I understand that the services I and/or my dependent will receive at LifeCycle Family Counseling (LCFC) are based on currently accepted practice in the fields of mental health diagnosis and treatment. I also understand that the outcome of treatment cannot be guaranteed and that services continue with my voluntary consent. I understand that I can withdraw my consent and discontinue treatment at any time.
I recognize that in order for services to be provided to me or my dependent, I may be asked to consult with a psychiatrist, when this is considered necessary by the clinical staff.
Confidentiality and Records Release
I understand that my records or the records of my dependent(s) are confidential under the law and may be released only as allowed under existing applicable statutes.
I understand that LCFC may release client information without client consent
under the following conditions:
- If the client threatens to harm him/herself or others
- If the staff suspect child, elder abuse or neglect
- To medical personnel to handle a medical emergency
- To management and financial auditors
- Under a court order or subpoena
Fees, Billing, Insurance and Self-Pay
I understand that by signing this agreement, if I am using my insurance for services. I also give LCFC permission to bill my insurance company for services rendered to me or my dependent(s) and to release any information, such as diagnosis, treatment plans, and Protected Health Information, as necessary to obtain payment for services. I agree to disclose all relevant and current insurance information both completely and accurately, including any changes to my insurance coverage and any updates. It is my responsibility to understand my insurance benefits, including limitations and/or exclusions, co-pays, and year maximum, as well as obtaining an authorization if necessary.
I understand that it is the policy of LCFC to charge me for any appointment in which I fail to attend or fail to call and cancel less than 24 hours prior to my appointment time. Insurance companies will not pay for any missed appointment.
I understand that out of office expenses that are not covered by my insurance company are my responsibility to pay. These billable tasks include: School visits, letter preparation, court visits, copying records, telephone consultations over 5 minutes, etc. A fee schedule for these expenses can be obtained from my therapist.
I understand that fees for services including co-pays are to be paid at the time of the appointment unless other arrangements have been made. It is not LCFC policy to send out statements for unpaid copays. If my insurance company does not cover any fees or any portion of fees for the services my dependent(s) or I have received through LCFC, I accept responsibility for these costs. If maximum insurance benefits have been reached, I will be fully responsible for any fees for services subsequently rendered to my dependent(s) or myself. I understand that it is my responsibility to understand and be responsible for my insurance benefits, including limitations and/or exclusions, co-pay’s, and yearly maximums, as well as to obtain authorization if necessary.
I understand that unpaid balances over $200 and/or over 90 days old will automatically be transferred to the LCFC collection agency unless formal payment arrangements have been made. I understand that my defaulting on the payment arrangement will lead to my account going immediately back into a collection status.
I understand that LCFC shall not be obligated to send any report concerning me or my dependent(s) to anyone, unless the balance on my account is paid in full.
Contact by LCFC
I understand that it may be necessary for LCFC to contact me by mail or telephone during or after my or my dependent’s treatment for the purpose of confirming or scheduling appointments, billing and payment issues, completion of forms, conducting surveys, and any necessary follow-up. I understand that I have the right to request contact and/or confidential information by alternative means, at a different location.
My signature below acknowledges that I am voluntarily authorizing diagnostic and treatment services at LCFC for myself and/or my dependent(s). I recognize that I may refuse any aspect of treatment. I also accept that such a refusal may, in some instances, result in termination of services by LCFC.
My signature below acknowledges that I have read this Consent to Treatment, that I agree to abide by the policies and procedures of LCFC.