TO MAKE YOUR UPCOMING VISIT EASIER, WE HAVE INCLUDED ALL DOCUMENTS THAT REQUIRE YOUR ATTENTION. OUR AIM IS TO STOP THE NEED TO COMPLETE ANY PAPERWORK WHEN YOU COME TO THE OFFICE FOR THE FIRST TIME.
How many brothers/sisters (not including yourself)
I'VE HAD PERIODS OF TIME WHEN I WAS NOT MY USUAL SELF AND... Check each item that applies to you.
Consents, Policies, and Procedures
OFFICE HOURS: Professional staff and Office Manager are available from 9:00 am to 5:00 pm Tuesday – Thursday. For emergencies after hours please call 911 or go directly to the nearest Emergency Room. If you need someone to contact you after hours, please call our office number, leave a message, and a provider will contact you as soon as possible.
CANCELLATIONS: Please give 24 hours advance notice for cancellations. The provider reserves the right to charge the full fee for no shows or late cancellations, payable by the patient or guardian. Your insurance does not pay these fees.
FEES: All deductibles and co-payments are payable prior to seeing your provider. This also applies to those who may not have insurance and are classified as SELF-PAY individuals.
INSURANCE: As a service to our clients, we submit your claims to your insurance company. Our office will make every effort to obtain accurate information about your benefits and limits of coverage. We will also try to have this informationavailable to you; however, YOU ARE RESPONSIBLE FOR YOUR BILL. You agree to pay all charges that your insurance does not pay. WE ARE UNABLE TO PARTICIPATE WITH MEDICARE AND MEDICAID INSURANCE PROGRAMS; however, we will work with you to make your care affordable. We encourage you to contact your insurance company to be sure that you understand the limits of your coverage. CONFIDENTIALITY: Information regarding your treatment will not be released unless there is 1) written consent, 2) an indication that clear and immediate danger exists, 3) a court order which directs the release of information, or 4) youdisclose sexual abuse, physical abuse or neglect of a child under the age of 18. We ask that you check the box below, giving your consent, so we can provide the information that your insurance company requires, ensuring that your treatment is medically necessary and appropriate.
AUTHORIZATION TO RELEASE INFORMATIONI authorize my mental health practitioner to release information about me to my insurance company and the professional who referred me. This information is protected under the Privacy Act, the Drug Abuse Office and Treatment Act, and the comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act.
HIPAA Compliance Notice of Privacy Practices
WE ARE REQUIRED BY LAW TO PROTECT MEDICAL INFORMATION ABOUT YOU.
We are required by law to protect the privacy of medical information about you and that identifies you. This medical information may be information about health care we provide to you or payment for health care provided to you. It may also be information about your past, present, or future physical or mental health. We are also required by law to provide you with this Notice of Privacy Practices explaining our legal duties and privacy practices with respect to medical information. We are legally required to follow the terms of this Notice. In other words, we are only allowed to use and disclose medical information in the manner that we have described in this Notice. We may change the terms of this Notice in the future. We reserve the right to make changes and to make the new Notice effective for all medical information that we maintain. If we make changes to the Notice, we will:
The rest of this Notice will:
WE MAY DISCLOSE HEALTH INFORMATION ABOUT YOU UNDER SEVERAL CIRCUMSTANCES.
This notice explains in some detail how we may use and disclose medical information about you in order to provide health care, obtain payment for that health care, and operate our business efficiently. This section then briefly mentions several other circumstances under which we may use or disclose medical information about you. For more information about any of these uses or disclosures, or about any of our privacy policies, procedures or practices, please contact us.
1. Treatment: We may use and disclose health information about you to provide health care treatment to you. In other words, we may use and disclose health information about you to provide, coordinate or manage your health care and related services. This may include communicating with other health care providers regarding your treatment and coordinating and managing your health care with others.
2. Payment: We may use and disclose health information about you to obtain payment for health care services that you received. This means that, within Triumph, we may use health information about you to arrange for payment (such as preparing bills and managing accounts). We also may disclose mental information about you to others (such as insurers, collection agencies, and consumer reporting agencies). In some instances, we may disclose health information about you to an insurance plan before you receive certain health care services because, for example, we may want to know whether the insurance plan will pay for a particular service.
3. Health care operations: We may use and disclose health information about you in performing a variety of business activities that we call "health care operations". These "health care operations" activities allow us to, for example, improve the quality of care we provide and reduce health care costs. For example, we may use or disclose medical information about you in performing the following activities:
4. Persons involved in your care: We may disclose health information about you to a relative, close personal friend or any other person you identify if that person is involved in your care and the information is relevant to your care. If the patient is a minor, we may disclose medical information about the minor to a parent, guardian or other person responsible for the minor except in limited circumstances. For more information on the privacy of minors' information, please contact us. We may also use or disclose health information about you to a relative, another person involved in your care or possibly a disaster relief organization (such as the Red Cross) if we need to notify someone about your location or condition.
