written authorization, or a court order, or if we receive a subpoena of which you have been properly notified and you have failed to inform me that you oppose the subpoena. If you are involved in or contemplating litigation, you should consult with an attorney to determine whether a court would be likely to order me to disclose information.

2. If a government agency is requesting the information for health oversight activities, within its appropriate legal authority, we may be required to provide it for them.

3. If a patient files a complaint or lawsuit against us, we may disclose relevant information regarding that patient in order to defend myself.

4. If a patient files a worker's compensation claim, and we are providing necessary treatment related to that claim, we must, upon appropriate request, submit treatment reports to the appropriate parties, including the patient's employer, the insurance carrier or an authorized qualified rehabilitation provider.

5. We may disclose the minimum necessary health information to our business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. Our business associates sign agreements to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.


There are some situations in which we are legally obligated to take actions, which we believe are necessary to attempt to protect others from harm, and we may have to reveal some information about a patient's treatment:


1. If we know, or have reason to suspect, that a child under 18 has been abused, abandoned, or neglected by a parent, legal custodian, caregiver, or any other person responsible for the child's welfare, the law requires that I file a report with the Florida Abuse Hotline. Once such a report is filed, we may be required to provide additional information.

2. If we know or have reasonable cause to suspect, that a vulnerable adult has been abused, neglected, or exploited, the law requires that we file a report with the Florida Abuse Hotline. Once such a report is filed, we may be required to provide additional information.

3. If we believe that there is a clear and immediate probability of physical harm to the patient, to other individuals, or to society, we may be required to disclose information to take protective action, including communicating the information to the potential victim, and/or appropriate family member, and/or the police or to seek hospitalization of the patient.


CLIENT RIGHTS AND THERAPIST DUTIES


Use and Disclosure of Protected Health Information:


- For Treatment - We use and disclose your health information internally in the course of your treatment. If we wish to provide information outside of our practice for your treatment by another health care provider, we will have you sign an authorization for release of information. Furthermore, an authorization is required for most uses and disclosures of psychotherapy notes.

- For Payment- We may use and disclose your health information to obtain payment for services provided to you as delineated in the Therapy Agreement.

- For Operations - We may use and disclose your health information as part of our internal operations. For example, this could mean a review of records to assure quality. We may also use your information to tell you about services, educational activities, and programs that I feel might be of interest to you.



Patient's Rights:

- Right to Treatment - You have the right to ethical treatment without discrimination regarding race, ethnicity, gender identity, sexual orientation, religion, disability status, age, or any other protected category.

- Right to Confidentiality - You have the right to have your health care information protected. If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will agree to such unless a law requires us to share that information.

- Right to Request Restrictions - You have the right to request restrictions on certain uses and disclosures of protected health information about you. However, we are not required to agree to a restriction you request.

- Right to Receive Confidential Communications by Alternative Means and at Alternative Locations - You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations.

- Right to Inspect and Copy - You have the right to inspect or obtain a copy (or both) of PHI. Records must be requested in writing and release of information must be completed. Furthermore, there is a copying fee charge of $1.00 per page. Please make your request well in advanced and allow 2 weeks to receive the copies. If we refuse your request for access to your records, you have a right of review, which we will discuss with you upon request.

- Right to Amend - If you believe the information in your records is incorrect and/or missing important information, you can ask us to make certain changes, also known as amending, to your health information. You have to make this request in writing. You must tell us the reasons you want to make these changes, and we will decide if it is and if we refuse to do so, we will tell you why within 60 days.

- Right to a Copy of This Notice - If you received the paperwork electronically, you have a copy in your email. If you completed this paperwork in the office at your first session a copy will be provided to you per your request or at any time.

- Right to an Accounting - You generally have the right to receive an accounting of disclosures of PHI regarding you. On your request, we will discuss with you the details of the accounting process.

- Right to Choose Someone to Act for You - If someone is your legal guardian, that person can exercise your rights and make choices about your health information; we will make sure the person has this authority and can act for you before we take any action.

- Right to Choose - You have the right to decide not to receive services with me. If you wish, we will provide you with names of other qualified professionals.

- Right to Terminate - You have the right to terminate therapeutic services with me at any time without any legal or financial obligations other than those already accrued. We ask that you discuss your decision with me in session before terminating or at least contact me by phone letting me know you are terminating services.

