Consent for Treatment, Payment, Privacy Practices and Client Handbook

Notice of Privacy Practice – Approved 09/12/2024 – Version: 091224

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

You can access this notice at our office or online at https://www.hwsbesthealth.com/resources, where HIPAA and its application to your health information are explained in detail.

Explanation of Form.

HWS Best Health, LLC dba HWS Best Health Counseling & Psychiatry (HWS) (the "Practice") handles personal health information ('PHI") about you, and how that information is handled is regulated by law. To comply with the law, the Practice asks you to acknowledge receiving this notice in writing.

Types of Uses and Disclosures.

PHI about you may be used or disclosed by the Practice for treatment, payment, and health care operations without your authorization. Treatment includes consultation, diagnosis, provision of care, and referrals. Payment includes all those things necessary for billing and collection, such as claims processing. Health care operations include things the Practice does to assess the quality of care, train staff, and manage the Practice's business. Some examples of these disclosures are below.

Example of Treatment Disclosure. The Practice may disclose PHI about you to a medical specialist, a hospital, or other providers to help them diagnose and treat an injury' or illness. The Practice may use your PHI to send you (via telephone, email, text, or other electronic communication means) information and/or reminders about upcoming appointments, refills, and other aspects related to your care and treatment, including to describe health-related products or services that are provided by the Practice. The Practice may also use or disclose your PHI to direct or recommend alternative treatments, therapies, health care providers, or settings of care.
Example of Payment Disclosure. The Practice may disclose your PHI when your insurance company requires the information before paying for your health care services.
Example of Health Care Operations Use. The Practice may use your PHI when it hires new staff whose training requires information about the medical needs of our patients.
Other Uses and Disclosures.

The Practice may also use or disclose your PHI in the following situations without your authorization. These situations include:

As Required by Law. The Practice may use or disclose your PHI to the extent that the use or disclosure is required by law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law.
Public Health and Health Oversight. The Practice may disclose PHI for public health activities and purposes to a public health authority that is permitted by law to collect or receive the PHI. The disclosure will be made for the purpose of controlling disease, injury, or disability. The Practice may also disclose PHI, if directed by the public health authority, to another government agency that is collaborating with the public health authority. The Practice may also disclose PHI to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws.
Communicable Diseases. The Practice may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.
Abuse or Neglect. The Practice may disclose your PHI to a public health authority that is authorized by law to receive repolls of child and other types of abuse or neglect. In addition, the Practice may disclose PHI if the Practice believes that you have been a victim of abuse, neglect or domestic violence to the governmental entity or agency authorized to receive such PHI. In this case, the disclosure will be made consistent with applicable law.
Food and Drug Administration. The Practice may disclose your PHI to a person or company required by the Food and Drug Administration to report adverse events. product defects or p10blems, biologic product deviations, track products; to enable product recalls; to make repairs or replacements, or to conduct post marketing surveillance, as required.
Legal Proceedings. The Practice may disclose PHI in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), in certain conditions in response to a subpoena, discovery request or other lawful process.
Law Enforcement. The Practice may also disclose PHI, so long as applicable legal requirements are met, for law enforcement purposes. These law enforcement purposes include
legal processes and otherwise required by law
limited information requests for identification and location purposes,
pertaining to victims of a crime
suspicion that death has occurred as a result of criminal conduct
in the event that a crime occurs on the premises of the Practice
medical emergency not on the premises and it is likely that a crime has occurred
Coroners, Funeral Directors, and Organ Donation. The Practice may disclose PHI to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. The Practice may also disclose PHI to a funeral director, as authorized by law, in order to permit the funeral director to carry out his duties. The Practice may disclose such PHI in reasonable anticipation of death. PHI may be used and disclosed for cadaveric organ, eye, or tissue donation purposes.
Research. The Practice may disclose your PHI to researchers when the research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information.
Criminal Activity. Consistent with applicable federal and state laws, the Practice may disclose your PHI if the Practice believes that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. The Practice may also disclose PHI if it is necessary for law enforcement authorities to identify or apprehend an individual.
Military Activity and National Security. When the appropriate conditions apply, the Practice may use or disclose PHI of individuals who are Armed Forces personnel.
for activities deemed necessary by appropriate military command authorities
for the purpose of a determination by the Department of Veterans Affairs of eligibility for benefits
to foreign military authority if you are a member of that foreign military service.
The Practice may also disclose PHI to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized.
Workers' Compensation. PHI may be disclosed by the Practice as authorized to comply with workers compensation laws and other similar legally established programs.
Inmates. The Practice may use or disclose PHI if you are an inmate of a correctional facility and your physician created or received your PHI in the course of providing care to you.
Required Uses and Disclosures. Under the law, the Practice must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine compliance with the law. Also, the Practice may make any other disclosures required by law.
Others Involved in Your Healthcare.

