I agree to participate in a telemedicine evaluation and/or ongoing treatment performed by an independently contracted provider who assumes sole responsibility and liability for treatment. By signing this agreement, I authorize the electronic transmission of my medical information and/or videoconference session so that it can be viewed by a doctor and other persons involved in my medical or mental health care. [Note: The likelihood of this transmission being intercepted by persons other than those at the consulting site is extremely small].

I understand that I can withdraw my permission at any time and that I do not have to answer any questions that I consider to be inappropriate or am unwilling to have heard by other persons. I understand that if I do not choose to participate in a telemedicine session, no action will be taken against me that will cause a delay in my care and that I may still pursue face-to-face consultation. I understand that as with any technology, telemedicine does have its limitations.

There is no guarantee, therefore, that this telemedicine session will eliminate the need for me to see a specialist in person. I understand that medical records of telemedicine services will be kept at the office. I understand that some or all of my medical information may be used for teaching or educational purposes. I agree to have my telemedicine medical records reviewed for the purposes of evaluation (data collection, analysis, and presentation in verbal or written format at scientific meetings). I understand that any presentation will not identify me by name or other identifiable markers.

Informed Consent

Bluegrass Recovery, LLC

By signing this form, you agree to receive mental health services provided by Bluegrass Recovery, LLC, and its independent contractors. We know that starting counseling is a big decision and you may have many questions. We will do our best to answer any questions or concerns. This form explains information about Bluegrass Recovery policy, State and Federal Laws, and your rights about counseling.

All Bluegrass Recovery employees and contractors have met the highest level of education, certification, and licensing requirements set forth by Kentucky state law. Counseling practices, philosophy, and plan limitations and risks will be discussed with you today.

TREATMENT PROCESS AND DOCUMENTATION

It is the mental health professional’s responsibility to keep accurate records including Evaluations, Treatment Plans, and Progress Notes. By signing this document, you are consenting to the Treatment Plan that your provider creates and agree to any goals, objectives, and therapy techniques that may be used in your therapy process.

INSURANCE BILLING

If you plan to use insurance to pay for services, claims will be sent to the insurance company based on information used at the time of service. Sometimes, insurance information may change or may not be up to date. If for any reason, inaccurate information related to deductibles, co-pays, or the number of available sessions, etc. is retrieved at the time of service, Bluegrass Recovery will bill the client for any additional
costs associated with mental health services rendered. Additional services may not be provided until the client’s balance is current. If balances remain unpaid for 60 days, client information will be sent to a collection agency.

MISSED APPOINTMENT FEES

Appointments will be canceled and $35.00 fee will be assessed if client is 15 minutes late without notice. If client cancels appointment without a notice greater than 24 hours,
Bluegrass Recovery will charge the client $35.00.

RETURNED CHECK FEE

If your check is returned, your account will be assessed a $35.00 fee.

CREDIT CARD PAYMENTS

You may be required by Bluegrass Recovery to store your credit card information in your chart for future bills you may incur not covered by insurance. Bluegrass Recovery will automatically process all outstanding balances one time per month (typically the second week of each month) and will not provide any additional warning other than what is written in this section of the Informed Consent form.

Please be aware that if your balance is not paid in full after 3 statement cycles your account will be sent to collections with GLA. Please note that once your debt is filed with GLA you will then be liable for an additional charge of 30% of your total
balance. We will not permit you to be seen until you have satisfied your outstanding balance in full with GLA.

CONFIDENTIALITY AND EMERGENCY SITUATIONS

Confidential information discussed in session is not discussed with anyone without your written permission except for:

1. Diagnosis and dates of service shared with your insurance company to process your claims

2. Information you tell Bluegrass Recovery about physical, sexual or elder abuse; then, by Kentucky State Law, I have to report this to the Kentucky Department of Children and Family Services

3. Where you sign a release of information to have specific information shared

4. If you tell Bluegrass Recovery you are in danger of harming yourself or others

5. Information shared with therapist’s clinical supervisor if applicable

6. When required by law.

If you need to contact us between counseling sessions we're available at bluegrassrecovery.com via live chat. Text messages and social networking sites are not confidential and we may not be able to respond. In the event of an emergency please call 911.

Bluegrass Recovery requires all clients to maintain an active credit/debit card on file at all times. We will ask for this information over the phone at the time of scheduling, and your information will be kept confidential and secure within our electronic medical record system.

By signing below, you authorize Bluegrass Recovery, LLC to store and charge your credit/debit account for all balances due for services rendered, including late/cancellation fees, and patient responsibilities not covered by insurance that you may incur during treatment. We will process all credit cards 1 time per month without further notice if there is an outstanding balance on your account. This typically takes place during the second week of each month.

This authorization will remain in effect until you cancel this authorization in writing or verbally, and you may do so at any time. If you request to cancel this authorization, you are providing Bluegrass Recovery permission to use the card on file at the time of your request to pay all outstanding balances before the card is removed. If your payment is declined at the time your card is processed, your services may be subject to termination. My signature indicates that I have read and accept these disclosures.