- Right to Release Information with Written Consent - With your written consent, any part of your record can be released to any person or agency you designate. Together, we will discuss whether or not we think releasing the information in question to that person or agency might be harmful to you.


Therapist's Duties:

- We are required by law to maintain the privacy of PHI and to provide you with a notice of my legal duties and privacy practices with respect to PHI. We reserve the right to change the privacy policies and practices described in this notice. Unless we notify you of such changes, however, I am required to abide by the terms currently in effect. If I revise my policies and procedures, I will provide you with a revised notice in office during our session.


COMPLAINTS


If you are concerned that your privacy rights have been violated, or you disagree with a decision made about access to your records, you may contact us, the State of Florida Department of Health, or the Secretary of the U.S. Department of Health and Human Services.


YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS AND ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPAA NOTICE FORM DESCRIBED ABOVE.

( Type Full Name )
( Full Name )
Billing Permissions

I give consent for The Hope Connection Therapy Company, LLC. to provide psychotherapy services to myself or to my child if they are the referred or identified client.


I realize that some payers require notes pertaining to my visits and I authorize The Hope Connection Therapy Company, LLC to send any required progress notes to my insurance company, Primary Care Physician, and/or referral source, as requested or needed, for payment purposes and/or treatment coordination.


Please assign directly to The Hope Connection Therapy Company, LLC all medical benefits for services rendered. I understand that I am financially responsible for all charges whether or not paid for by my health insurance or equivalent. I authorize the therapist to release all information necessary to secure payment for benefits.


I authorize The Hope Connection Therapy Company, LLC to keep my signature on file, to store my MasterCard, Visa, Discover, or American Express card information, and to charge my MasterCard, Visa, Discover, or American Express account as indicated below:

    A. Balance of charges not paid by insurance within ninety (90) days after the date of service for all visits.

    B. Recurring charges, including copays, for on-going treatments.

    C. Any charges I may acquire in accordance to the Late Cancellation and No Show policy.


I understand I can cancel this authorization of benefits through written notice to The Hope Connection Therapy Company, LLC


My signature affirms that I have read the Billing Permissions document and agree to the policy that is outlined.

( Type Full Name )
( Full Name )
Confidentiality Agreement

Florida law protects the privacy of all communication between a patient and a mental health provider. In most situations, if you are 18 years of age or older, your therapist can only release information about your treatment to others if you sign a written authorization form that meets certain legal requirements imposed by the Health Insurance Portability and Accountability Act (HIPAA) and/or Florida law. However, in the following situations, no authorization is required.

  - Consultation with other health and mental health professionals. During such consultations, your therapist cannot reveal any information that identifies you without your written consent. All other professionals are also legally bound to keep the information confidential. In most cases, your therapist will not tell you about these consultations unless it is beneficial to your work together. All consultations will be noted in your clinical record.

  - Teaching and supervision. At times, your therapist may refer to clinical cases for teaching or supervision purposes. In these situations, your therapist will not reveal any information that could identify you. In most cases, your therapist will not discuss these occurrences with you unless it is beneficial to your treatment.

  - Your therapist may consult with colleagues in this office regularly as a means of providing the highest quality of care to his/her clients. Your therapist may need to share protected information with these individuals for both clinical and administrative purposes such as scheduling, billing and quality assurance. All of the mental health professionals are bound by the same rules of confidentiality.

  - If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, your information is protected by the therapist-patient privilege law. Your therapist cannot disclose any protected information without a court order. If you are involved in or contemplating litigation, you should consult your attorney to determine whether a court would be likely to order your therapist to disclose information.

  - In most legal proceedings, you can refuse to permit your therapist from providing information about you or your treatment. However, in some cases, including but not limited to child custody proceedings and situations in which your emotional condition is an issue, a judge may require your therapist to testify in court.

  - If you file a lawsuit against your therapist, he/she may disclose relevant information regarding you to defend himself/herself.


These are some situations in which your therapist is legally obligated to take actions, which he/she believes are necessary to protect you or others from harm. In this case, he/she may have to reveal some protected health information.

  - If your therapist believes that you present a clear, imminent risk of serious physical or mental injury or death to yourself, he/she is required to take protective actions that can include notifying the police, seeking hospitalization or releasing relevant information to friends or family in order to keep you safe.

  - If you have made a specific threat of violence against another or if your therapist believes you present a clear, imminent risk of serious physical harm to another, he/she may be required to disclose information in order to take protective actions such as notifying the potential victim, contacting the police or seeking hospitalization.