Unless you object, the Practice may disclose to a member of your family, a relative, a close friend or any other person you identify, your PHI that directly relates to that person's involvement in your health care. If you are unable to agree or object to such a disclosure, the Practice may disclose such PHI as necessary if the Practice determines that it is in your best interest based on its professional judgment. The Practice may use or disclose PHI to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition, or death. Finally, the Practice may use or disclose your PHI to an authorized entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care.

Other Uses and Disclosures.

Disclosure of your PHI or its use for any purposes other than those listed above requires your specific written authorization. If you change your mind after authorizing the use or disclosure of your PHI, you may submit a written revocation of the authorization. However, your decision to revoke the authorization will not affect or undo any use or disclosure of PHI that occurred before you notified the Practice of your decision to revoke your authorization. Without your authorization, the Practice may not use or disclose your PHI for marketing purposes. The Practice may not sell your PHI without your authorization. The Practice may not disclose some psychotherapy notes without your authorization. The Practice maintains a video surveillance system throughout the common areas and hallways of its locations. The Practice may use video and other images captured by the surveillance system for the purposes of general premises security and safety. Signage will be posted where video surveillance is in use.

Restrictions.

You have the right to request restrictions on the use and disclosure of your PHI; however, we are not required to agree to your requests. The Practice will only be bound by the restrictions if the Practice notifies you in writing that it agrees with them. The Practice will always agree to a request to restrict a release of PHJ to an insurance provider if you pay the bill out of pocket and in full.

Confidentiality.

You have the right to have the Practice use only confidential means of communicating with you about PHI. This means you may have PHI delivered to you at a certain place, or in a manner that keeps your PHI confidential. Such requests must be in writing, signed and dated.

Access, Amendment and Accounting.

You may generally inspect or copy your PHI that the Practice maintains. Your request will be reviewed and will generally be approved unless there are legal or medical reasons to deny the request. As permitted by federal regulation, the Practice requires that all requests regarding your PHI be submitted in writing. Any requested copies will be made at a reasonable cost to you (as permitted by the law), which is payable prior to the pickup or delivery. You have the right to have the Practice amend your PHI it maintains. The Practice may refuse to amend PHI that is accurate, that was created by someone else, or is not disclosable to you. You have the right to see a list of disclosures of PHI about you by the Practice, made within a period of time up to 6 years prior to the date of your request, excluding certain disclosures, such as those made for treatment, payment, or health care operations.

Complaints.

If you would like to submit a complaint about the privacy practices related to your PHI/medical records maintained at a facility where services were provided to you by the Practice, please contact that facility's Privacy Officer directly. If you would like to submit a complaint about the Practice's privacy practices, or if you believe that your privacy rights have been violated by the Practice, you should call the matter to our attention by sending a written letter outlining your concerns to HWS Best Health, LLC's Privacy Officer, or to the Secretary of the U.S. Department of Health and Human Services. To contact our Privacy Officer, please submit your complaint in writing to: Privacy Officer, HWS Best Health, LLC, 3878 Old Hickory Ave NW Canton, Ohio 44718. The Practice will not retaliate against you for filing a complaint.

Right to privacy breach notification.

In the event of a breach of unsecured protected health information, if your information has been compromised it is our duty to notify you.

Privacy Notice.

The Practice is required by law to keep your PHI private and to give you this notice. The Practice is required to abide by the privacy policies and practices outlined in this notice. As permitted by law, the Practice may amend or modify its privacy policies and practices at any time, including this notice. You have the right to receive the most recently revised copy of this notice. You have the right to receive a paper copy of the most recently revised notice. If you receive(d) Practice's services at a facility/site (such as a skilled nursing facility, etc.), you may request a copy of this notice from the administrator of that facility.

