I hereby declare that I am the parent or legal guardian of the above-named child. I give consent and authorization for Psychosocial/Psychiatric Evaluation/treatment and medication management by Bienstar Counseling Services, PLLC (BCS). I am aware that I may contact Bienstar Counseling Services if I have any questions or concerns.

Release of information: The information in my child’s health record is confidential and will not be released to any unauthorized person or agency without my consent. I understand that federal law requires that visits made by and health information pertaining to a child/adolescent must remain confidential if he or she requests confidentiality. I understand that this means that certain information will not be released to me if my child has made a request that it remain confidential.

Bienstar Counseling Services, PLLC provide a) Services related to family life such as counseling regarding child and adolescent growth and development, personal responsibilities, and decision-making; b) Activities to promote healthy development for children and their families; c) Mental Health evaluation/assessment/psychiatric and ongoing treatment; d) Mental Health treatment if a parent or guardian cannot be present; e) Bienstar Counseling Services reserve the right to refuse filling disability forms, unemployment, FMLA, travel, emotional support animal, or forms for legal benefits such as divorce, custody, lawsuit, or any other legal benefit. BCS reserve the right to discontinue professional services to an active patient, the patient will receive a notification along with a referral order for the continuity of the services.

Fees and billing authorization: Services available through BCS’s fees are based on services provided. To assist in providing services and billing, I understand that BCS Financial Forms will be completed and agree to provide copies of my child’s
Medicaid, state children’s health plan program (‘CHIP”), private health insurance, or other health benefits plan card and other information concerning health insurance as may be requested by BCS representatives. To further assist in the providing of services and billing, I also authorize the following: 1) billing my health insurance for services that are normally part of my health plan; 2) cooperating with my insurance company/health plan to assist BCS staff in billing insurance, managed care organizations, Medicaid or other similar entities for services my child received; 3) disclosure by BCS of all or any portion of my child’s medical record to any authorized person for the purpose record-keeping, billing or verification of my child’s health coverage or benefits. (Contact may be made with my employer by telephone or in writing for these purposes); and 4) direct payment to BCS or any entity performing billing services on its behalf of all health benefits to which I would otherwise be entitled to these services.

This consent is in effect for one (1) year unless I revoke it in writing sooner. I understand that it is my responsibility to notify BCS about changes in guardianship and insurance coverage. I have read and understood each of the items above. And by signing below, I agree to ongoing services provided by the BCS personnel for my child and family, as needed.

The following specifies your rights regarding this authorization under the Health Insurance Portability and Accountability Act of 1996, as amended from time to time (“HIPAA”)

1. Tell your mental health professional if you don’t understand this authorization, and they will explain it to you.

2. You have the right to revoke or cancel this authorization at any time, except (a) to the extent information has already been shared based on this authorization; or (b) this authorization was obtained as a condition of obtaining insurance coverage. To revoke or cancel this authorization, you must submit your request in writing to your mental health professional and your insurance company, If applicable.

3. You may refuse to sign this authorization. Your refusal to sign will affect your ability to obtain treatment, make payment, or affect your eligibility for benefits. If you refuse to sign this authorization, and you are in a research-related treatment program or have authorized your provider to disclose information about you to a third party, your provider has the right to decide not to treat you or accept you as a client in their practice.

4. Once the information about you leaves this office according to the terms of your authorization, this office has no control over how it will be used by the recipient. You need to be aware that at that point your information may no longer be protected by HIPAA.

5. Special instruction for completing this authorization for the use and disclosure of Psychotherapy Notes. HIPAA provides special protections to certain medical records known as “Psychotherapy Notes.” All psychotherapy notes
recorded on any medium (i.e., paper, electronic) by a mental health professional (such as a psychologist or psychiatrist) must be kept by the author and filed separately from the rest of the client’s medical records to maintain a higher standard of protection. “Psychotherapy Notes” are defined under HIPAA as notes recorded by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session and that are separate from the
rest of the individual’s medical records. Excluded from the “Psychotherapy Notes” definition are the following: (a) medication prescription and monitoring, (b) counseling session start and stop times, (c) the modalities and frequencies of treatment furnished, (d) the results of clinical tests, and (e) any summary of diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date.

For a medical provider to release “Psychotherapy Notes” to a third party, the client who is the subject of the psychotherapy notes must sign another authorization to specifically allow for the release of psychotherapy notes. Such authorization must be separate from an authorization to release other medical records.

Authorization and Signature

I understand my information is protected health information, as described in the directions above. I understand that the information to be disclosed is protected by law, and the use/disclosure is to be made to conform to my directions. The information that is used and/or disclosed pursuant to this authorization may be re-disclosed by the recipient unless the recipient is covered by state laws that limit the use and/or disclosure of my confidential protected health information.

PAA Notice of Privacy Practice Statement

THIS NOTICE DESCRIBES HOW MENTAL HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

All information describing your mental health treatment and related health care services ("mental health information") is personal, and we are committed to protecting the privacy of the personal and mental health information you disclose to us.

