As a Behavioral Health Program, we offer group activities on-site, as well as opportunities for education including but not limited to: chronic health monitoring skills, daily living skill development and etc. Off-site services include but are not limited to: home visits and appointments within the community, as necessary. By choosing “Both On-Site and Off-Site” you are not required to participate in both types but have it as an option for treatment.)

Also, I give my consent to You First Health Systems (YFHS):

• To administer First Aid or authorize treatment to me/my child in case of an emergency that requires immediate or urgent attention.
• To obtain additional assistance in the form of Police, and/or emergency mental health professionals if I/my child is acting in a violent or out of control manner and poses a danger to him/her or others and verbal interventions are unsuccessful at redirecting the behavior.

Finally, I release and hold harmless You First Health Systems and its employees, staff agents, or participants from any claim for injuries or unforeseen accidents while I/my child is participating in any organized activities. The site program in no way implies that its employees or agents are liable for any claims for injuries or unforeseen accidents.

All individuals requesting services from You First Health Systems, have a right to receive such services without regard to race, ethnicity, age, color, religion, creed, gender, national origin, sexual orientation, veteran status, financial condition, handicap, or disability, HIV infection – whether asymptomatic or symptomatic, AIDS-related complex or AIDs. No distinction will be formulated in determining eligibility for participation in services provided by YFHS based on any of these identifiers, conditions or circumstances.

All individuals requesting services from YFHS shall receive this Statement of Client Rights as part of the intake and initial orientation process, and if appropriate, on an annual basis. Said statement shall conform to all applicable regulations issued by State, Federal and other funders; and shall include, but not be limited to:

1. The right to be treated with consideration and respect for personal dignity, autonomy, and privacy.
2. The right to service in a humane setting which is the least restrictive feasible as defined in the treatment plan.
3. The right to be informed of one’s own condition, of proposed or current services, treatment or therapies, and of the alternatives.
4. The right to consent to refuse any service, treatment, or therapy upon full explanation of the expected consequences of such consent or refusal.
5. The right to a current, written, individualized service plan that addressed one’s own mental health, physical health, social and economic needs, and that specifies the provision of appropriate and adequate services, as available, either directly or by referral.
6. The right to activate and informed participation in the establishment, periodic review, and reassessment of the service plan.
7. The right to be free from intellectual, emotional and/or physical abuse.
8. The right to be free from abuse, financial or other exploitation, retaliation, humiliation, and neglect.
9. The right to access to information pertinent to the client in enough time to facilitate his/her decision making.
10. The right to informed consent, refusal or expression of choice regarding service delivery, release of information, concurrent services, and composition of service delivery team.
11. The right to access or referral to legal entities for appropriate representation, self-help support services, and advocacy services.
12. The right to freedom from unnecessary or excessive medication.
13. The right to freedom from unnecessary restraint or seclusion.
14. The right to participate in any appropriate an available agency service, regardless of refusal of one or more other services, treatments, or therapies, or regardless of relapse from earlier treatment in that or another service, unless there is a valid and specific necessity which precludes and/or requires the client’s participation in other services. This necessity shall be explained to the client and written in the client’s current service plan.
15. The right to be informed of and refuse any unusual or hazardous treatment procedures.
16. The right to be advised of and refuse observation by techniques such as one-way vision mirrors, tape recorders, televisions, movies, or photographs.
17. The right to have the opportunity to consult with independent treatment specialists or legal counsel, at one’s own expense.
18. The right to confidentiality of communications and of all personally identifying information within the limitations and requirements for disclosure of various funding and/or certifying sources, state or federal statues, unless release of information is specifically authorized by the client or parent or legal guardian of a minor client or court-appointed guardian of the person of an adult client.
19. The rights to have access to one’s own psychiatric, medical or other treatment records, unless access to particular identified items of information is specifically restricted for that individual client for clear treatment reasons in the client’s treatment plan. “Clear treatment reasons” shall be understood to mean only severe emotional damage to the client such that dangerous or self-injurious behavior is an imminent risk. The person restricting the information shall explain to the client and other persons authorized by the client the factual information about the individual client that necessitates the restriction. The restriction must be renewed at least annually to retain validity. Any person authorized by the client has unrestricted access to all information. Clients shall be informed in writing of agency policies and procedures for viewing or obtaining copies of personal records.
20. The right to be informed in advance of the reason(s) for discontinuance of service provision, and to be involved in planning for the consequences of that event.
21. The right to receive an explanation of the reasons for denial of service.
22. The right not to be discriminated against in the provision of service on the basis of religion, race, color, creed, sex, national origin, age, lifestyle, physical or mental handicap, developmental disability, or inability to pay.
23. The right to know the cost of services.
24. The right to be fully informed of all rights.
25. The right to exercise any and all rights without reprisal in any form including continued and uncompromised access to service.
26. The right to file a grievance.
27. The right to have oral and written instructions for filing a grievance
28. The right to investigation and resolution of an alleged infringement of rights.