The law requires your signature to acknowledge that we have provided you with this information. Although these documents may be lengthy and complex, it is crucial that you review them carefully and ask any questions you may have about our procedures or treatments.

By signing the document, you are agreeing to its terms, except where obligations are imposed on us by your health insurer to process or substantiate claims, or if there are outstanding financial obligations. If you have any concerns or questions, please don't hesitate to discuss them with us.

 Service Agreement & Consent – Approved 09/12/2024 – Version: 091224

INTRODUCTION

At HWS Best Health Counseling & Psychiatry, our mission is to provide exceptional mental health care that empowers individuals and families. We are committed to offering compassionate and evidence-based services that promote wellness of the mind, body, and spirit. We strive to reduce barriers to mental health services by offering comprehensive, innovative, and cost-effective care. Our values emphasize honesty, integrity, and fairness, and we envision a world where everyone has access to high-quality mental health care.

Table of Contents for Consent Packet

Service Agreement and Consent Form
Overview of the services offered, treatment consent, and patient rights.
Services Offered
Description of the types of mental health services available, including individual and group counseling, case management, and psychiatric care.
Appointments
Guidelines for scheduling, rescheduling, and canceling appointments.
Confidentiality, Records, and Release of Information
Information on how your health records are kept confidential and circumstances where disclosures may be made.
Professional Consultations
Details about consultations between clinicians to improve care quality while protecting your identity.
Supervision Notification
Explanation of the supervision of clinicians and your consent to have sessions observed for training purposes.
Payment for Services
Policies regarding payment, insurance billing, and financial responsibilities.
Your Rights and Protections Against Surprise Medical Bills
Explanation of protections from unexpected medical costs, including balance billing.
Health Care Insurance
Information on insurance claims, including your role in managing out-of-network claims.
Professional Records
Details about the types of information kept in your health record and your right to access it.
Patient Rights
Outline of your rights as a client, including privacy, consent, and grievance procedures.
Grievance Policy
Procedure for filing a grievance regarding services or staff.
Risks and Benefits of Therapy
Explanation of the potential emotional challenges and positive outcomes of therapy.
Telehealth Services Informed Consent
Consent to participate in telehealth services and the associated risks, benefits, and confidentiality measures.
Prohibition of Recording Counseling Sessions
Policy prohibiting the unauthorized recording of sessions to protect privacy and confidentiality.
Video and Audio Privacy Addendum
Guidelines for video and audio recording of sessions, including consent, storage, and usage.
SERVICES OFFERED

We offer services specifically tailored to meet your needs or will provide referrals to other professionals if necessary. Our clinical and behavioral services include individual assessments, individual/group/family counseling for mental health, case management (CPST/TBS), and psychiatric evaluation and management (medication management).

By signing this document, you authorize HWS Best Health, LLC to provide any necessary assessments and treatment (Consent for Treatment).

APPOINTMENTS

Except in rare emergencies, we will see you (or your child) at the scheduled time. We understand that circumstances such as illness or family emergencies may occasionally require you to cancel appointments. To avoid any misunderstandings, we ask that you contact us directly and provide as much notice as possible to cancel or reschedule. This allows us to offer the appointment time to someone else.

CONFIDENTIALITY, RECORDS, AND RELEASE OF INFORMATION

Psychological services are most effective when provided in an atmosphere of trust. Because trust is essential, all services are confidential, except when you provide written authorization to release specific information to designated individuals, or as required by Ohio and Federal law, and in accordance with our professional codes of conduct and ethics.

TO PROTECT THE CLIENT OR OTHERS FROM HARM

If we suspect that a minor, elderly, or disabled person is being abused, we are legally required to report this, along with any additional information requested, to the appropriate state agency. If we believe that a client is threatening serious harm to themselves or others, we are obligated to take protective actions. These actions may include contacting the police, notifying the intended victim, informing a minor's parent(s), or seeking appropriate hospitalization.

PROFESSIONAL CONSULTATIONS

Counselors often consult with other professionals about cases. In doing so, we make every effort to protect your identity, and consulting professionals are required to maintain confidentiality regarding any information shared. Unless you object, we generally do not inform clients about these consultations; however, they will be documented in your Private Health Information. If you would like us to communicate with or release specific information to other professionals involved in your care, you will need to sign an authorization specifying what information can be shared and with whom.

