Complete Registration

As you get ready to fill out our New Client Paperwork, here is some helpful information to review before starting the form:

• This form will take approximately 10 minutes to complete. Once you start the form, there is no way to save your progress. This form is best compelted in one sitting.
  
  
• Before filling out this form, you will need to have your Insurance Card (if using insurance), Credit Card (to put on file), Physicians info, and medication info (if you are taking any).

I acknowledge that I am responsible for all payments to Heritage Counseling Center, Inc. (HCCI). I understand that it is my responsibility to bill my insurance company unless otherwise arraged with HCC, and that I am responsible for all co-payments, deductibles, services, and missed sessions my insurance does not cover. I further understand that payment is always due at the time of service and outstanding balances may prevent me from scheduling another appointment until paid.

Directions: Please complete the following information in order for this letter to be faxed or mailed to your primary care physician. You may choose not to send this letter by checking one of the boxes and signing the bottom of the page.

 

Heritage Counseling Center Office Use Only

Date Faxed:

Faxed By:

Dear Physician,

 

I have been advised by my counselor that it is in my best interest to advise my primary care physician of my counseling services at Heritage Counseling Center, Inc. (HCC) in Plainfield, IL. I also consent to my counselor releasing this information. Please place this letter in my file as notification that I am currently receiving counseling services. If you would like information about the initial evaluation (including information gathered in the first three sessions only), you may contact my counselor at the number above.

 

I understand that I may change the choice I have made at any time upon written notification to HCC, and will hold HCC blameless for any information previously withheld or provided to my physician before my change of consent. I also acknowledge that this consent will be in effect for 90 days following my last visit to the Center.

Printed name / Signature of HCC Councelor	Date

I have read the above letter, and choose NOT to have my counselor contact my physician at this time.

Signature of HCC Counselor

Heritage Counseling Center, Inc would like to thank you for choosing us to provide your counseling needs. The policies listed below have been approved by management with the goal of providing quality and professional service to our clients.

 

Heritage Counseling Center, Inc shall provide services regardless of race, color, creed, handicap, socioeconomic status and sexual orientation.

 

Bill Responsibility

 

All patients or gurantors receiving services are financially responsible for the timely payment of all charges incurred. While Heritage Counseling Center, Inc will file claims with the patient’s designated insurance company as a courtesy, the patient/guarantor shall ultimately be responsible for any outstanding balance not covered by insurance in accordance with the posted counseling fees presently in effect.

 

Balances post insurance payment due within the guidelines of your insurance card holder agreement unless other satisfactory arrangements have been made with Heritage Counseling Center, Inc.

 

Not all services are covered by all insurance companies. It shall be understood that by accepting and consenting to services, the patient is responsible for payment regardless of insurance coverage.

 

Point of Service Collections

 

Payment for services is due upon services rendered. Non-emergency services may be deferred until necessary payment arrangements have been established.

 

Clients unable to comply with Point-of-Service payment policy will be assisted in making necessary arrangements.

 

If patients account is not paid in full or a satisfactory arrangement made within allowable time frames, Heritage Counseling Center, Inc reserves the right to refer the account to an attorney and or a collection agency. You the responsible party agrees to be responsible and charged for all legal and/or collection related fees.

 

Payment Arrangements

 

Heritage Counseling Center, Inc will make a reasonable effort to assist patients in meeting their financial obligations. Financial arrangements or payments shall be at the office manager’s discretion based on the amount due.

 

Acceptance of Insurance

 

The clinic will accept “Estimation of Benefits” on verified insurance policies and submit a claim on patient’s behalf. It is understood that insurance is filed as a courtesy and does not relieve the patient of financial responsibility. Patients/guarantor shall be responsible for all balances due post insurance payment.

 

Rejected Claims

 

Our clinicians and office manager are here to assist you with your insurance questions. Coverage issues can only be addressed by your employer or group health administrator. Although our assistance is available, we cannot act as a mediator on your behalf.

Therapist Signature	Date

The following rights are extended to each client regardless of age receiving services at Heritage Counseling Center without reservation or limitation:

 

1. The right of confidentiality: The client has the right to privacy concerning his or her treatment. All communications, records and treatment information pertaining to his or her care will be treated as private and confidential. Treatment records may only be inspected or removed from the program office with administrative approval and written authorization of the client, or by law or court process. In the event of suspected child abuse or potential for violent or criminal activity towards another, the staff is required by law to contact the appropriate legal authorities.
   
