Financial Policy & Agreement

We are committed to providing you with the best possible care and would be happy to discuss our financial fees with you at any time. Copayments or Full payment if deductible applies, are due at the time of service. We do not accept checks.

Insurance: If you have insurance, we will help you receive maximum benefits. You are responsible for providing all insurance coverage information and establishing the primary and secondary coverage between you and your insurance carrier. All co-pays must be paid at the time of service. If your insurance requires a deductible before they will pay, you will be responsible for your deductible until it is paid. Once we file your insurance, if payment is not received within 60-days, you will need to submit the payment for the balance due or make payment arrangements with our office.

Financial Responsibility: By signing below, you acknowledge and agree to be financially responsible for any charges not covered by your insurance. This includes, but is not limited to, deductibles, co-payments, and services deemed non-covered or out-of-network. You understand that you are personally responsible for payment of all fees incurred for the services provided.

Minor Children: The parent(s) or guardian who brings a child to therapy or psychiatrist appointments are responsible for the account. It is our policy to consider an 18-year-old who is still in high school a “minor”. Insurance billing for the minor is the same as the above section on insurance. As a client, the following fees apply for services received.

ORIENTATION CHECKLIST

The following information has been provided as part of the consumer orientation. A check of the item and the signatures below indicate that each area has been fully explained and is understood by the consumer. 

• Client Rights and grievance and the appeals procedures
• Privacy Rights are as follows: this information has been disclosed to you from records protected by federal confidentiality rules (42 CFR part 2). The federal rules prohibit you from making any further disclosure of information in this record that identifies a patient as having or having had a substance use disorder either directly, by reference to publicly available information, or through verification of such identification by another person unless further disclosure is expressly permitted by the written consent of the individual whose information is being disclosed or as otherwise permitted by 42 CF part 2. A general authorization for the release of medical or other information is not sufficient for this purpose (see 42 CFR 2.31). The federal rules restrict any use of the information to investigate or prosecute with regard to a crime any patient with a substance use disorder, except as provided at 42 CFR 2. 12(c)(5) and 42 CFR 2.65."; or, (b) "42 CFR part 2 prohibits unauthorized disclosure of these records. Access to emergency services, after hours
• Services provided, days and hours of operation, expected level of participation
• Code of ethics/conduct
• Confidentiality policy, limits of confidentiality
• Methods, opportunities, and policy on input
• Explanation of financial obligations, fees, and financial arrangements
• Fire, safety, and emergency precautions
• Policy on restraint
• Policy on tobacco products
• Policy on illicit or licit drugs being brought into the program or onto the premises
• Policy on weapons brought into the program or onto the premises
• Identification of the person responsible for service coordination
• Program rules, including restrictions and the loss and regaining of rights
• Requirement to report
• Individual plan development
• Discharge/transition criteria and procedures
• QA/QC questionnaire and reporting concerns
• Appointment Expectations for Doctor Day, Assessments, and Case Manager

Consent for Electronic Signature

This is to certify my request for an electronic signature. Using an electronic signature, I agree that the information I provide is accurate and complete to the best of my knowledge. I agree that the electronic signatures appearing on this agreement (and other documents that require electronic signatures provided by Transformations Health Services, LLC are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility. Please note that you may withdraw your consent to sign documents electronically at any time. To withdraw consent, I must notify Transformations Health Services, LLC that I wish to withdraw consent and request that my future documents be prepared in paper format.

Consent for Treatment

I agree and consent to participate in behavioral health care services offered and provided at/by Transformations Health Services, LLC, a behavioral healthcare provider. I understand that I am consenting and agreeing only to those services that the above-named provider is qualified to provide within:

(a) Scope of the provider’s license, certification, and training; or

(b) Scope of license, certification, and training of the behavioral healthcare providers directly supervising the services received by the patient. If the patient is under age 18 or unable to consent to treatment, I attest that I have legal custody of this individual and am authorized to initiate and consent for treatment and/or legally authorized to initiate and consent to treatment on behalf of this individual.

Financial Release

I understand that Therapist may use confidential information about me to bill and be paid for services. I hereby consent for Therapist to release information to our Electronic Health Record Company, Integrity Support Inc., and its contracted clearinghouse, and/or to the funding source, and for the funding source to release information to Therapist and Integrity Support, Inc. for this purpose.

