Thank you for choosing Jordan West Family Counseling (JWFC). We are committed to providing you with high-quality, respectful care.

• High-Quality Care - Receive respectful, dignified, and safe services.
• Privacy and Safety - Receive services in a private and protective environment.
• Independence - Receive care that respects your freedom and is least intrusive.
• Informed Consent - Consent voluntarily to services (except as legally permitted).
• Participation - Be involved in your service planning and include others of your choice.
• Refusal - Refuse services or procedures without punitive consequences.
• Notice of Termination - Not be involuntarily terminated without prior notice or information on alternative services.
• Communication - Communicate privately with rights protection programs.
• Declaration of Treatment - Execute a mental health treatment declaration.
• Fee Transparency - Be informed in writing of any fees.
• Non-Discrimination - Receive services free of discrimination.
• Grievance Process - File a grievance if your rights are violated.

• Treat staff and others with courtesy and respect.
• Notify us 24 hours in advance if you cannot attend an appointment.

If you have concerns about your care or feel your rights have been violated, you may submit a grievance. Step 1: Submit the grievance in writing to your therapist. They will respond within 10 days. Step 2: If unsatisfied, submit a written request for review by the Clinical Director within 30 days of the incident. The Clinical Director will respond within 10 days.

For grievance assistance, contact the Clinical Director at 801-566-0749.

• You can also contact the Utah Office of Licensing (OL) by:
• Calling: 801-538-4242- Emailing: dlbc@utah.gov
• Submitting an online form through their website.

Updated 02/5/2025-JWFC

Your insurance will be billed standard rates based upon the CPT (current procedural terminology) code. You will be responsible for co-pays, co-insurance, late cancelation, missed appointment fees or deductibles as directed by your insurance company at the time of service.

An appointment is a reservation for time with a counselor. Out of courtesy and respect for your counselor please contact Jordan West Family Counseling if you need to cancel an appointment. If an appointment is missed, without notifying Jordan West Family Counseling, a fee of $50.00 will be assessed. If an appointment is cancelled less than 24 hours prior to the appointment a fee of $50.00 will be assessed.

Due to insurance carriers' tardiness regarding service claims submitted by providers, please read the following information:

• If your insurance company does not respond in a timely fashion a "Statement" will be released to you. Upon receipt of the "Statement" we suggest that you contact your insurance carrier and request that they process your claim.
• Should you receive any correspondence from your insurance company in regard to your services in this office, you must respond to that correspondence immediately, in order to have the claim processed and paid.
• Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. Some companies pay a fixed allowance for certain procedures, and others pay a percentage of the charge. It is your responsibility to pay any deductible amount, co-insurance, or any other balance not paid by your insurance at the time of service.
• Jordan West Family Counseling will only bill the Primary Insurance. You will need to bill your Secondary Insurance. Documentation can be provided if it is required. You will be required to pay any co-payment or co-insurance at the time of service. Secondary insurance is not a substitute for co-payments/co-insurance.

Patient's or authorized person's signature: I authorize the release of any medical, behavioral health or other information necessary to process my insurance claim.

Insured's or authorized person's signature: I authorize payment of medical, behavioral health benefits to the provider for services. I fully understand that, regardless of insurance coverage, I am legally responsible for all fees due. I further understand Jordan West Family Counseling's missed appointment and late cancellation policy

Returned checks will be assessed a $30.00 fee. Please note that unless your appointment is cancelled with a 24-hour notice, late cancellation fees will apply. Delinquent accounts are subject to referral to collection agencies. If your account is referred to a collection agency the balancewill be charged 35% collection fee. Interest will be assessed at a rate of 18% per annum will apply for balances over 60 days old. Any questions regarding financial issues may be directed to the Office Manager.

Jordan West Family Counseling 11-2021

* Note to Parents - if you are financially responsible for your child, it is your responsibility to make sure you know when your child's appointments are and it is your responsibility to pay this fee if the appointment is missed. I have discussed this policy with my client and have offered a copy to my client. The client understands and agrees to the terms contained in it.

Please complete all fields. You may cancel this authorization at any time by contacting us. This authorization will remain in effect until canceled.

I authorized Jordan West Family Counseling to initiate electronic withdrawals, in the preauthorized amounts and timing, from my card account ending in ____________, of which I am the authorized signer.

I understand a receipt will be emailed to me confirming this StoredPay activation and for each subsequent StoredPay transaction.

I understand that I can cancel StorePay at anytime at HTTPS://myproviderlink.com or by contacting Jordan Family Counseling.

Disclosure of Mental Health Information: Your mental health information and communication of that information is essential to your treatment. We prefer to speak directly with each patient but we understand that other individuals of family members may have knowledge of and be assisting in your treatment and progress. Please, list the individual(s) who we are authorized to discuss your treatment/progress with. (NOTE: We cannot discuss your treatment/progress with others, including parents, spouse, other family members, caseworkers, attorney general, Guardian Ad Litem, Judge, or court clerks unless they are listed below.)