   
2. The right to be fully informed of all client rights by receiving a written copy of the list of Client Rights, by having them posted within full view in the appropriate treatment service area, and if necessary, by some other communication form in a language the client understands. In the case of the client having a legal guardian, the guardian will receive a copy of the Client Rights.
   
   
3. The rights of a citizen of the State of Illinois and the United States of America.
   
   
4. The right to have impartial access to treatment regardless of race, religion, sex, ethnicity, age, psychological characteristics, sexual orientation and physical condition or source of financial support.
   
   
5. The right to have personal dignity recognized and respected in the provision of all care and treatment.
   
   
6. The right to religious freedom.
   
   
7. The right to receive individualized treatment including the provision of an individualized treatment plan, active participation in the development of the treatment plan by the client with periodic review of the plan by staff, and implementation and supervision of the plan by qualified professional staff.
   
   
8. The right to receive prescribed services within the least restrictive but appropriate environment.
   
   
9. The right to assurance and protection of privacy and confidentiality of communication with treatment staff, and of material written in the client's individualized record.
   
   
10. The right to be presumed mentally competent unless a court has ruled otherwise.
    
    
11. The right to a clean and humane environment in which you are protected from harm, have privacy with regard to personal needs, and are treated with respect and dignity.
    
    
12. The right to be free from mistreatment, abuse, neglect, and exploitation.
    
    
13. The right to initiate a complaint or grievance and to be informed of the appropriate grievance process.

 

I have been advised of my rights as a client at Heritage Counseling Center and of the center's policies in order to receive treatment. I understand these rights and policies and agree to abide by them. I consent to treatment, and I understand I have a right to receive a copy of the Basic Rights and Consent to Treatment upon request.

Thank you for choosing Heritage Counseling Center for your counseling needs. We are committed to giving you the best care possible. To acquaint you further with the procedures & policies of our center, we are providing the following information.

Locations of Interest: There are restrooms available down the main hallway of the building floor.

Children: Children age 12 or younger are not allowed to be left unattended at anytime.

Appointments: If you need to cancel an appointment, a minimum of 36 hours notice is required, otherwise, you are subject to a charge of $75 for the missed appointment. When the office is closed, you may leave a vQmail, which will accurately record the date and time you called. Our staff will do their best to be punctual for your appointment unless they have an emergencyR we ask that you be punctual as well. If you are late for any reason, you will receive only the remainder of your scheduled time in order to keep other patient appointments on schedule.

Emergencies: During regular office hours if you call and leave a vQmail for your therapist, he/she will call at his/her earliest availability. For emergencies requiring immediate assistance, please call your local emergency providers. To leave a message for your Heritage Counseling Center provider, call his/her regular daytime phone number.

Financial Responsibility: You are fully responsible for all services provided. Full payment, coQpayment, and/or deductible amounts are expected at the time of service. Payment may be made by cash, personal check or money order, payable to Heritage Counseling Center, Inc. or Visa, Mastercard or Discover cards. There is a $25.00 service charge for personal checks returned for any reason. If you have any questions regarding your account, you should speak directly with the billing department ext. 251 . PLEASE NOTE: Billing processes may include a monthly statement, phone call or correspondence regarding the patient due portion of the account balance. Statements, phone calls and correspondence will be addressed to the patient/guarantor address or phone number listed on the Face Sheet. If any of these business office procedures present a problem to you or your treatment, please discuss your concern with your therapist and write them here:

Insurance Billing: Heritage Counseling Center does not routinely bill insurance unless the Heritage Counseling Center provider is contracted with your insurance plan and benefits have been verified before your visit. For nonQcontracted insurance plans, payment is required in full at the time of service and you may seek reimbursement directly from your insurance carrier using the receipt provided. For contracted insurance plans, your benefits will be verified and your responsibility as quoted by your insurance representative will be reviewed with you prior to your appointment. You are responsible only for any coQpayment, deductible and nonQcovered service as determined by your insurance carrier. We will submit all appropriate claim forms to your carrier for reimbursement. You are responsible for notifying us immediately of any change in your insurance plan or coverage. Insurance company quoted benefits are not a guarantee of payment. Any appointment prior to notifying this office of insurance benefits will be the responsibility of the client.