SUPERVISION NOTIFICATION

HWS Best Health, LLC is committed to providing training opportunities for new professionals in the field, partnering with accredited colleges and universities that uphold the highest academic standards. At times, your clinician may be under the supervision of another licensed professional, and you will be informed of this during intake. This means your counselor may review your case with their supervisor or another licensed professional contracted with HWS Best Health, LLC.

You have the right to meet with the supervising clinician at any time. All guidelines for protecting your Protected Health Information will still apply. As a training facility, your clinician may occasionally ask for verbal permission to allow a supervisee to observe your session. You have the right to grant or deny this request, and refusal will not impact your access to services.

By signing, you provide written consent for observation by a supervisee, with the understanding that your clinician is under supervision.

PAYMENT FOR SERVICES

If you have any questions or objections regarding assessed fees, these must be raised within 60 days of receiving the relevant invoice to allow for review and consideration. Inquiries regarding invoices older than 60 days will be considered untimely, and payment for services will be expected. Insurance claims are submitted electronically as needed. Additionally, we may seek assistance from an outside party to collect payment. In such cases, only the minimum necessary information will be disclosed to achieve this purpose.

The laws and professional standards surrounding these matters are complex. It is important to discuss any questions or concerns you (or your minor child) may have at our first meeting or as they arise during our work together. If such situations occur, we will make every effort to fully discuss them with you before taking any action, limiting disclosures to what is absolutely necessary. Please note, we are not attorneys, and you may wish to seek formal legal advice for specific concerns.

YOUR RIGHTS AND PROTECTIONS AGAINST SURPRISE MEDICAL BILLS

When you receive emergency care or are treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from balance billing. In these cases, you should not be charged more than your plan’s copayments, coinsurance, or deductible.

What is "balance billing" (also known as "surprise billing")?

When you visit a doctor or other healthcare provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, or deductible. If you receive care from a provider or visit a healthcare facility that is out-of-network—meaning they haven’t contracted with your health plan—you may face additional costs or even the full bill.

Balance billing occurs when an out-of-network provider bills you for the difference between what your health plan pays and the full charge for the service. This amount is often higher than in-network costs and may not count toward your deductible or out-of-pocket limit.

Surprise billing happens when you receive an unexpected balance bill, typically when you cannot control who is involved in your care, such as in an emergency, or when you schedule a visit at an in-network facility but are treated by an out-of-network provider. Surprise medical bills can be expensive, depending on the service.

You are protected from balance billing for:

Emergency services: If you have an emergency medical condition and receive care from an out-of-network provider or facility, the most they can bill you is your plan’s in-network cost-sharing amount (such as copayments, coinsurance, and deductibles). This includes any services received after you are stabilized, unless you provide written consent and waive your protection from balance billing for post-stabilization services.
Certain services at in-network hospitals or ambulatory surgical centers: If you receive care at an in-network hospital or surgical center, certain providers may still be out-of-network. In these cases, the most they can bill you is your plan’s in-network cost-sharing amount. This protection applies to services like emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeons, hospitalists, and intensivists. These providers cannot balance bill you and cannot ask you to waive your protections.
Your rights:

You are never required to waive your billing protections.
You are not obligated to receive out-of-network care. You can always choose a provider or facility within your plan’s network.
Additional protections when balance billing is prohibited:

You are only responsible for your share of the cost (e.g., copayments, coinsurance, and deductible) as if the provider or facility were in-network.
Your health plan will cover any additional costs for out-of-network providers and facilities directly.
Your health plan must:

Cover emergency services without requiring prior authorization.
Cover emergency services provided by out-of-network providers.
Calculate your cost-sharing based on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.
Apply any payments you make for emergency or out-of-network services toward your in-network deductible and out-of-pocket limit.
If you believe you’ve been wrongly billed, you can contact the federal complaint line at 1-800-985-3059 or visit www.cms.gov/nosurprises/consumers for more information about your rights under federal law.

HEALTH CARE INSURANCE

If we do not file your insurance claim, we will provide you with the necessary statements or forms required by your insurance carrier to obtain reimbursement for out-of-network providers. To assist you with this, your insurance carrier may request additional information, such as a clinical diagnosis, treatment plans, or copies of your Medical Record. In such cases, we will make every effort to release only the minimum information necessary. Once provided, this information will likely become part of the insurance company’s files and may be stored electronically.