  - If your therapist has reasonable cause to believe that a child under 18, a disabled person or an older adult known to him/her in his/her professional capacity is or ever has been abused or neglected by a parent, caretaker or other person responsible for a child's welfare, the law requires that he/she file a report with the local office of the Department of Children and Families Services. Once a report is filed, your therapist may be required to provide additional information.


If you are a client who is under age 12, your therapist may discuss relevant treatment information with your parents or legal guardians without your written consent. If you are a client between the ages of 12 and 18, your written consent is necessary before your therapist can share information with your parents, legal guardian or others. However, this excludes situations in which the therapist believes you are a danger to yourself or others.


In addition, in signing this confidentiality agreement, you as a client also agree to protect the privacy of other clients. This means that you agree not to disclose the identities or other personal information of those you may see or interact with at this office. Furthermore, if you participate in any groups or workshops affiliated with this practice, you agree to keep the identities and personal information of other group members or workshop participants confidential.


My signature affirms that I have read and fully understand the Confidentiality Agreement document and will abide by its terms and conditions.

( Type Full Name )
( Full Name )
Late Cancellation and No Show Policy

Description

"No Show" shall mean any patient who fails to arrive for a scheduled appointment or arrives 15 minutes after the expected arrival time for the scheduled appointment. "Late Cancellation" shall mean any patient who cancels an appointment less than 24 hours before their scheduled appointment.


Policy

It is the policy of the practice to monitor and manage appointment no shows and late cancellations. The goal of The Hope Connection Therapy Company, LLC. is to provide excellent care to each patient in a timely manner. If it is necessary to cancel an appointment, patients are required to call or leave a message at least 24 hours before their appointment time to avoid penalty fees. Notification allows the practice to better utilize appointments for other patients in need of prompt medical care.


Each client is allowed one (1) "no-show" and one (1) "late cancellation," respectively, without a fee being charged. Once a client exceeds one (1) of either type of cancellation, a fee will be incurred onto the client's account and will need to be paid before another appointment can be scheduled. The charge for each "no show" following the first is $90.00. The charge for each "late cancellation" following the first is $25.00.


Procedure

A patient is notified of the appointment "No Show, Late, & Cancellation Policy" at the time of scheduling. This policy can and will be provided in writing to patients at their request.


    A. Established patients:

         a. Appointment must be cancelled at least 24 hours prior to the scheduled appointment time.

         b. In the event a patient arrives late as defined by "no show" to their appointment, they will be rescheduled for a future clinic visit, if available. If appointments are not yet available for their provider, a reminder will be placed for the patient to call to make a future appointment once the schedule opens and they will be placed on a waiting list.

         c. In the event a patient has incurred three (3) documented "no-shows" or three (3) documented "late cancellations," the patient may be subject to dismissal from The Hope Connection Therapy Company, LLC. The patient's chart is reviewed and dismissals are determined by a psychotherapist and President only, no exceptions, in accordance The Hope Connection Therapy Company, LLC. guidelines.


    B. New patients:

         a. Appointment must be cancelled at least 24 hours prior to scheduled appointment time.

         b. In the event of a "no show," The Hope Connection Therapy Company, LLC may require a new referral sent from the referring physician.

         c. In the event of two (2) documented "late cancellations," the patient may be subject to dismissal from The Hope Connection Therapy Company, LLC. The patient's chart is reviewed and dismissals are determined by a psychotherapist or President only, no exceptions, in accordance with The Hope Connection Therapy Company, LLC. guidelines.


My signature affirms that I have read and agree to the policy outlined in the Late Cancellation and No Show document.

( Type Full Name )
( Full Name )
Mental Health Advanced Directive

If you believe you may be hospitalized for mental health care in the future and that your doctor may think you aren't able to make good decisions about your treatment, completion of a mental health advance directive will help make your treatment preferences known. It is important that you decide now what types of treatment you do or do not want and to appoint a friend or family member to make the mental health care decisions that you want carried out.


You can use the advance directive form to direct your future care.

  - Read each section of the form carefully and talk about your choices with your case manager, doctor, or other trusted persons.

  - The person you choose to be your health care surrogate and alternate must be a competent person who is at least 18 years old, whose civil rights have not been taken away. The person you choose should not be a mental health professional, an employee of a facility which might provide services to you, an employee of the Department of Children & Family Services, or a member of the Local Advocacy Council.