We are required by law to maintain the confidentiality of information that identifies you and the care you receive. When we disclose information to other persons and companies to perform services for us, we require them to protect your privacy, too. This Notice applies to your counselor, psychotherapist, psychiatrist, and other health care professionals who provide care to you. We must also provide certain protections for information related to your medical diagnosis and treatment, including HIV/AIDs, and information about alcohol and other substance abuse. We are required to give you this notice about our privacy practices, your rights, and our
legal responsibilities.

WE MAY USE AND DISCLOSE YOUR MENTAL HEALTH INFORMATION:

For treatment for example. We may give information about your psychological condition to other health care providers to facilitate your treatment, referrals, or consultations.

For payments, for example, we may contact your insurer to verify what benefits you are eligible for, to obtain prior authorization, and receive payment from your insurance carrier.

For appointments and services to remind you of appointments or tell you about treatment alternatives or health-related benefits or services.

WITH YOUR WRITTEN AUTHORIZATION. We may use or disclose mental health information for purposes not described in this notice only with your written authorization.

WE MAY USE YOUR MENTAL HEALTH INFORMATION FOR OTHER PURPOSES WITHOUT YOUR WRITTEN AUTHORIZATION

As REQUIRED BY LAW when required or authorized by other laws, such as the reporting of child abuse, elder abuse, or dependent adult abuse.

For HEALTH OVERSIGHT ACTIVITIES to governmental, licensing, auditing, and accrediting agencies as authorized or required by law including audits; civil, administrative, or criminal investigations; licensure or disciplinary actions; and monitoring of compliance with the law.

For HEALTH OVERSIGHT ACTIVITIES to governmental, licensing, auditing, and accrediting agencies as authorized or required by law including audits; civil, administrative, or criminal investigations; licensure or disciplinary actions; and monitoring of compliance with the law.

TO PUBLIC HEALTH AUTHORITIES to prevent or control communicable disease, injury, or disability, or ensure the safety of drugs and medical devices.

TO LAW ENFORCEMENT, for example, to assist in an involuntary hospitalization process.

TO THE STATE LEGISLATIVE SENATE OR ASSEMBLY RULES COMMITTEES for legislative investigations.

FOR RESEARCH PURPOSES subject to a special review process and the confidentiality requirements of state and federal law.

TO PREVENT A SERIOUS THREAT TO HEALTH OR SAFETY of an individual. We may notify the person, tell someone who could prevent the harm, or tell law enforcement officials.

TO PROTECT CERTAIN ELECTIVE OFFICERS including the President, by notifying law enforcement officers of potential harm.

 

To receive a copy of this Notice when you obtain care.

To request restrictions. You have the right to request a restriction or limitation on the mental health information we disclose about you for treatment, payment, or health care operations. You must put your request in writing. We are not required to agree with your request. If we do agree with your request, we will comply with your request except to the extent that disclosure has already occurred or if you need emergency treatment and the information is needed to provide the emergency treatment.

To inspect and request a copy of your Mental Health Record except in limited circumstances. You must put your request for a copy of your records in writing. If you are denied access to your mental health records for certain reasons, we will tell you why and what your rights are to challenge that denial.

To request an Amendment and/or Addendum to your Mental Health Record. If you believe that information is incorrect or incomplete, you may ask us to amend the information or add an addendum (addition to the record) of no longer than 25 words for each inaccuracy.

Your request for amendment and/or addendum must be in writing and give reason for the request. We may deny your request for an amendment if the information was not created by us, or if the information is already accurate and complete. Even if we accept your request, we do not delete any information already in your records.

To receive an accounting of certain disclosures we have made of your medical health information. You must put your request for an accounting in writing.

To request that we contact you by alternative means (e.g., fax versus mail) or at alternate locations. Your request must be in writing, and we must honor reasonable requests.

CHANGES TO THIS NOTICE. We reserve the right to change this Notice. We reserve the right to make the revised or changed Notice effective for information we already have about you as well as any information we receive in the future. We will post a copy of the current Notice on the BCS website: http://www.bienstarcounseling.com

CONTACT INFORMATION:

If you have any questions about this Notice or believe your privacy rights have been violated, you may contact:

The Secretary of the Department of Health and Human Services

Contact the office for Civil Rights
7-866-627-7748, 1-800-537-7697 (TTY)
http:/www.hhs.gov/ocr/privacy/hipaa/complaints/index.html

Filing a complaint will not affect the services you received.

By law, Bienstar Counseling Services is required to follow the terms in this privacy notice. BCS has the right to change the way your personal health information is used and given out. If BCS makes any changes to the way your personal health information is used and given out while you are a current client at BCS, you will get a new notice, directly or by mail, within 60 days of the change.

I hereby acknowledge that I have received and have been given an opportunity to read a copy of the Bienstar Counseling Services, PLLC Notice of Privacy Practices. The Notice of Privacy Practices has been explained to me, and I have had the opportunity to have my questions about the Notice answered, if applicable. I understand that if I have further questions regarding the Notice or regarding my privacy rights, I can contact BCS.