 

Client Responsibilities:

• Actively participate in your rehabilitation and help to develop your plan of care with a You First Health Systems staff member.
• Take part in planning and participating in your own psychosocial rehabilitation program and provider information concerning your mental health and medical history.
• Attend scheduled unit meetings and to select the unit of your choice to participate in.
• Contact You First Health Systems staff if you are going to be absent from the program. Cancel your transportation, if applicable, as soon as you know you will be unable to attend the program.
• Ask question(s) when you do not understand what is happening to you.
• Let a staff know when you have a problem or feel sick.
• Show respect for the property and rights of others.
• Obey the laws which apply to all citizens.
• Be familiar with and observe the rules and policies of You First Health Systems.
• Accept responsibility for your actions.
• Cooperate with the goal of achieving self-sufficiency in the management of your everyday living.

The Health Insurance Portability and Accountability Act (HIPAA) and the Health Information Technology of Economic and Clinical Act (the HITECH Act) are regulatory standards for privacy and security. Care Connection, Inc. is committed to maintaining the privacy and integrity of privileged information and complying with all the requirements of HIPPA and the HITECH Act.

The American Recovery and Reinvestment Act of 2009 contains significant changes to the HIPAA Act of 1996. Security Breach notifications, applications to Business Associate Agreements, and improved enforcement are areas that have been incorporated into the American Recovery and Reinvestment Act of 2009.

An important part of HIPPA, known as the Privacy Rule, was developed to address the electronic transfer of private participant information. The Privacy Rule seeks to prevent dissemination of protected health information (PHI), i.e., that sort of information that a participant might have an expectation will not be shared without his or her permission. Enumerated in 45 C.F.R. § 164.514, an individual’s PHI includes information that could identify and/or reveal medical information about the person.

If you believe your privacy rights have been violated, you can file a complaint, or to receive more information about our privacy practices, please contact:

Corporate Office
4325 Forbes Boulevard, Suite E
Lanham, MD 20706
Phone Number: 301-329-0177

One has the right to file a formal, written complaint with us at the address below, or with the Department of Health & Human Services, Office of Civil Rights, in the event one feels privacy rights have been violated.

We will not retaliate against one for filing a complaint.
For more information about HIPPA or to file a complaint:
The U.S. Department of Health & Human Services
Office of Civil Rights 200 Independence Avenue, S.W.
Washington, D.C. 20201
Toll Free: 877.696.6775

Telehealth is live two-way audio and video electronic communications that allow therapists and clients to meet outside of a physical office setting. I understand that telehealth services are completely voluntary and that I can withdraw this consent at any time.