  - Make sure your surrogate understands your wishes and is willing to take the responsibility.

  - You and your surrogate (and a back-up alternate surrogate if you wish) should sign the form in front of two witnesses.

  - Have copies made and give them to your surrogate, your case manager, your doctor, the hospital or crisis unit at which you are most likely be taken, your family, and anyone else who might be involved in your care. Discuss your choices with each of them.


You can change your advance directive at any time you are competent to do so. If you travel, be sure to take a copy of the advance directive with you. Your advance directive will not take effect unless a physician decides that you are incompetent to make your own treatment decisions. If you are in a psychiatric facility, you will have an attorney appointed to represent your interests, and will have a hearing in front of a judge or hearing master. A health care surrogate is not authorized to consent to treatment for a person on voluntary status.


My signature affirms that I have reviewed the Mental Health Advanced Directive document and realize a copy will be provided for me upon request for completion if I feel the need to have this document on file.

( Type Full Name )
( Full Name )
Patient Rights

Right of Individual Dignity:

  - To be respected at all times.

  - To be free from abuse or neglect.

  - To have your values and belief systems recognized and respected.


Right to Treatment:

  - To receive treatment regardless of your ability to pay.

  - To receive treatment in the least restrictive setting as possible.

  - To have reasonable access to care regardless of race, religion, sex, sexual orientation, gender identity, ethnicity, age, or disability.

  - To refuse treatment.

  - To participate in individualized treatment and in developing and reviewing your treatment plan.

  - To participate in making decisions regarding your own care.


Right to Express and Informed Consent:

  - To be informed about the nature of your treatment.

  - To consent or not consent to treatment.

  - To request a second opinion.

  - To be informed of agency rules and regulations.


Right to Quality Treatment:

  - To receive treatment that is skillfully, safely, and humanely administered.

  - To receive referral for services as needed.


Right of Clinical Records:

  - To have reasonable access to your own records.

  - To authorize release of information to persons or agencies.

  - To have your record kept confidential.


My signature affirms that I have read and fully understand the Patient Rights document.

( Type Full Name )
( Full Name )
Blueprint AI
Blueprint Informed Consent

Automated Notetaker

Your clinician has opted to use Blueprint's note-taking system as part of their effort to provide excellent care to clients. Blueprint's note-taker temporarily records sessions and uses this recording to automatically generate a progress note (a required form of clinical documentation). After a progress note is generated, the recording is automatically deleted from Blueprint's servers and database.

Use of this technology allows your therapist to be fully present during your sessions, without having to slow down to take notes or trying to remember important information during the session. This allows them to focus all of their attention on your care.

Blueprint's software is HIPAA compliant and SOC 2 Type 2 certified, which means an external third-party auditor reviews Blueprint's systems, policies, and processes on an ongoing annual basis to ensure Blueprint meets certain data privacy and security standards.

By signing this consent form, you are agreeing to allow your clinician to record your sessions and utilize software to assist them in generating progress notes to document these encounters.


( Type Full Name )
( Full Name )
Consent for Services

This form is called a Consent for Services (the "Consent"). Your therapist, counselor, psychologist, doctor, or other health professional ("Provider") has asked you to read and sign this Consent before you start therapy. Please review the information. If you have any questions, contact your Provider.

THE THERAPY PROCESS
Therapy is a collaborative process where you and your Provider will work together on equal footing to achieve goals that you define. This means that you will follow a defined process supported by scientific evidence, where you and your Provider have specific rights and responsibilities. Therapy generally shows positive outcomes for individuals who follow the process. Better outcomes are often associated with a good relationship between a client and their Provider. To foster the best possible relationship, it is important you understand as much about the process before deciding to commit.

Therapy begins with the intake process. First, you will review your Provider's policies and procedures, talk about fees, identify emergency contacts, and decide if you want health insurance to pay your fees depending on your plan's benefits. Second, you will discuss what to expect during therapy, including the type of therapy, the length of treatment, and the risks and benefits. If your Provider is practicing under the supervision of another professional, your Provider will tell you about their supervision and the name of the supervising professional. Third, you will form a treatment plan, including the type of therapy, how often you will attend therapy, your short- and long-term goals, and the steps you will take to achieve them. Over time, you and your Provider may edit your treatment plan to be sure it describes your goals and steps you need to take. After intake, you will attend regular therapy sessions at your Provider's office or through video, called telehealth. Participation in therapy is voluntary - you can stop at any time. At some point, you will achieve your goals. At this time, you will review your progress, identify supports that will help you maintain your progress, and discuss how to return to therapy if you need it in the future.

