Primary Insurance Holder
(This information is for the person who holds the policy)
Name: First Name Last Name Relationship to client: Date of Birth: Date Address : Street Address Address Line 2 City State Zip Phone: Area Code Phone Number Insurance Company Name: Insurance ID Number: Group Number: *
I elect to use Self Payment option and am responsible for all associated fees with my services. The self pay rate is $145.00.
Card on file (Required- Can be HSA/ FSA Card, Debt or Credit Card)
Card Number: Number* Expiration Date: Date* CVC: Number Card Type: Please SelectDebit CardCredit CardHSAFSAOther* Billing Zip Code: Number*
I am responsible for all fees associated with my services. The self pay (and intial session) rate is $145. Please compelte the section below as we require an active card on file for all clients.
Date of Birth: Date* Client Name: First Name* Last Name* I, First Name* Last Name* the undersigned, hereby attest that I have Voluntarily entered into treatment, or give my consent for the minor or person under my legal guardianship mentioned above, with Heart 2 Heart Wellness Center hereby referred to as the Center. Further, I consent to have treatment provided by a psychiatrist, psychologist, social worker, counselor, or intern in collaboration with his/her supervisor. The rights, risks, and benefits associated with the treatment have been explained to me. I understand that the therapy may be discontinued at any time by either party. The clinic encourages that this decision be discussed with the treating psychotherapist. This will help facilitate a more appropriate plan for discharge.Recipient’s Rights: I certify that I have received the Recipient’s Rights pamphlet and certify that I have read and understand its content. I understand that as a recipient of services, I may get more information from the Recipient’s Rights Advisor.Nonvoluntarily Discharge from Treatment: A client may be terminated from the Center nonvoluntarily if: (A) the client exhibits physical violence, verbal abuse, carries weapons, or engages in illegal acts at the clinic, and/or (B) the client refuses to comply with stipulated program rules, refuses to comply with treatment recommendations, or does not make payment or payment arrangements in a timely manner. The client will be notified of the nonvoluntary discharge by letter. The client may appeal this decision with the Clinic Director or request to reapply for services at a later date.Client Notice of Confidentiality: The confidentiality of patient records maintained by the Center is protected by federal and/or state law and regulations. Generally, the Center may not say to a person outside the Center that a patient attends the program or disclose any information identifying a patient as a client unless: (1) the patient consents in writing, (2) the disclosure is allowed by a court order, or (3) the disclosure is made to medical personnel in a medical emergency, or to qualified personnel for research, audit, or program evaluation. Violation of federal and/or state law and regulations by a treatment facility or provider is a crime. Suspected violations may be reported to appropriate authorities. Federal and/or state law and regulations do not protect any information about a crime committed by a patient either at the Center, against any person who works for the program, or about any threat to commit such a crime. Federal law and regulations do not protect any information about suspected child (or vulnerable adult) abuse or neglect, or adult abuse from being reported under federal and/or state law to appropriate state or local authorities. Health care professionals are required to report admitted prenatal exposure to controlled substances that are potentially harmful. It is the Center’s duty to warn any potential victim when a significant threat of harm has been made. In the event of a client’s death, the spouse or parents of a deceased client have a right to access their child’s or spouse’s records. Professional misconduct by a health care professional must be reported by other health care professionals, in which related client records may be released to substantiate disciplinary concerns. Parents or legal guardians of nonemancipated minor clients have the right to access the client’s records. When fees are not paid in a timely manner, a collection agency will be given appropriate billing and financial information about the client, not clinical information. My signature below indicates that I have been given a copy of my rights regarding confidentiality. I permit a copy of this authorization to be used in place of the original. Client data of clinical outcomes may be used for program evaluation purposes, but individual results will not be disclosed to outside sources.I consent to treatment and agree to abide by the above-stated policies and agreements with Heart 2 Heart Wellness, LLC.