Confidentiality: Your patient records are the property of Heritage Counseling Center and shall be treated as confidential. To insure quality record maintenance and patient confidentiality, Heritage Counseling Center will conduct routine patient record audits. To comply with state and federal laws regarding patient confidentiality, your records will not be released without the properly executed written consent. Everything about your care will be held in strictest confidence with the exception of those situations which we are required by law to report such as suspected or reported child abuse, threat to harm self or another, etc. . If you choose to have your counselor keep a third party such as a pastor, doctor or family member informed of your progress while in treatment at Heritage Counseling Center, it will be necessary to complete a release form which will be kept on file.

BEFORE TREATMENT CAN BE PROVIDED, please sign below showing that you read and understand the above information. A copy of this consent can be requested for your records. Your consent can be revoked with written notice at any time for future treatment.

Privacy Policy

 

I acknowledge having been offered Heritage Counseling Center’s Notice of Privacy Policies and Client Rights, according to HIPAA regulations.

 

Missed or Cancelled Appointments

 

I understand all future appointments I make with a Heritage Counseling Center Counselor that are missed or cancelled without a 36-hour notice will be charged back to me at $75.00 per session. I understand my therapist has reserved this spot for me. I agree to pay these charges promptly. Missed appointments are normally not covered by insurance companies.

 

Telephone Calls

 

I also understand that phone calls that are longer than 8 minutes will be considered a phone consultation and charged at 15 minute increments. Each 8-15 minute increment is $2.25. I can assume that phone calls beyond the 8 minutes will automatically be billed to my account. Phone calls are normally not covered by insurance companies. This phone charge is also incurred when calls to outside professionals (i.e. doctors, psychiatrists, schools, etc.) are made on your behalf.

 

Session Charges

 

Each session lasts 38-55 minutes. Your first session will be $200.00. Each individual session after is $165.00 and family session is $185.00. I understand that I am responsible for the whole charge. The only exceptions are those that my insurance company has agreed to pay, in which case I am responsible for any deductibles, coinsurances or copayments.

 

Report Writing

 

I understand that I may request that my therapist write a letter or report on my behalf to authorities such as the court, school systems, doctor’s offices, governmental agencies, etc. Reports will be charged at a rate of $85 for the first page and $65 for each additional page generated. In the case of pre-made forms, which require responses but not full reports to be generated, the fee of $65 will be charged, regardless of the length of the form.

 

Appearances outside of the Office

 

Situations may occur where it would be beneficial for you to ask your therapist to appear on your behalf outside of the office, for example in court or at your child’s school. Such appearances will be charged at the hourly rate of $185.00, starting at the time your therapist leaves the office until such time as he or she returns. This fee is not subject to insurance or other discounts.

Video and audio recordings are commonly used for consultation in therapy. Consultation is a vital source of professional development and accountability. It provides additional clinical expertise as a resource to your therapy. The recording of sessions can enhance the effectiveness of your treatment, but is not required. You may decline to have sessions recorded.

The strictest confidentiality will be maintained, and there will be no sharing of the recorded material beyond private review of the session in clinical consultation. Except for your first names and your voice and image on the recording, there will be no information that could identify you. The recordings will never knowingly be shared with anyone who knows you. Mental health professionals who may view the recording of your session are bound by law and code of ethics to protect your confidentiality.

I understand that making recordings is considered among best practices for therapists, and that these recordings will be viewed only by clinical consultants who have been engaged to provide expert clinical consultation regarding the therapy process. I further understand that these videos will be kept in a secure location, my identity will be kept confidential, and the recordings will be destroyed after the consultation.

I have the right to revoke this authorization at any time by providing written notification to my therapist at Heritage Counseling Center. However, this revocation will not be effective to the extent that she/he has previously taken action in reliance on the consent.

THIS NOTICE DESCRIBES HOW TREATMENT INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

 

We respect client confidentiality and only release confidential information about you in accordance with state and federal law. This notice describes our policies related to the use of the records of your care at Heritage Counseling Center. If you have any questions about this policy or your rights, please contact your therapist.

