If divorced, please answer the following questions:
How We Collect Information About You: Serenity Counseling and Mediation Center (“the Practice”) and its employees collect data through a variety of means including by not necessarily limited to letters, phone class, emails, voicemails, and from the submission of applications that are either required by law or necessary to process applications or other requests for assistance through our organization.’
What We Do Not Do With Your Information: Information about your financial situation and medication conditions and care that you provide to us in writing, via email, on the phone (including information left on voicemails), contained in or attached to applications, or directly or indirectly given to us, is held in strictest confidence.
We do not give out, exchange, barter, rent, sell, lend, or disseminate any information about applicants or clients who apply for or actually receive our services that is considered patient confidential, is restricted by law, or has been specifically restricted by a patient/client in a signed HIPAA consent form.
How We Do Use Your Information: Information is only used as a reasonable necessary to process your application or to provide you with health or counseling services which may require communication between the Practice and health care providers, insurance companies, and other providers necessary to verify your medical information is accurate and determine any health care services you may need.
If you apply or attempt to receive assistance through us and provide information with the intent or purpose of fraud or that results in either an actual crime or fraud for any reason including willful or un- willful acts of negligence whether intended or not, or in any way demonstrates or indicates attempted fraud, your non-medical information can be given to legal authorities including police, investigators, courts, and/or attorneys or other legal professionals, as well as any other information as permitted by law.
Your Health Information Rights
The health and billing records we create and store are the property of the practice. The protected health information in it, however, generally belongs to you. You have a right to:
We are required to:
We have the right to change our practices regarding the protected health information we maintain. If we make changes, we will update this Notice. You may receive the most recent copy of this Notice by call and asking for it or by visiting our office to pick one up.
To Ask for Help or Complain
If you have questions, want more information, or want to report a problem about the handling of your protected health information, you may contact:Christian Cid, CEO 615-527-3060
If you believe your privacy right have been violated you may discuss your concerns with Christian Cid, CEO. You may also deliver a written complaint to the CEO at our practice. You may also file a complaint with the U.S. Secretary of Health and Human Services.
We respect your right to file a complaint with us or with the U.S. Secretary of Health and Human Services. If you complain, we will not retaliate against you.
By law, protected health information may be released without your consent or authorization for the following:
• Child abuse• Suspected sexual abuse of a child• Adult and domestic abuse• Court order• Serious threat to health or safety – “Duty to Warn” law• Workers Compensation claims – All of your protected health information is automatically subject to review by your employer and/or insurer(s).• Uses and disclosures not in this Notice will be made only as allowed or required by law or with your written authorization.
If you cancel less than 24 hours before a session, you will be billed for the full cost of the missed session.
I/We have legal custody of the child and have the authorization to provide counseling for the child(ren) mentioned above.
Counseling is a unique therapeutic relationship that is grounded on the basis of confidentiality. We will strive to provide each client with the highest quality services, including a level of confidentiality that makes the experience safe and comforting for the client. Counseling session information will not be released without your written consent, unless otherwise dictated by state/national laws.
There are laws that dictate the necessary limits of confidentiality. We are committed to conforming to these laws in the strictest fashion. Our “duty to warn” includes issues of suspected or reported child abuse, elder abuse, threats to self-harm/suicidal tendencies, and threats to others/homicidal tendencies. In addition, occasionally judges will subpoena a counselor for testimony or order the release of confidential information in court proceedings. In these instances, the client is notified of the subpoena and/or court order and every effort is made to protect confidential information.
If you understand these disclosure statements and desire to proceed with the counseling relationship, please indicate this below with your signature and today’s date. If you have any questions, please don’t hesitate to ask.
When you schedule an appointment with a Clinician that time is specifically held for you. By making an appointment, you accept the responsibility to pay the full fee for the professional time that is reserved for you. If you cancel an appointment with your Clinician, you agree to do so as early as possible and the office will attempt to reschedule for a time convenient to you.
Serenity Counseling Center (the “Practice”) has a policy of charging Clients for the full cost of any appointment the Client fails to attend unless the appointment is canceled at least 24 hours in advance. To avoid charges, cancellations must be made by communicating to the office of the Practice the Client’s desire to cancel the appointment at least 24 hours in advance of the scheduled appointment time. You may leave a message with the answering service of the need to cancel.
“24 hours in advance of the scheduled appointment time” means the time and date of the business day prior to the scheduled appointment time and date. For example, if your appointment is set for 4:00 PM on Thursday, your cancellation must be communicated to the Practice by 4:00 PM on the preceding Wednesday in order to avoid being charged for the appointment. (This example assumes that Wednesday is a day the Practice is open for appointments. It the office were close on that Wednesday, then the cancellation must be communicated to the Practice by 4:00 PM on the last business day prior to the appointment day in order to avoid charges.)
PROCEDURE AND FEES:
A. If you attend a scheduled appointment, you will be charged a fee or co-payment based on the specifics of your mental health insurance.
B. If you cancel or reschedule more than 24 hours in advance, you will not be charged a fee for that appointment time, as we will be able to offer that time to another Client.
C. If you cancel or reschedule an appointment less than 24 hours in advance, you will be charged the full fee for that time. Payment of this fee will be due immediately for late cancellations. (Please note: Insurance plans will NOT cover any portion of this fee.)
D. If you miss an appointment without any notice, you will be charged an $85.00 fee or the negotiated rate of the Practice and all previously scheduled appointments with the Clinician will be cancelled. Only after you have made arrangements with the Business Manager to pay for the missed appointment, will you be allowed to schedule a subsequent appointment. (Please note: Insurance plans will NOT cover any portion of this fee.)
I authorize the release of any medical or other information to process insurance claims. I authorize the payment of medical benefits to Serenity Counseling and Mediation Center.
If the cost of my treatment exceeds by benefits from my insurance company, to the full extent contractually allowed, I understand and agree that I am responsible for the full and timely payment.
I agree to cancel appointments no less than twenty-four hours prior to the appointment time. If I do not give twenty-four hours notice, I understand that I will be charged the counselors’ regular fee for that clinical hour.
Illness and other situations beyond my control will be given due consideration on a case-by-case basis. A letter address to the business manager can be submitted if I would like to have the situation assessed.
Missed appointments or appointments canceled with less than twenty-four hours notice are not covered by most insurance plans. If this is the case, I understand I will be personally responsible for payment.
*If preferred, we can also make a copy in the office.
Upload all at once.