Permissions: Children over the age of 12 will be given consent for a counselor / Jordan West Family Counseling to communicate with parent(s) regarding their progress. In cases of an "in custody" client, permission will be given to communicate with foster parent(s), caseworker(s), Guardian Ad Litem, Attorney General or Judge. In addition, clients who are court referred into treatment will give consent to communicate with probation officers, Judge(s) and court clerks in order to send updates, treatment progress, treatment summaries, and treatment termination.

Note: This restriction applies only to mental health treatment provided by Jordan West Family Counseling. Other providers involved in your treatment may require you to complete a separate request for restriction. Either you, or Jordan West Family Counseling to may terminate this restriction by completing the following.

Jordan West Family Counseling uses an automated reminder service to improve communication with clients. The service may communicate electronically through mobile phones, landline phones, and email accounts. You remain in control of your participation and may change or stop reminder messages at any time.
There is no fee charged by Jordan West Family Counseling to participate. Standard message, calling, and data rates may apply according to your phone or internet plan.

By choosing voice calls, text messages, or email reminders, you understand that these methods may involve privacy risks. Messages may be seen or heard by other people who have access to your phone, voicemail, email account, or shared devices. Jordan West Family Counseling will use reasonable care, but cannot guarantee the privacy or security of communications sent through these methods.

Reminder calls or messages are generally sent between approximately 6:00 p.m. and 8:00 p.m. on the day before your appointment. If you need to cancel or reschedule, please contact the office at least 24 hours in advance to avoid a late-cancellation or no-show fee of $50.00.
Example reminder: "John/Mary, this is an important reminder that it is time for your appointment with [therapist name]."

Clients who choose no reminders should request a written appointment card from their counselor. By initialing above, the client confirms that they understand they will not receive reminder calls, texts, or emails.

Jordan West Family Counseling | 801-566-0749 | Page 1

This section applies when the client selects text message (SMS) reminders or other office text communications.

Jordan West Family Counseling may send SMS messages for the following purposes:

• Appointment reminders and confirmations
• Scheduling and rescheduling requests
• Billing and payment-related communications
• General office communications
• Administrative updates regarding services

SMS messages are not intended for emergencies, crisis situations, urgent clinical matters, or the transmission of highly sensitive confidential information.

By signing this form and providing a mobile phone number, I expressly consent to receive SMS text messages from Jordan West Family Counseling at the number listed on this form. I understand and acknowledge the following:

• Messages will be sent by Jordan West Family Counseling.
• Message frequency varies depending on my interactions with the practice.
• Message and data rates may apply according to my wireless carrier's plan.
• Text messaging is not a fully secure method of communication and may involve privacy risks.
• SMS communications should not be used for emergencies or urgent clinical concerns.
• Consent to receive text messages is voluntary and is not a condition of receiving treatment or services.
• I may opt out of future text messages at any time by replying STOP.
• I may receive assistance by replying HELP or by calling Jordan West Family Counseling at 801-566-0749.
• If I opt out, I may not receive appointment reminders, scheduling updates, or other office communications by text.
• It is my responsibility to notify Jordan West Family Counseling if my mobile phone number changes.

I have read and understand this Communication Preferences, Appointment Reminders, and SMS Consent form. I voluntarily choose the communication method indicated above and consent to communications under the terms described in this form.

Please check the areas that apply to you now or have been important recently. Your therapist will review your answers with you.

If you are in immediate danger or cannot stay safe, call 911 or go to the nearest emergency department.

I understand that this screening helps my therapist identify areas to discuss. It is not a diagnosis and does not replace a clinical assessment.

For clinical use: Review positive safety responses promptly and document follow-up in the clinical record.

Please review each statement before signing. Telehealth may be provided by secure video or, when needed, by telephone.

1. Consent to telehealth
I authorize Jordan West Family Counseling to use telehealth for evaluation, testing, diagnosis, and treatment related to my care.

2. Technology limitations
I understand that technical difficulties may occur before or during a session and may delay, interrupt, or end the appointment.

3. Video or telephone sessions
I understand that sessions may be conducted by video. If video cannot be used because of internet speed or other technical limitations, the session may be conducted by telephone.

4. Insurance and fees
I understand that my insurance may not cover all telehealth services and that I may be responsible for charges not paid by my insurance company.

5. Records and privacy
I understand that telehealth services will be documented in my health record for evaluation, analysis, and treatment purposes, and that Jordan West Family Counseling will keep my information private as required by law.

Jordan West Family Counseling | 9263 Redwood Road, Building 8, Suite B, West Jordan, Utah 84088 | 801-566-0749

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.

