LFS Adult Consent
  • LFS Adult Consent Form

  • LFS Counseling Client Intake Summary Sheet
    The Client Orientation Packet is available at www.lfscounseling.com/contact where you can access information regarding Client’s Rights, Consent for Treatment, Criteria for Discharge, Fire and Safety Plan, Grievance Procedures, and more. LFS will provide you with printed materials upon request. You may also request this packet from the office at any time by contacting LFS Counseling at: 
    LFS Counseling
    333 W. Main Street, Suite 140
    Ardmore, OK 73401
    (580) 224-2929
    info@lfscounseling.com

    I acknowledge that the therapist has satisfactorily supplied me with information on how to locate the Client Orientation Packet and am aware of the information contained within the packet.

  • Transportation Liability Waiver
    I hereby authorize LFS Counseling (Lynch Family Services LLC) and it's Providers to provide transport ONLY in the event of an emergency. I hereby authorize my LFS therapist to seek emergency care at the nearest hospital and make decision on my behalf. My signature releases LFS personnel/therapist, as well as, LFS Counseling of any negligence or liability that may arise from the decision. The waiver has been explained to me and I hereby sign it without reservation or duress.

     

  • TELEMEDICINE PATIENT CONSENT

    I, hereby give my consent to LFS Counseling Therapist/Provider, to complete Intake, as well as provide any subsequent treatment via telemedicine and/or videoconference session based on the Intake results for Behavioral/Mental Health. This agreement authorizes the electronic transmission of my medical/personal information and/or video-conference session so that it can be viewed by my counselor and /or other persons involved in my 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 telemedicine is the use of electronic information and communication technologies by a health care provider to deliver services to an individual when he/she is located at a different site than the provider; and hereby consent to LFS Counseling providing health care services to me via telemedicine. 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 be seen in person. I understand that medical records of telemedicine services will be kept at LFS Counseling’s Administration Site. I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine and that information will not be released without signed consent. Furthermore, I understand that all audio and video telecommunications are compliant with the Health Insurance Portability and Accountability Act (HIPAA) and all laws and policies that protect privacy and the confidentiality of medical information. I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment. I understand 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 may revoke my consent orally or in writing at any time by contacting LFS Counseling or my counselor directly. As long as this consent is in force (has not been revoked) LFS Counseling may provide health care services to me via telemedicine without the need for me to sign another consent form.

     

  • Notice of Privacy Practices and Consumer Rights
    At LFS Counseling, our policy is that your information is only used for purposes directly related to your care. Your information will never be used or shared without your written consent. All records and transactions are confidential and privileged and are handled in accordance with the provisions of Public Law 93-579, the “Privacy Act of 1974”, and as appropriate Federal Guidelines governing Alcohol Abuse information 42 CFR Part II and HIPAA. You have the right to request a copy of your own records. LFS Counseling requires a written request for this and reserves the right to charge copying/shipping fees. No more than 15 cents will be charged for each page and no more than $5.00 will be charged for shipping. (See HIPAA Compliance Rule for more information) In most cases, your copies must be given to you within 30 days. You have the right to change any wrong information in your file or add information to your file if you think something is missing or incomplete. You have the right to find out who has seen your information. You have the right to ask that your information not be shared with certain people, groups, or companies. You can ask for other kinds of restrictions, but if those restrictions could affect your care, then we reserve the right to not agree to those restrictions. You have the right to make reasonable requests to be contacted at different places or in a different way, whether by mail, phone, etc. If you think your rights are being denied or your information is not being protected, you have the right to file a complaint with LFS Counseling, your health insurer, or the U.S. Department of Health and Human Services (See contact info below). Office for Civil Rights Headquarters U.S. Department of Health & Human Services 200 Independence Avenue, S.W. Washington, D.C. 20201 Toll Free Call Center: 1-800-368-1019 TTD Number: 1-800-537-7697
    I have received notification of LFS Counseling’s Privacy Practices and understand my rights regarding my protected health information.