As a recipient of services at our facility, we would like to inform you of your rights as a patient. The information
contained in this brochure explains your rights and the process of complaining if you believe your rights have been
YOUR RIGHTS AS A PATIENT
1. Complaints. We will investigate your complaints.
2. Suggestions. You are invited to suggest changes in any aspect of the services we provide.
3. Civil rights. Your civil rights are protected by federal and state laws.
4. Cultural/spiritual/gender issues. You may request services from someone with training or experiences from a
specific cultural, spiritual, or gender orientation. If these services are not available, we will help you in the referral
5. Treatment. You have the right to take part in formulating your treatment plan.
6. Denial of services. You may refuse services offered to you and be informed of any potential consequences.
7. Record restrictions. You may request restrictions on the use of your protected health information; however, we
are not required to agree with the request.
8. Availability of records. You have the right to obtain a copy and/or inspect your protected health information;
however, we may deny access to certain records. If so, we will discuss this decision with you.
9. Amendment of records. You have the right to request an amendment in your records; however, this request could
be denied. If denied, your request will be kept in the records.
10. Medical/legal advice. You may discuss your treatment with your doctor or attorney.
11. Disclosures. You have the right to receive an accounting of disclosures of your protected health information that
you have not authorized.
YOUR RIGHTS TO RECEIVE INFORMATION
1. Medications used in your treatment. We will refer you to provider.
2. Costs of services. We will inform you of how much you will pay.
3. Termination of services. You will be informed as to what behaviors or violations could lead to termination of
services at our clinic.
4. Confidentiality. You will be informed of the limits of confidentiality and how your protected health information will
5. Policy changes. You will be informed.
OUR ETHICAL OBLIGATIONS
1. We dedicate ourselves to serving the best interest of each client.
2. We will not discriminate between clients or professionals based on age, race, creed, disabilities, handicaps,
preferences, or other personal concerns.
3. We maintain an objective and professional relationship with each client.
4. We respect the rights and views of other mental health professionals.
5. We will appropriately end services or refer clients to other programs when appropriate.
6. We will evaluate our personal limitations, strengths, biases, and effectiveness on an ongoing basis for the
purpose of self-improvement. We will continually attain further education and training.
7. We respect various institutional and managerial policies but will help to improve such policies if the best interest
of the client is served.
1. You are responsible for your financial obligations to the clinic as outlined in the Payment Contract for Services.
2. You are responsible for following the policies of the clinic.
3. You are responsible to treat staff and fellow patients in a respectful, cordial manner in which their rights are not
4. You are responsible to provide accurate information about yourself.
WHAT TO DO IF YOU BELIEVE YOUR RIGHTS HAVE BEEN VIOLATED
If you believe that your patient rights have been violated, contact the Indiana Board of Social Work.
I authorize Heart 2 Heart to send and receive my entire record, except psychotherapy notes, that will be used for planning appropriate treatment and coordination of care. This release will only be used in the event that best treatment method would involve collaboration between providers. I understand that this information may be protected by Title 42 (Code of Federal Rules of Privacy ofIndividually Identifiable Health Information, Parts 160 and 164) and Title 45 (Federal Rules ofConfidentiality of Alcohol and Drug Abuse Patient Records, Chapter 1, Part 2), plus applicable state laws. Ifurther understand that the information disclosed to the recipient may not be protected under theseguidelines if they are not a health care provider covered by state or federal rules.I understand that this authorization is voluntary, and I may revoke this consent at any time by providingwritten notice, and after (some states very, usually 1 year) this consent automatically expires. I have beeninformed what information will be given, its purpose, and who will receive the information. I understandthat I have a right to receive a copy of this authorization. I understand that I have a right to refuse to signthis authorization.
I , First Name* Last Name* the Client or legal representative, acknowledge that I have read and understand the Release of Information Policy at Heart 2 Heart. By typing my FULL NAME below, I agree to release my client file with the Authorized Recipient identified.
Thank you for completing this intake and we look forward to meeting with you!