This office is required to maintain the privacy of your health information and to provide you with notice of its legal duties and privacy practices. This office will not use or disclose your health information except as described in this Notice. If you consent, the office is permitted by federal privacy laws to make uses and disclosures of your health information for purposes of treatment, payment, and health care operations. Protected health information is the information we create and obtain in providing our services to you. Such information may include documenting your symptoms, medical history, examination and test results, diagnoses, treatment, and applying for future care or treatment. It also includes billing documents for those services.

Examples of uses of your health information for treatment purposes are:

• A provider or assistant obtains treatment information about you and records it in a health record.
• During the course of your treatment, the provider determines he/she will need to consult with another specialist in the area. He/she will obtain your signed authorization before sharing information with such specialists to obtain his/her input.
• Referral information may be forwarded to Diagnostic Testing Labs for further treatment or testing where the provider will want results of such treatment or testing reported bock to him/her.
• If the provider is a specialist, your health information and progress may be reported back to your primary care provider or referring provider, upon receipt of your written authorization.

Example of use of your health information for payment purposes:

• We submit requests for payment to your health insurance company. The health insurance company requests health information from us regarding medical care given. We will provide information to them about you and the care given. For example, a bill sent to your health insurance company may include information that identifies your diagnosis, and the procedures and supplies used.

Example of use of your health information for health care operations:

• We obtain services from our insurers or other business associates (an individual or entity under contract with us to perform or assist us in a function or activity that necessitates the use or disclosure of health information) such as quality assessment, quality improvement, outcome evaluation, protocol and clinical guidelines development, training programs, credentialing, medical transcription, medical review, legal services, and insurance. We will share health information about you with our insurers or other business associates as necessary to obtain these services. We require our insurers and other business associates to protect the confidentiality of your health information.

The health and billing records we maintain are the physical property of the treating provider. The information in it, however, belongs to you. You have the right to:

• Request a restriction on certain uses and disclosures of your health information by delivering the request in writing to our office. We are not required to grant the request, but we will comply with any request granted as required bylaw:
• Obtain a paper copy of the Notice of Privacy Practices for Protected Health information ("Notice") by making a request at our office.
• Request that you be allowed to inspect and copy your billing record - you may exercise this right by delivering the request in writing to our office;
• Obtain an accounting of disclosures of your health information as required to be maintained by law, upon request. An accounting will not indude internal uses of information for treatment, payment, operations, or disclosures made to you; and
• Revoke authorizations that you made previously to use or disclose information except to the extent information or action has already been taken by delivering a written revocation to our office.

You have the right to review this Notice before signing the consent authorizing use and disclosure ofyour protected health information for treatment, payment, and health care operations purposes.

Jordan West Family Counseling 11-2021

This office is required to:

• Maintain the privacy of your health information as required by law;
• Provide you with a notice as to our duties and privacy practices as to the information we collect and maintain about you;
• Abide by the terms of this Notice;
• Notify you if we cannot accommodate a requested restriction or request; and
• Accommodate your reasonable requests regarding methods to communicate health information with you.

We reserve the right to amend, change, or eliminate provisions in our privacy practices and access practices and to enact new provisions regarding the protected health information we maintain. If our information practices change, we will amend our Notice. You are entitled to receive a revised copy of the Notice by calling and requesting a copy or our "Notice" or by visiting our office and picking up a copy.

If you have questions, would like additional information, or want to report a problem regarding the handling of your information, you may contact Betty Owen at 801-566-0749. Additionally, if you believe your privacy rights have been violated, you may file a written complaint at our office by delivering the written complaint to Betty Owen. You may also file a complaint by mailing it to the Department of Health and Human Services. We cannot, and will not, require you to waive the right to file a complaint with the Department of Health and Human Services (HHS) as a condition of receiving treatment from the office. Likewise, we cannot, and will not, retaliate against you for filing a complaint with the Secretary of Health and Human Services.

Appointment Reminders and Treatment Information: We may contact you and/or leave a message on your telephone answering machine to provide you with appointment reminders, lab results, prescription information, or billing information.

Law Enforcement: We may disclose your health information for law enforcement purposes as required by law, such as when required by a court order; for identification of a victim of a crime if certain protective requirements are met; to report a crime in emergencies; and other appropriate situations as permitted by law.

Judicial/Administrative Proceedings: We may disclose your health information in the course of any judicial or administrative proceeding as allowed or required by law or as directed by a proper court order or in response to a subpoena, discovery request or other lawful process if certain specific requirements are met. To avert a serious threat to health or safely, we may disclose your health information consistent with applicable law to prevent or lessen a serious, imminent threat to the health or safety of a person or the public.

HIPAA requires that we make the Notice of Privacy Practices available to you. We ask that you sign and date this form. When you sign and date this form you are agreeing that you were given a copy of the Notice of Privacy Practices. You are not agreeing to what the notice says.