SERVICE	COST
Individual Psychosocial Evaluation	$150
Psychosocial Evaluation for Couples	$180
Psychiatric Evaluation	$300
Individual Therapy Session	$150
Family Therapy Session	$180
Couples Therapy Session	$180
Psychiatric Follow-up	$120
Psychosocial Evaluation for Immigration	$1,400

It is the patient's responsibility to inform about any changes to your insurance or expiration; if insurance is expired and notice was not given, the patient will be responsible for paying any remaining balance for services provided. For self-pay
appointments a $75 deposit is required to set up an appointment, the amount will be deducted from the total amount of the appointment, for a full deposit refund, the appointment must be canceled within 24 hours.

EMERGENCIES:
➢ Call 911
➢ 24/7 Mobile Crisis Hotline 988
➢ Counseling Support 1-800-247-2809
➢ Contact our Office 214-682-7842

NO SHOW POLICY:

It is your responsibility to keep up with your appointment whether you receive a phone call/text reminder or not. You are required to call and cancel/reschedule your therapy appointment 24 hours before and 48 hours before your psychiatric appointment. For non-compliance, your account will be billed, a cancellation fee of $40.00 for therapy and $50 for a psychiatric appointment. (at the patient's responsibility)

BCS has the right to disclose a patient after two consecutive missed or canceled appointments for noncompliance. The patient will be allowed to schedule a new appointment after one year from termination.

Our clinicians are available to meet with clients via Telehealth using video conferencing.

To receive telehealth services, please complete the following Consent for Mental Health Services. Note that the confidentiality and the exceptions to confidentiality that have been outlined in the existing Bienstar Counseling Services Consent for Services still apply in Telehealth services.

This informed Consent for Telehealth contains information focusing on psychotherapy and psychiatry services that use the phone or the internet. Please read carefully.

Benefits and Risks of Telehealth

Telehealth refers to providing psychotherapy and psychiatric services remotely using telecommunication technology via video conferencing. One of the benefits of Telehealth is that the client and clinician can engage in services without being
in the same physical location. Psychiatric services will be offered by video call at the BCS offices, patients are required to be at the clinic with no exceptions. Telehealth, however, requires technical competence in both parts to be helpful. Although there are benefits of Telehealth, there are some differences between in-person services, as well as some risks. For example:

Risk to confidentiality: Because Telehealth therapy sessions take place outside of the clinician’s private office, there is potential for other people to overhear sessions if the client is not in a private place during the session. The clinician will take reasonable steps to ensure client privacy. It is important for the client to find a private place for the therapy session where there will not be interruptions. It is also important for the client to protect the privacy of the session via cell phone or another electronic device. The client should participate in therapy only while in a room or area where other people are not present and cannot overhear the conversation. We strongly suggest that you only communicate through a device that you know is safe and technologically secure (e.g., has a firewall, anti-virus software installed, is password-protected, not accessing the internet through a public wireless network, etc.) During a session with a client, the clinician will take all reasonable efforts to ensure client privacy in the space in which s/he is providing services as well as the device being used to provide the service.

Issues related to technology: There are many ways that technology issues might impact telehealth services. For example, there may be difficulties with hardware, software, equipment, and/or services supplied by a 3rd party that may result in
service interruptions; technology may stop working during a session; other people might be able to get access to the private conversation, or stored data could be accessed by unauthorized people or companies. Bienstar Counseling Services
is taking all reasonable measures to ensure the confidentiality of clients’ information on devices and systems used by BCS to provide services, please see Confidentiality Section below for additional information.

 

 

Crisis management and intervention: The clinician will not engage in Telehealth with clients who are currently in a crisis and require high levels of support and intervention. Before engaging in Telehealth, the client and clinician will develop an emergency response plan to address potential crisis situations that may arise during the Telehealth work. The clinician determines whether the client is in crisis using her/his professional judgment to assess the overall circumstance presented.

Electronic Communications

The client and the clinician will decide together which kind of Telehealth service to use. The client may have to have certain computer or cellphone systems to use Telehealth services.

Confidentiality

Clinician has a legal and ethical responsibility to make their best efforts to protect all communications that are a part of Telehealth services. However, the nature of electronic communications technologies is such that the clinician canno guarantee that communications will be kept confidential or that other people may not gain access to communications. The clinician will try to use updated encryption methods, firewalls, and backup systems to help keep client information private, but there is a risk that electronic communication may be compromised, unsecured, or accessed by others. The client should also take responsible steps to ensure the security of communications (for example, only using secure networks for Telehealth sessions and having passwords to protect the device you use for Telehealth).

Emergencies and Technology

If the session is interrupted for any reason, such as the connection fails, and the client is having an emergency, do not call the clinician; instead, call 911 or go to your nearest emergency room.

If the session is interrupted and the client is not having an emergency, disconnect from the session and the clinician will wait two (2) minutes and then re-contact you via the telehealth platform on which we agreed to conduct therapy.

Records

The Telehealth sessions shall not be recorded in any way. However, as with an in-person session, BCS will create a record to document the session, which becomes a permanent part of the client’s file.

Informed Consent

I understand that this is an addendum to my previously signed consent for treatment-BCS Consent for Services/Parent Permission and hereby give consent to the revised delivery of services. This serves as my electronic signature and consent.