IN-PERSON VISITS & SARS-CoV-2 ("COVID-19")
When guidance from public health authorities allows and your Provider offers, you can meet in-person. If you attend therapy in-person, you understand:
- You can only attend if you are symptom-free (For symptoms, see: https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html);
- If you are experiencing symptoms, you can switch to a telehealth appointment or cancel. If you need to cancel, you will not be charged a late cancellation fee.
- You must follow all safety protocols established by the practice, including:
- Following the check-in procedure;
- Washing or sanitizing your hands upon entering the practice;
- Adhering to appropriate social distancing measures;
- Wearing a mask, if required;
- Telling your Provider if you have a high risk of exposure to COVID-19, such as through school, work, or commuting; and
- Telling your Provider if you or someone in your home tests positive for COVID-19.
- Your Provider may be mandated to report to public health authorities if you have been in the office and have tested positive for infection. If so, your Provider may make the report without your permission, but will only share necessary information. Your Provider will never share details about your visit. Because the COVID-19 pandemic is ongoing, your ability to meet in person could change with minimal or no notice. By signing this Consent, you understand that you could be exposed to COVID-19 if you attend in-person sessions. If a member of the practice tests positive for COVID-19, you will be notified. If you have any questions, or if you want a copy of this policy, please ask.

TELEHEALTH SERVICES
To use telehealth, you need an internet connection and a device with a camera for video. Your Provider can explain how to log in and use any features on the telehealth platform. If telehealth is not a good fit for you, your Provider will recommend a different option. There are some risks and benefits to using telehealth:

Risks
- Privacy and Confidentiality. You may be asked to share personal information with the telehealth platform to create an account, such as your name, date of birth, location, and contact information. Your Provider carefully vets any telehealth platform to ensure your information is secured to the appropriate standards.
- Technology. At times, you could have problems with your internet, video, or sound. If you have issues during a session, your Provider will follow the backup plan that you agree to prior to sessions.
- Crisis Management. It may be difficult for your Provider to provide immediate support during an emergency or crisis. You and your Provider will develop a plan for emergencies or crises, such as choosing a local emergency contact, creating a communication plan, and making a list of local support, emergency, and crisis services.

Benefits
- Flexibility. You can attend therapy wherever is convenient for you.
- Ease of Access. You can attend telehealth sessions without worrying about traveling, meaning you can schedule less time per session and can attend therapy during inclement weather or illness.

Recommendations
- Make sure that other people cannot hear your conversation or see your screen during sessions.
- Do not use video or audio to record your session unless you ask your Provider for their permission in advance.
- Make sure to let your Provider know if you are not in your usual location before starting any telehealth session.


CONFIDENTIALITY
Your Provider will not disclose your personal information without your permission unless required by law. If your Provider must disclose your personal information without your permission, your Provider will only disclose the minimum necessary to satisfy the obligation. However, there are a few exceptions.
- Your Provider may speak to other healthcare providers involved in your care.
- Your Provider may speak to emergency personnel.
- If you report that another healthcare provider is engaging in inappropriate behavior, your Provider may be required to report this information to the appropriate licensing board. Your Provider will discuss making this report with you first, and will only share the minimum information needed while making a report. If your Provider must share your personal information without getting your permission first, they will only share the minimum information needed. There are a few times that your Provider may not keep your personal information confidential.
- If your Provider believes there is a specific, credible threat of harm to someone else, they may be required by law or may make their own decision about whether to warn the other person and notify law enforcement. The term specific, credible threat is defined by state law. Your Provider can explain more if you have questions.
- If your Provider has reason to believe a minor or elderly individual is a victim of abuse or neglect, they are required by law to contact the appropriate authorities.
- If your Provider believes that you are at imminent risk of harming yourself, they may contact law enforcement or other crisis services. However, before contacting emergency or crisis services, your Provider will work with you to discuss other options to keep you safe.

RECORD KEEPING
Your Provider is required to keep records about your treatment. These records help ensure the quality and continuity of your care, as well as provide evidence that the services you receive meet the appropriate standards of care. Your records are maintained in an electronic health record provided by CounSol. CounSol has several safety features to protect your personal information, including advanced encryption techniques to make your personal information difficult to decode, firewalls to prevent unauthorized access, and a team of professionals monitoring the system for suspicious activity. CounSol keeps records of all log-ins and actions within the system.