    Oklahoma Department of Mental Health and Substance Abuse Services
    CONSUMER RIGHTS
    Each consumer has the right to be treated with respect and dignity.
    Furthermore: Each consumer shall retain all rights, benefits, and privileges guaranteed by law except those lost through due process of law. Each consumer has the right to receive services suited to his or her condition in a safe, sanitary and humane treatment environment regardless of race, religion, gender, ethnicity, age, degree of disability, handicapping condition or sexual orientation. No consumer shall be neglected or sexually, physically, verbally, or otherwise abused. Each consumer shall be provided with prompt, competent, and appropriate treatment; and an individualized treatment plan. A consumer shall participate in his or her treatment programs and may consent or refuse to consent to the proposed treatment. The right to consent or refuse to consent may be abridged for those consumers adjudged incompetent by a court of competent jurisdiction and in emergency situations as defined by law. Additionally, each consumer shall have the right to the following: Allow other individuals of the consumer's choice participate in the consumer's treatment and with the consumer's consent; To be free from unnecessary, inappropriate, or excessive treatment; To participate in consumer's own treatment planning; To receive treatment for co-occurring disorders if present; To not be subject to unnecessary, inappropriate, or unsafe termination from treatment; and To not be discharged for displaying symptoms of the consumer's disorder. Every consumer's record shall be treated in a confidential manner. No consumer shall be required to participate in any research project or medical experiment without his or her informed consent as defined by law. Refusal to participate shall not affect the services available to the consumer. A consumer shall have the right to assert grievances with respect to an alleged infringement on his or her rights. Each consumer has the right to request the opinion of an outside medical or psychiatric consultant at his or her own expense or a right to an internal consultation
    upon request at no expense. No consumer shall be retaliated against or subjected to any adverse change of conditions or treatment because the consumer asserted his or her rights.
    CONSUMER ADVOCACY DIVISION
    To advocate for a consumer is to defend their rights and to promote their interest. The Consumer Advocacy division accomplishes this in many different ways. The Consumer Advocacy monitors facilities to ensure they comply with applicable treatment standards, as well as state and federal laws and guidelines. Regular monitoring enhances the quality of life for consumers by promoting effective communication between staff members, consumers and families and in identifying potential problem areas. Educating consumers of their rights is a critical function of Advocacy. Equally important is increasing staff knowledge of consumer rights. One way this is accomplished is by participating in new employee orientation. The Advocacy division works cooperatively with representatives of the Oklahoma Disability Law Center, the Oklahoma Consumer Council and the Oklahoma National Alliance for the Mentally Ill. We are also a resource for consumers in finding and accessing services. Providing information to consumers and families, monitoring treatment facilities, training staff and working with rights organizations are some ways the Consumer Advocacy Division protects and promotes Consumer Rights.
    How to Contact the Advocacy Division ODMHSAS: Office of Consumer Advocacy, E-Mail: AdvocacyDivision@odmhsas. org Local: (405) 521-4256 Toll Free: (866) 699-6605 Reachout Hotline (800) 522-9054

     

  • Court Appearance Statement and Fee Structure
    Lynch Family Services, LLC dba LFS Counseling and personnel reserve the right to charge a fee for any requests for court involvement, including but not limited to; the submission of records, appearing in court, and providing testimony. Note: Any payment received from the party or individual responsible for requesting court involvement and/or issuing a subpoena will not influence the information or testimony provided. Personnel are only to testify to the facts of the case.

    Below is the fee structure of possible charges pursuant to requests for court involvement by LFS Counseling and personnel: 
    Preparation and submission of records to be paid to the office administrator: $40.00/hr
    Phone calls: $100.00/hr
    Depositions: $250.00/hr
    Time Required in giving testimony: $250.00/hr
    Mileage: $0.40/mile
    All attorney fees and costs incurred by LFS Counseling and/or personnel as a result of the legal action.
    Filing a document with the court: $100.00
    The fee for a court appearance: up to $1,500.00
    A retainer of up to $1500 is due in advance. If a subpoena or notice to meet attorney(s) is received without a minimum of 48 hours notice, there  will be an additional $250 "express" charge. 
    Also, if the case is reset with less that 72 hours notice, then the client will charged $500.00. 

    I acknowledge that I have been informed of the possible fees associated with requesting court involvement and that I am responsible for submitting payment for possible charges. I acknowledge that personnel are only able to testify to the facts of the case and that any information provided or testimony given may not be in my favor.

  • Please Contact our Office to receive a Treatment Advocate From

    580-224-2929 or info@lfscounseling.com

  • What is a Treatment Advocate?

    A "Treatment Advocate" is a family member or other concerned individual designated by a consumer to participate in treatment and discharge planning, and acts in the best interest of and serves as an advocate for the consumer. As an adult client of LFS Counseling, you have the right to designate a family member or other concerned individual as a Treatment Advocate. Your Treatment Advocate should act in your best interest at all times. You may change or revoke the designation of a Treatment Advocate at any time and for any reason. Your Treatment Advocate may participate in your treatment planning and discharge planning to the extent that you consent to and as permitted by law. 450:-27-5-44

  • LFS Counseling Financial Agreement for Counseling Services

  • Soonercare/Medicaid: If you are a Soonercare/Medicaid patient, your eligibility status will be verified monthly. As a courtesy to you, your account will be billed directly to Medicaid. 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.

    Self-Pay or Insurance Co-Payments: All Self-pay or co-payment amounts are due at the time of service. LFS Counseling accepts cash or credit/debit cards only.

    Non-payment on Account: Non-payment will result in the cancellation services until payment can be made in full.

    Additional Charges: LFS Counseling does not impose any additional charges. Charges are only for services rendered face-to-face or services agreed to prior to their completion such as treatment plans.

    Acknowledgement
    By signing below, each of the undersigned acknowledges that: (i) I have read, understand, and agree to the provisions and agree to the specified terms; (ii) I agree to pay all charges due (or to become due) to LFS Counseling, including self pay charges, co- payments and deductibles, as required or provided pursuant to my insurance plan and/or the insurance plan of another, as applicable; (ii) benefits, if any, paid by a third-party will be credited on my account; and (iv) if I failed to make any of the payment for which I am responsible in a timely manner, I will be responsible for making payment before the continuation of services.

     

  •  
    Consent to Treatment
    I, hereby give consent to LFS Counseling (Lynch Family Services LLC) and it's Providers, to complete Intake, as well as provide any subsequent treatment based on the Intake results for Behavioral/Mental Health Therapy. I have read and understand my rights as a client. I understand that all records are treated in a confidential manner and that my information will not be released without my signed permission. ONCE I HAVE SIGNED THIS AGREEMENT, I AGREE TO ALL OF THE TERMS AND CONDITIONS CONTAINED HEREIN AND THE AGREEMENT SHALL
    BE IN FULL FORCE AND EFFECT.

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