Although insurance companies claim to maintain confidentiality, we have no control over how they handle your information once it is in their possession. By signing this Agreement, you authorize us to provide the required information to your insurance carrier if you choose to file a claim for services. You may also request that we refrain from submitting any claims on your behalf, in which case you agree to pay in full for all services rendered and assume financial responsibility for any associated costs. Payment for these services is required at the time they are provided.

PROFESSIONAL RECORDS

Please be aware that HWS Best Health, LLC maintains clients’ Protected Health Information (PHI) in our professional records. This information may include, but is not limited to:

Reasons for seeking our services
Impact of any current or ongoing issues
Assessment, consultative, or therapeutic goals
Progress toward those goals
Medical, developmental, educational, and social history
Treatment history
Treatment records received from other providers
Reports from professional consultations
Billing records, releases, and any reports sent to third parties, including statements for your insurance carrier and the billing service agency we use
In most cases, you or your legal representative may request, in writing, to examine or obtain a copy of your Clinical Record. However, access may be restricted in certain situations, such as when the information could cause harm to you or others, or if it contains references to another person (unless they are a healthcare provider).

We encourage you to discuss the contents of your Clinical Record with your provider at HWS Best Health, LLC.

PATIENT RIGHTS UNDER HIPAA

Under HIPAA, you are entitled to several rights concerning your Clinical Record and the disclosure of protected health information. These rights include:

Requesting amendments to your record
Requesting restrictions on what information from your Clinical Record is disclosed to others
Requesting an accounting of disclosures of protected health information that you have neither consented to nor authorized
Specifying the location where protected information disclosures are sent
Having any complaints about our policies and procedures documented in your record
Receiving a paper copy of this Agreement and our privacy policies and procedures
GRIEVANCE POLICY

All clients have the right to file a grievance regarding the services provided or about any employee or contractor affiliated with HWS Best Health, LLC. A copy of the grievance policy is provided for your review, and additional copies are available at our office.

All grievances should be forwarded to the Client Rights Advocate, Jeffrey Bonchek, at 760-310-3611. Due to professional commitments, we may not always be immediately available by phone. If you leave a message, we will make every effort to return your call within 24 to 48 hours (excluding weekends and holidays).

Please note, we do not provide 24/7 on-call coverage. In the event of an emergency or crisis, contact your physician, call 911, or visit the nearest hospital emergency room.

For confidentiality reasons, HWS Best Health, LLC and its staff will not correspond about specific clients via unsecure email or other electronic methods outside of our Electronic Health Records (EHR) system.

HIPAA-COMPLIANT ARTIFICIAL INTELLIGENCE IN CLINICAL PRACTICE CLAUSE

By signing this agreement, I acknowledge and consent to the use of HIPAA-compliant artificial intelligence (AI) technologies by HWS Best Health, LLC in both the management of my care and in clinical practice. AI may be employed to assist in data analysis, clinical decision-making, treatment planning, and other aspects of care, with the goal of improving accuracy, efficiency, and outcomes. These AI tools are fully compliant with HIPAA regulations and are used to support clinicians in providing high-quality, personalized care.

I understand that the use of AI in clinical practice is intended to complement, not replace, the professional judgment of my healthcare provider. HWS Best Health, LLC ensures that all AI systems are secure, respect client privacy, and are accessed only by authorized personnel. My personal health information (PHI) will remain protected in accordance with HIPAA regulations and will not be used or disclosed in any way that violates privacy laws.

I acknowledge and accept the use of HIPAA-compliant AI technology in both the management and clinical aspects of my care at HWS Best Health, LLC.

FINANCIAL AGREEMENT

We are committed to providing you with the best possible care. If you have medical insurance, we are here to help you receive your maximum allowable benefits. To achieve this, we need your cooperation and understanding of our payment policy or Financial Agreement.

