PATIENT INFORMATION

FINANCIAL AGREEMENT

All fees have been explained to me and any questions have been answered. I authorize my insurance benefits be paid directly to the physician who has treated me. I understand that I am financially responsible for any balance unpaid by insurance. I also authorize the release of any information to my insurance company required to process my claims. I understand that it is my responsibility to inform of any insurance coverage and/or eligibility changes and that failing to do so may result in a charge of the full billed amount. I understand that payment is required at the time of service unless other arrangements have been made. Prompt payment is required and past due accounts will be sent to collections. Returned check fee is $25.00.

INFORMED CONSENT OF TREATMENT AND RELEASE

I agree and consent to participate in the services offered by providers employed by or associated with Grand Island Mental Health & Medical Clinic, LLC. This could include any or all of the following services from the time of intake to discharge: community support, behavioral health, and/or medical health care. I agree to release information regarding my treatment to all providers associated with Grand Island Mental Health & Medical Clinic to use as a benefit and resource to my overall treatment goals. I understand that I am consenting and agreeing only to those services that the provider(s) is qualified to provide within: (1) the scope of the provider's license, certification, and training; or (2) the scope of license, certification, and training of the health care providers directly supervising the services received by the patient. If the patient is under the age of nineteen or unable to consent to treatment, I attest that I have legal custody of this individual and am authorized to initiate and consent for treatment and/or legally authorized to initiate and consent to treatment on behalf of this individual.

INSURANCE BILLING

We are happy to bill your insurance company or payor source on your behalf. Check with the front desk staff to be sure the provider who is treating you is in-network with your insurance company. If you have a secondary insurance company, we will send claims for payment to your secondary insurance upon receipt of Explanation of Benefits from your primary insurance company. Any remaining balance will be your responsibility to pay in full in a timely matter. We ask that you inform our office as soon as possible of any insurance coverage and/or eligibility changes. Failing to do so may result in a charge of the full billed amount. Copay amounts will be collected at the time of the service. Any Medicaid charges will be considered payment in full.

HIGH DEDUCTIBLES

If you have a high deductible plan or have not met your deductible yet, we ask that you pay $50.00 at the time of your visit to ensure that your account balance does not get too large. Once you have met your deductible, you will no longer be asked to pay $50.00 for each session at the time of service and the amount due at time of service will reflect your copay and/or co-insurance amounts set by your insurance company. If insurance happens to pay the entire amount for your session or you have a credit on your account, this amount will be reimbursed to you.

Initial Session with Diagnostic Assessment- $160.00

60 Minute Individual Session- $135.00

45 Minute Individual Session- $90.00

30 Minute Individual Session- $60.00

Family Session- $120.00

Substance Abuse Evaluation- $225.00

Substance Abuse Addendum- $120.00

Community Support Visit Per 15 Min Increment- $30.00

FINANCIAL HARDSHIP SLIDING SCALE

We can provide a sliding scale rate to any clients who qualify for our reduced rate services through hardship verification. To comply with federal regulations, in order to give a reduced rate for services, it is necessary for us to obtain income verification. You must verify your income at least every year. Your adjusted gross income is used to figure the sliding scale rate. Household adjusted gross income x .001 = Rate of session with no amount being less than $45 or higher than regular session rate. (Ex: $45,000 per year = $45/session, $95,000 per year = $95/session.)

SERVICE DEFINITIONS

Community Support provides a wide array of services to recipients based on their individual needs and disabilities. Services are designed to assist children, adolescents, and adults challenged with mental health, substance abuse, and/or intellectual/developmental disabilities. These services help service recipients achieve, regain, and maintain their highest level of functioning, thereby allowing them to live more independently and participate in the community.

Outpatient Therapy services are provided to persons of all ages with mental health, substance abuse, or co-occurring disorders. Treatment services are provided by qualified clinical personnel, utilizing an array of treatment modalities (e.g., individual, family, and/or group therapy) to assist service recipients in addressing a variety of behavioral health challenges.

Medication management is the level of outpatient treatment where the sole service rendered by a qualified prescriber is the evaluation of the individual's need for psychotropic medications, provision of a prescription, and ongoing medical monitoring for those medications. Complete with an initial assessment that identifies the need for medication management and medication monitoring routinely and as needed.

OFFICE INFECTIOUS CONTROL/SICKNESS INFORMATION

If you are currently sick or have been exposed to a communicable disease and are not seeking medical services for that illness from our office, we do ask that you kindly notify our staff prior to your appointment and reschedule to a later date. If you have any communicable diseases we ask that you indicate them on intake paperwork in order for us to accommodate any needs you may have and better protect and reduce risk to all other individuals in our office. We ask that all individuals in our office practice safe hand hygiene by washing hands with antibacterial soap and/or use hand sanitizer to decontaminate hands. Hand hygiene guides are posted in all bathrooms. All staff in this office are trained in standard precautions and will provide care to the best of their ability according to CDC regulations. A copy of the office Infectious Control Policy can be obtained by request at any time.

RIGHTS AND RESPONSIBILITIES

You have the right as a Patient to:

• Be treated fairly and with respect, regardless of race, religion, gender, ethnicity, age, disability, or source of payment.
• Have your treatment and other member information kept confidential. Only where permitted by law may records be released without your permission.
• Refuse care or treatment at any time.
• Know about your treatment choices and be fully informed about the charges and services provided to you.
• Share in developing and periodically revising a plan of care.
• Receive a clear explanation of your condition and treatment options.
• Ask your provider about their work history and training.
• Have provider decisions about your care made on the basis of treatment needs.
• Choose and identify your healthcare provider.
• Receive proper and timely medical care.
• Be protected in this office by staff who are trained and follow emergency, safety, and infectious control protocols.
• Have voiced concerns or complaints to proper sources investigated and without experiencing reprisals.
• Have interpreters available, if necessary, during appointments and in all discussions with your health care providers.

As a patient you are responsible to:

• Keep scheduled appointments or call your healthcare provider in advance if you cannot keep an appointment.
• Inform your healthcare provider of your medical and mental health diagnosis, symptoms, and concerns.
• Ask questions if you do not understand.
• Follow your health care provider's orders and treatment plan.
• Treat those giving you care with dignity and respect.
• Give providers accurate information needed in order to deliver quality care.
• Tell your provider about medication changes, including medications given to you by others.
• Put your own health and the health of others at a high priority which may include rescheduling an appointment if you contract a communicable disease and/or comply with appropriate treatment to cure communicable diseases.
• Let the provider know if the treatment plan is not working for you.

*Your care and treatment in our office are our top priorities. If any of our services do not exceed your expectations please report to administration as soon as possible (308-398-0350, Debra ext 1 and Jordan ext 2). Report billing discrepancies to the billing department at 308-398-0350 ext 3. If necessary report complaints to the DHHS hotline at 402-471-0316 hours M-F 8am-5pm CST or ACHC at 919-785-1214. More detailed information regarding this process can be obtained by request at any time.

POWER OF ATTORNEY/ADVANCED DIRECTIVES AND RELEASE OF MEDICAL INFORMATION

I have been made aware of and understand all Member Rights and Responsibilities. I have been offered a copy of the office Notice of Privacy Practices. Any questions I have regarding these have been answered and I understand that my participation is voluntary and my progress will be evaluated every 90 days to continue participation. I attest the above information is true to the best of my knowledge. My signature authorizes my provider to provide treatment to the person listed as the client.