COMMUNICATION
You decide how to communicate with your Provider outside of your sessions. You have several options:
Texting/Email
- Texting and email are not secure methods of communication and should not be used to communicate personal information. You may choose to receive appointment reminders via text message or email. You should carefully consider who may have access to your text messages or emails before choosing to communicate via either method.
Secure Communication
- Secure communications are the best way to communicate personal information, though no method is entirely without risk. Your Provider will discuss options available to you. If you decide to be contacted via non-secure methods, your Provider will document this in your record.
Social Media/Review Websites
- If you try to communicate with your Provider via these methods, they will not respond. This includes any form of friend or contact request, @mention, direct message, wall post, and so on. This is to protect your confidentiality and ensure appropriate boundaries in therapy.
- Your provider may publish content on various social media websites or blogs. There is no expectation that you will follow, comment on, or otherwise engage with any content. If you do choose to follow your Provider on any platform, they will not follow you back.
- If you see your Provider on any form of review website, it is not a solicitation for a review. Many such sites scrape business listings and may automatically include your Provider. If you choose to leave a review of your Provider on any website, they will not respond. While you are always free to express yourself in the manner you choose, please be aware of the potential impact on your confidentiality prior to leaving a review. It is often impossible to remove reviews later, and some sites aggregate reviews from several platforms leading to your review appearing other places without your knowledge.

FEES AND PAYMENT FOR SERVICES
You may be required to pay for services and other fees. You will be provided with these costs prior to beginning therapy, and should confirm with your insurance if part or all of these fees may be covered. You should also know about the following:

No-Show and Late Cancellation Fees
- If you are unable to attend therapy, you must contact your Provider before your session. Otherwise, you may subject to fees outlined in your fee agreement. Insurance does not cover these fees.


Balance Accrual
- Full payment is due at the time of your session. If you are unable to pay, tell your Provider. Your Provider may offer payment plans or a sliding scale. If not, your Provider may refer you to other low- or no-cost services. Any balance due will continue to be due until paid in full. If necessary, your balance may be sent to a collections service.

Administrative Fees
- Your Provider may charge administrative fees for writing a letter or report at your request; consulting with another healthcare provider or other professional outside of normal case management practices; or for preparation, travel, and attendance at a court appearance. These fees are listed in the fee agreement. Payment is due in advance.


 Insurance Benefits
- Before starting therapy, you should confirm with your insurance company if:
- Your benefits cover the type of therapy you will receive;
- Your benefits cover in-person and telehealth sessions;
- You may be responsible for any portion of the payment; and
- Your Provider is in-network or out-of-network.
- Sharing Information with Insurance Companies
- If you choose to use insurance benefits to pay for services, you will be required to share personal information with your insurance company. Insurance companies keep personal information confidential unless they must share to act on your behalf, comply with federal or state law, or complete administrative work.


Covered and Non-Covered Services
- When your Provider is in-network, they have a contract with your insurance company. Your insurance plan may cover all or part of the cost of therapy. You are responsible for any part of this cost not covered by insurance, such as deductibles, copays, or coinsurance. You may also be responsible for any services not covered by your insurance.
- When your Provider is out-of-network, they do not have a contract with your insurance company. You can still choose to see your Provider; however, all fees will be due at the time of your session to your Provider. Your Provider will tell you if they can help you file for reimbursement from your insurance company. If your insurance company decides that they will not reimburse you, you are still responsible for the full amount.

Payment Methods
- The practice requires that you keep a valid credit or debit card on file. This card will be charged for the amount due at the time of service and for any fees you may accrue unless other arrangements have been made with the practice ahead of time. It is your responsibility to keep this information up to date, including providing new information if the card information changes or the account has insufficient funds to cover these charges.

COMPLAINTS
If you feel your Provider has engaged in improper or unethical behavior, you can talk to them, or you may contact the licensing board that issued your Provider's license, your insurance company (if applicable), or the US Department of Health and Human Services.


Acknowledgement

My signature on this document represents that I have received the Consent for Services form and that I understand and agree to the information therein. Further, I consent to use an electronic signature to acknowledge this agreement.

( Type Full Name )
( Full Name )