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Dear Client (“You”),
As the practitioners and staff (the “Staff”) of Tides of Mind Counseling, we would like to extend our appreciation for the opportunity to work with you and your family. We look forward to an ongoing therapeutic relationship with you now and in the future. In order to facilitate our mutual cooperation and understanding, we would like to advise you as to your right to consent to treatment and highlight our administrative and financial policies for your review and agreement.
Tides of Mind Counseling provides therapeutic assessments, counseling, and psychotherapy services for individuals, children, couples, families, and corporate clients using a variety of methods and client-specific treatment options. At the outset of our working relationship, you have the right to consent, or to refuse to consent, to receive diagnostic evaluation, examination, counseling, and treatment from our Staff; your consent is deemed to be given and effective by your signature at the end of this form, and such consent shall remain effective until and unless revoked in writing at a later date. Note that express authorization through your signature of an additional, distinct form (titled “Authorization to Release Information”) is required in order for our Staff or office to disclose or exchange records pertaining to your mental and/or medical health, psychiatric and/or psychological evaluation and/or treatment, HIV/AIDS diagnosis and/or treatment, and drug and/or alcohol abuse.
Please be advised of the following policies of Tides of Mind Counseling:
You hereby authorize Tides of Mind Counseling to file any claims for payment of any portion of bills for treatment as may be necessary and assign all rights and benefits to Tides of Mind Counseling therefore. You further agree, subject to state and federal law, to pay all costs, attorney fees, expenses and interest in the event that Tides of Mind Counseling takes action to collect payment for services because of your failure to pay all incurred charges in full.
You understand that it is impossible to guarantee the security and confidentiality of information stored on computers or telecommunications equipment connected to the internet. You further understand that it is impossible to guarantee the confidentiality of information being transmitted via email, text, cordless telephones, mobile telephones, or similar telecommunications equipment. You hereby agree to waive legal action against Tides of Mind Counseling and its Staff with regard to the storage or transmission of any confidential information and further hold Tides of Mind Counseling and all of its Staff harmless for any interception of your medical information resulting from use of the aforementioned equipment. Please be advised that Tides of Mind Counseling may rely on a third-party billing company for claims processing and billing, pursuant to a HIPAA-compliant Business Associate Agreement.
By signing this form, you agree that you have read, understand and hereby agree to the above policies and accept responsibility for your account. Further, you consent to treatment by Tides of Mind Counseling for yourself and/or your minor child including diagnostic evaluation, examination, counseling and therapy, and you confirm that you have the legal right to consent to your child’s mental health treatment without the consent of any other individuals. As stated above, this consent shall remain effective until and unless revoked in writing at a later date.
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
As a Mental Health Provider, Tides of Mind Counseling and its practitioners and staff (the “Staff”) are required by federal law to take reasonable efforts to maintain the privacy of your medical information. In the course of evaluation and treatment, we may receive and maintain medical information from other medical providers (“Providers”) from whom you have received services; this medical information is known as Protected Health Information, or PHI. In accordance with the law and for your benefit, we will at all times take reasonable steps to secure client records, adopt clear privacy procedures, and restrict other parties’ access to your PHI – while ensuring that you can obtain copies of your records and expressly authorize transfer of your records to other Providers, as may be necessary. We will not disclose your PHI without your permission, except as described in this notice. We encourage you to ask any questions you may have regarding this notice and our policies for safeguarding your PHI.
Tides of Mind Counseling reserves the right to revise our privacy practices and implement new policies effective and applicable on a going-forward basis to all PHI maintained by our office and Staff. Should we implement such a change to our privacy practices, we will amend this notice, post notice of such changes in our office, and provide clarification regarding such changes upon request. This notice is effective and current as of March 7, 2017.
USES AND DISCLOSURES
We believe that protecting client confidentiality and responsibly maintaining your individually identifiable health information and PHI are of the utmost importance. As a result, we have adopted clear internal privacy procedures and have trained our Staff to understand and abide by our practices; we strive to secure and protect our electronic and physical records, our electronic or telephonic communications with you, and confidential information and materials related to your treatment and your relationship with our Staff. Pursuant to HIPAA rule 45 CFR 164.501, we afford special protection to psychotherapy notes, such notes being defined as documentation by a mental health professional analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session, and such notes being separate from the rest of your medical record. We will not provide these sensitive notes to third-party payers without your express authorization.
It is our policy to obtain your written authorization through the use of an “Authorization to Release Information” form prior to disclosing your PHI to any person or entity outside of our office for any purpose other than treatment, payment and in-office health care operations (as described in more detail below). As noted in the form, you may revoke your authorization at any time, except to the extent that we have already acted upon it. Such authorization automatically expires after a period of one (1) year.
We may use your Protected Health Information (PHI) without authorization for:
Other permitted disclosures of your Protected Health Information (PHI) without authorization might include the following:
YOU HAVE THE RIGHT TO:
HOW YOU CAN REPORT A PROBLEM:
If you have any concerns about our efforts to ensure your privacy, we encourage you to contact Chelsea Humphrey, 230 Frost Road Unit B, Waterbury, CT 06705. If you feel your privacy rights have been violated, you have the right to file a written complaint with the U.S. Department of Health and Human Services’ Office for Civil Rights, either by visiting:
by contacting OCRComplaint@hhs.gov, or by writing to Centralized Case Management Operations, U.S. Dept. of Health and Human Services, 200 Independence Avenue, S.W., Room 509F HHH Bldg., Washington, D.C. 20201.
Tides of Mind Counseling has recently partnered with CMPS Billing. CMPS is a mental health billing organization located in Sarasota Florida. We have been in business since 2000. Our goal is to provide Tides of Mind patients support with all billing and insurance claims related matters. We have a team of certified medical coders and billers with over 100 years of combined experience.
CMPS billing is passionate about what we do, and we hope to be a support to Tides of Mind's clients!
What does this mean for you? We are here to help!
You will notice a few changes in the near future as we work to get account statements and billing information out to you in a timely manner. You may receive statements from us by mail or by the email you have provided. Please follow the secured link, create a login, view your detailed statement, and call the phone number below to make your payments. We may be contacting you by phone regarding balances or insurance questions.
Coming soon, you will be able to access a portal where all of your current billing information and forms will be located. You will be able to log on and view your information or pay an outstanding balance. This will help to make our communication efforts quick and easy for you and your provider. We will send out another letter to you before this goes into effect. We aim to provide compassionate, patient-centered care for all.
We are looking forward to working with you!
Please do not hesitate to contact us with any inquiries or billing questions at: (877) 299-5426 Option #4.
This section is informational only