Client Understanding: 

• I understand that none of the telehealth sessions will be recorded or photographed.
• I agree not to make or allow audio or video recordings of any portion of the sessions.
• I understand that the laws that protect the privacy and the confidentiality of client information also apply to telehealth and that no information obtained in the use of telehealth that identifies me will be disclosed to other entities without my consent.
• I understand that telehealth is performed over a secure communication system that is almost impossible for anyone else to access. I understand that any internet-based communication is not 100 % guaranteed to be secure.
• I agree that the therapist and practice will not be held responsible if any outside party gains access to my personal information by bypassing the security measures of the communication system.
• I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties.
• I understand that I or my therapist may discontinue the telehealth sessions at any time if it is felt that the video technology is not adequate for the situation.
• I understand that if there is an emergency during a telehealth session, then my therapist may call emergency services and/ or my emergency contact.
• I understand that this form is signed in addition to the Notice of Privacy Practices and Consent to Treatment and that all office policies and procedures apply to telehealth services.
• I understand that if the video conferencing connection drops while I am in a session, I will have an additional phone line available to contact my therapist, or I will make additional plans with my therapist ahead of time for re-contact.
• I understand my therapist will advise me about what telehealth platform to use and she will establish a video conference session.

Thank you for choosing You First Health Systems as your healthcare provider. The services you seek imply a financial responsibility on your part. This responsibility obligates you to ensure payment in full for the services you receive. To assist in understanding that financial responsibility, we ask that you read and sign this form. Feel free to ask if you have any questions regarding your financial responsibility. If someone else (parent, spouse, domestic partner, etc is financially responsible for your expenses or carries your insurance, please share this policy with them, as it explains our practices regarding insurance billing, copayments, and patient billing. By signing below and/or by receiving services from You First Health Systems, you agree:

• Please understand that payment of your bill is considered part of your treatment. Fees are payable when services are rendered. We accept cash, check, credit cards, and pre-approved insurance for which we are a contracted provider.
• It is your responsibility to know your own insurance benefits, including whether we are a contracted provider with your insurance company, your covered benefits and any exclusions in your insurance policy, and any pre-authorization requirements of your insurance company.
• We will attempt to confirm your insurance coverage prior to your treatment. It is your responsibility to provide current and accurate insurance information, including any updates or changes in coverage. Should you fail to provide this information, you will be financially responsible.
• If we have a contract with your insurance company we will bill your insurance company first, less any copayment(s) or deductible(s), and then bill you for any amount determined to be your responsibility. This process generally takes 45-60 days from the time the claim is received by the insurance company.
• If we do not contract with your insurance company, you will be expected to pay for all services rendered at the end of your visit. We will provide you with a statement that you can submit to your insurance company for reimbursement, if applicable.
• Proof of payment and photo Darerequired for all patients. We will ask to upload a copy of your ID and insurance card for our records. Providing a copy of your insurance card does not confirm that your coverage is effective or that the services rendered will be covered by your insurance company. 
• Please understand some insurance coverages have Out-of-Network benefits that have co-insurance charges, higher co-payments, and limited annual benefits. If you receive services that are part of an Out-of-Network benefit, your portion of financial responsibility may be higher than the In-Network rate.
• By signing below, you authorize You First to verify your insurance benefits and submit your claim, on your behalf, to your insurance carrier or other plan providers. You agree to facilitate payment of claims by contacting your insurance carrier or other plan providers when necessary.
• Once your insurance carrier processes your claim, we will bill you for any remaining patient responsibility deemed by your insurance carrier. If any payment is made directly to you for services billed by us, you agree to promptly submit payment in full same to You First until your patient account is paid in full. 
• You will be mailed a billing statement that contains the total cost of your service(s) or procedure(s) received during your visit(s You may generally expect this billing statement within twenty (20) days after your insurance company has responded to a submitted claim. You must notify us of any errors or objections to the billing statement within thirty (30) days or they will be deemed accurate, and the fees and expenses shall be deemed reasonable and necessary for the services incurred. If there is a problem with your account, it is your responsibility to contact our office to address the problem or to discuss a solution.
• Medicaid. If you are a Medicaid patient, you must present a valid eligibility card at the time of registration and prior to the time of service. Your eligibility status will be verified monthly. Without verification of coverage, you will be responsible for the full/entire balance of your account. As a courtesy to you, your account will be billed to Medicaid when we receive all the necessary information. You are responsible for non-covered portions and spend-down requirements associated with your individual coverage. If at any time you are not eligible for Medicaid coverage and wish to be seen, you will be treated as a self-pay patient and must make payment at the time of service.