 

USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

 

In order to effectively provide you care, there are times when we will need to share your confidential information with others beyond our counseling center, including:

 

Treatment. We may use or disclose treatment information about you to provide, coordinate or manage your care or any related services, including sharing information with others outside Heritage Counseling Center that we are consulting with or referring you to.

 

Payment. If necessary, information may be used to obtain payment for the treatment and services provided. This will include contacting your guarantor or health insurance company for prior approval of planned treatment, insurance verification, or for billing purposes.

 

Healthcare Operations. We may use information about you to coordinate our business activities. This may include setting up your appointments, reviewing your care, training staff.

 

Information Disclosed Without Your Consent. Under state and federal law, information about you may be disclosed without your consent in the following circumstances:

 

Emergencies. Sufficient information may be shared to address the immediate emergency you are facing.

 

Follow-Up Appointment/Care. We may be contacting you to remind you of future appointments or information about treatment alternatives or other health-related benefits and services that may be of interest to you. We will leave appointment information on your answering machine unless you tell us not to.

 

As Required by Law. This would include situations where we have a subpoena, court order or are mandated to provide public health information, such as communicable diseases or suspected abuse and/or neglect such as child abuse or elder abuse.

 

Coroners. We are required to disclose information about the circumstances of your death to a coroner who is investigating it.

 

Governmental Requirements. We may disclose information to a health oversight agency for activities authorized by law, such as audits, investigations, inspections, and licensure. There also might be a need to share information with the Food and Drug Administration related to adverse events or product defects. We are also required to share information, if requested, with the Department of Health and Human Services to determine our compliance with federal laws related to health care.

 

Criminal Activity or Danger to Others. If a crime is committed on our premises or against our personnel we may share information with law enforcement to apprehend the criminal. We also have the right to involve law enforcement when we believe an immediate danger may occur to someone.

 

To Increase Our Professional Standards. Information about your situation may be discussed with other mental health professionals in order to gain supervision and/or consultation. This will always be done in the most professional and ethical manner.

 

CLIENT RIGHTS

 

You have the following rights under state and federal law:

 

Copy of Record. You are entitled to inspect the client record our counseling center has generated about you. We may charge you a reasonable fee for copying and mailing your record.

 

Release of Records. You may consent in writing to release of your records to others, for any purpose you choose. This could include your attorney, employer, or other who you wish to have knowledge of your care. You may revoke this consent at any time, but only to the extent no action has been taken in reliance on your prior authorization.

 

Restriction on Record. You may ask us not to use or disclose part of the clinical information. This request must be in writing. Heritage Counseling Center is not required to agree to your request if we believe it is in your best interest to permit use and disclosure of the information.

 

Contacting You. You may request that we send information to another address or by alternative means. We will honor such request as long as it is reasonable and we are assured it is correct. We have a right to verify that the payment information you are providing is correct. We also will be glad to provide you information by e-mail if you request it. If you wish us to communicate by e-mail, you are also entitled to a paper copy of this privacy notice.

 

Amending Record. If you believe that something in your record is incorrect or incomplete, you may request we amend it. To do this, contact your therapist. In certain cases, we may deny your request. If we deny your request for an amendment you have a right to file a statement you disagree with us. We will then file our response and your statement and our response will be added to your record.

 

Accounting for Disclosures. You may request an accounting of any disclosures we have made related to your confidential information, except for information we used for treatment, payment or health care operations purposes or that we shared with you or your family, or information that you gave us specific consent to release. It also excludes information we were required to release. To receive information regarding disclosure made for a specific time period no longer than six years and after April 14, 2003, please submit your request in writing to your therapist. We will notify you of the cost involved in preparing this list.

 

Questions and Complaints. If you have any questions or wish a copy of this Policy or have any complaints you may address these with your therapist. If you believe your privacy rights have been violated, you may also complain to the Secretary of U.S. Department of Health and Human Services at: Office for Civil Rights, U.S. Department of Health and Human Services, 233 N. Michigan Avenue, Suite 240, Chicago, IL 60601.

 

Changes in Policy. Heritage Counseling Center reserves the right to change its Privacy Policy based on the needs of the center and changes in state and federal law.