You may ask us at any time not to disclose medical information about you to persons involved in your care. We will agree to your request and not disclose the information except in certain limited circumstances (such as emergencies) or if the patient is a minor. If the patient is a minor, we may or may not be able to agree to your request.
5. Required by law: We will use and disclose health information about you whenever we are required by law to do so. There are many state and federal laws that require us to use and disclose medical information. For example, state law requires us to report gunshot wounds and other injuries to the police and to report known or suspected child abuse or neglect to the Department of Social Services. We will comply with those state laws and with all other applicable laws.
6. National priority uses and disclosures: When permitted by law, we may use or disclose health information about you without your permission for various activities that are recognized as "national priorities". In other words, the government has determined that under certain circumstances (described below), it is so important to disclose information that it is acceptable to disclose medical information without the individual's permission. We will only disclose information about you in the following circumstances when we are permitted to do so by law. Below are brief descriptions of the "national priority" activities recognized by law.
7. Authorization: Other than the uses and disclosures described above, we will not use or disclose health information about you without the authorization, or signed permission, of you or your personal representative. In some instances, we may wish to use or disclose health information about you and we may contact you to ask you to sign an authorization form. In other instances, you may contact us to ask us to disclose health information and we will ask you to sign an authorization form.
If you sign a written authorization allowing us to disclose health information about you, you may later revoke (or cancel) your authorization in writing (except in very limited circumstances related to obtaining insurance coverage). If you would like to revoke your authorization, you may write us a letter revoking your authorization. If you revoke your authorization, we will follow your instructions except to the extent that we have already relied upon your authorization and taken some action.
YOU HAVE RIGHTS WITH RESPECT TO MEDICAL INFORMATION ABOUT YOU.
You have several rights with respect to medical information about you. This section of the Notice will briefly mention each of these rights. If you would like to know more about your rights, please contact us.
1. Right to a copy of this Notice: You have a right to have a paper copy of our Notice of Privacy Practices at any time. In addition, a copy of this Notice will always be posted in our waiting area. If you would like to have a copy of our Notice, ask the office manager for a copy.
2. Right of access to inspect and copy: You have the right to inspect (which means see or review) and receive a copy of health information about you that we maintain in your records. If you would like to inspect or receive a copy of health information about you, you must provide us with a request in writing. You may fill out an Access Request Form, available in our office. We may deny your request in certain circumstances. If we deny your request, we will explain our reason for doing so in writing. We will also inform you in writing if you have the right to have our decision reviewed by another person. We may be able to provide you with a summary of the information requested. Contact us for more information about this and possible additional fees.
3. Right to have medical information amended: You have the right to have us amend (which means correct or supplement) health information about you if you believe that we have information that is either inaccurate or incomplete. We may amend the information to indicate the problem and notify others who have copies of the inaccurate or incomplete information. If you would like us to amend information, you must provide us with a request in writing and explain why you would like us to amend the information. You may write a letter requesting an amendment. We may deny your request in certain circumstances. If we deny your request, we will explain our reason for doing so in writing. You will have the opportunity to send us a statement explaining why you disagree with our decision to deny your amendment request and we will share your statement whenever we disclose the information in the future.
4. Right to an accounting of disclosures we have made: You have the right to receive an accounting (which means a detailed listing) of disclosures that we have made for the previous six (6) years. If you would like to receive an accounting, you may send a letter requesting such accounting. The accounting will not include several types of disclosures, including disclosures for treatment, payment or health care operations. It will also not include disclosures made prior to April 14, 2003.
5. Right to request restrictions on uses and disclosures: You have the right to request that we limit the use and disclosure of health information about your treatment, payment and health care operations. We are not required to agree to your request. If we do agree to your request, we must follow your restrictions (except where the information is necessary for emergency treatment). You may cancel the restrictions at any time. In addition, we may cancel a restriction at any time as long as we notify you of the cancellation and continue to apply the restriction to information collected before the cancellation.
6. Right to request an alternative method of contact: You have the right to request to be contacted at a different location or by a different method. For example, you may prefer to have all written information mailed to your work address rather than to your home address. We will agree to any reasonable request for alternative methods of contact. If you would like to request an alternative method of contact, you must provide us with the request in writing. You may write us a letter.
YOU MAY FILE A COMPLAINT ABOUT OUR PRIVACY PRACTICES.
If you believe that your privacy rights have been violated or if you are dissatisfied with our privacy policies or procedures, you may file a complaint either with us or with the federal government. We will not take any action against you or change our treatment of you in any way if you file a complaint. To file a written complaint directly with us, you may mail it or bring your complaint to our office.
INFORMED CONSENT: We ask that patients sign the following general consent to treatment. The patient may at any time decline specific recommendations.CONSENT TO EXAMINATIONS AND TREATMENTI consent to have Serenity Mental Health Clinic, and it’s professional staff perform or order examinations, psychotherapy, and/or related mental health treatments and to order medications when deemed necessary or advisable by the appropriate members of the professional staff and /or consultants in consultation with Serenity Mental Health Clinic.