Permission to Seek Emergency Medical Care

I hereby give consent for Therapist, to seek and sign consent for emergency medical care if I am unable to do so for myself. It is understood that Therapist will attempt to locate me, or another legally responsible adult, as quickly as is possible in an emergency.

Telehealth Consent

I agree to participate in Telehealth services offered through Transformations Health Services, LLC. including outpatient therapy and medication management. I understand that I have the option to schedule appointments with Transformations Health Services, LLC, Psychiatrist, Medical Psychologist, Psychiatric Nurse Practitioner, or Outpatient Therapist in another Transformations Health Services, LLC office that supports an on-site practitioner. However, such a face-to-face appointment may require a wait time from one to 4 weeks and commuting from out of town will be at my own expense. By signing below, I acknowledge that:

Eligibility:

Service recipients must meet traditional eligibility services for requirements as determined by prevailing state, MCO or third-party insurance practice guidelines. In addition, the person served must be willing, able, and have the equipment and internet connection to use telehealth services.

Equipment:

Prior to the delivery of services and throughout services the agency will determine if the person-served and the assigned staff have the necessary equipment and internet access to use telehealth at their respective locations.

Privacy:

Prior to the start of each session all staff in the session will identify themselves to the person served. A company ID should be displayed to verify the staff identity. 

Prior to the start of each session all persons served and any other persons in attendance in the session will identify themselves to the staff.  Staff may verify the person served’ s identity by comparing to a photograph on record or asking to see a personal ID. The person served may vouch for others.

The staff will ask the person served to pan the camera around the persons served’ s location. If others are present the staff will ask the person served if any others in attendance are permitted to be in the session. If not, the session will be rescheduled.

People served will be advised to use headset/ear buds.  The staff must be in a private space to ensure conversations are private.

Emergency Procedures:

If applicable, the staff providing telehealth will become familiar with the emergency procedures of the remote site, if the procedures exist. For example: the fire evacuation procedure of an assisting living facility. Staff providing telehealth services will have access to the persons served’ s emergency contacts and crisis/safety plan when providing telehealth services.

If the telehealth service is not provided at a street address the staff will obtain a descriptor of the person served’ s location in case of emergency. For example, at the ABC Park in Anytown, KY at the bench by the main entrance. Staff providing telehealth services will have access to the persons served’ s local emergency resources, including phone numbers.

No-Show and Missed Appointment Policy

In compliance with our commitment to effective scheduling and optimal care provision, we uphold a policy regarding missed appointments. Any missed appointments or failure to provide at least a 24-hour notice of cancellation will be regarded as a 'no-show.' After two consecutive no-shows or three cumulative occurrences, patients will be charged a fee or face potential discharge from our services. We understand emergencies happen; therefore, exceptions can be made on a case-by-case basis. Nevertheless, consistent and timely attendance is crucial to ensure the best care for all our patients.

Communication

I understand that one of my rights is to be able to choose how I am contacted. I give permission for Transformations Health Services, LLC to contact me at the phone numbers that I provide them. 

Consent to Photograph

I give permission for Transformations Health Services, LLC to use my photo/video or likeliness in their Social Media Outlets, as it pertains to events held by Transformations Health Services, LLC.

Consent to Record Sessions

I hereby give consent to Transformations Health Services, LLC to record (audio/video) our counseling sessions, as needed. I acknowledge and understand that these recordings will be used solely for the professional development of employees of Transformations Health Services, LLC. I understand that the organization may/may not receive feedback from the professional community as well, when needed. I understand that myself or my family may or may not be the focus of any discussion during a month of recording. I understand that these recordings are anonymous and will only be heard by licensed counselors or unlicensed providers that have signed HIPAA agreements. All recordings will be promptly erased when no longer needed. I understand that refusal to sign this form will not affect my eligibility for receiving services nor affect the therapeutic relationship between myself and Transformations Health Services, LLC.

Consent to Visit School, When Needed

I understand that there may be times when staff members of Transformations Health Services, LLC, may need to visit my child’s school, to visit his/her teacher or school administration; observe the child’s classroom behavior; or to intervene in the event of a crisis. By signing this document below. I acknowledge and/or grant the agency staff permissions to enter the school on my behalf.