Payment Policy:

Payments for services are due at the time of service, unless prior arrangements have been made with our staff. We accept cash, checks, credit or debit cards (via the client portal), and Venmo.
We will assist in processing your insurance claim for reimbursement. You may choose not to have your claim submitted to your insurance carrier; however, you will be 100% responsible for the full fee at the time services are rendered.
If you elect to have your claim submitted to your insurance, we may accept the assignment of insurance benefits, but it is your responsibility to verify if HWS Best Health, LLC is a participating provider with your insurance plan.
Insurance Claims & Responsibilities:

HWS Best Health, LLC will process insurance claims and invoice any remaining balances. Please note that the billing agency must comply with HIPAA regulations.
Returned checks (with a $45 fee per occurrence) and balances over 30 days may be subject to additional collection fees and 1.5% interest per month (or 18% per year).
Our fees are generally considered reasonable by most insurance companies. However, insurance contracts are between you and your insurance company. We are not a party to this contract, and any disputes (e.g., deductibles, co-payments, “usual and customary” charges) are your responsibility.
Key Points to Consider:

Additional Services: Insurance usually does not cover additional services such as completing forms, copies, phone calls exceeding five minutes, and other services (e.g., special reports, court time). You are responsible for these costs, which will be discussed upon request.
Usual, Customary, and Reasonable Fees (UCR): Our fees are generally within the acceptable range, and most companies cover a percentage (e.g., 50%, 80%) of these fees. This does not apply to companies with an arbitrary schedule of fees unrelated to the actual cost of care.
Insurance Coverage: Insurance coverage is between you and your insurance company. We will not get involved in disputes beyond providing factual information.
Verifying Coverage: While we can provide a list of providers, you are responsible for verifying whether our provider is covered under your specific plan. If your insurance denies a claim due to plan provisions, you will be responsible for the balance.
Billing Agency: Insurance claims may be submitted by an outside billing agency. Your insurance will receive information such as diagnoses and dates of treatment sessions. By signing below, you authorize HWS Best Health, LLC to release necessary information to your insurance carrier.
Missed Appointments: Clients with commercial or private insurance (not Medicaid or Medicare) are subject to a $45 missed appointment fee. Appointments must be canceled or rescheduled at least 48 hours in advance. The fee will be charged to the payment method on file.
Co-payments and Deductibles: All co-payments and deductibles are due at the time of service. Failure to collect co-payments and deductibles may be considered fraud. Please ensure payment at each visit.
Insurance Coverage Limits: Not all services are covered by insurance. We emphasize that our relationship is with you, not your insurance company. While filing claims is a courtesy, all charges are your responsibility from the date services are rendered.
We understand that financial issues can sometimes affect the timely payment of your account. If this occurs, please contact us promptly so we can assist in managing your account.

If you have any questions or concerns about this information or your insurance coverage, please don’t hesitate to ask us. We are here to help.

CLIENT BILL OF RIGHTS

As a person receiving services, you have the right to:

The right to be treated with consideration and respect for personal dignity, autonomy, and privacy.
The right to reasonable protection from physical, sexual, or emotional abuse, neglect, and inhumane treatment.
The right to receive services in the least restrictive, feasible environment.
The right to participate in any appropriate and available service that is consistent with an individual service plan (ISP), regardless of the refusal of any other service, unless that service is a necessity for clear treatment reasons and requires the person's participation.
The right to give informed consent to or to refuse any service, treatment, or therapy, including medication, absent an emergency.
The right to participate in the development, review, and revision of one's own individualized treatment plan and receive a copy of it.
The right to freedom from unnecessary or excessive medication and to be free from restraint or seclusion unless there is an immediate risk of physical harm to self or others.
The right to be informed and the right to refuse any unusual or hazardous treatment procedures.
The right to be advised and the right to refuse observation by others and by techniques such as one-way vision mirrors, tape recorders, video recorders, television, movies, photographs, or other audio and visual technology. This right does not prohibit an agency from using closed-circuit monitoring to observe seclusion rooms or common areas, which does not include bathrooms or sleeping areas.
The right to confidentiality of communications and personal identifying information within the limitations and requirements for disclosure of client information under state and federal laws and regulations.
The right to have access to one's own client record unless access to certain information is restricted for clear treatment reasons. If access is restricted, the treatment plan shall include the reason for the restriction, a goal to remove the restriction, and the treatment being offered to remove the restriction.
The right to be informed a reasonable amount of time in advance of the reason for terminating participation in a service, and to be provided a referral, unless the service is unavailable or not necessary.
The right to be informed of the reason for denial of a service.
The right not to be discriminated against for receiving services on the basis of race, ethnicity, age, color, religion, gender, national origin, sexual orientation, physical or mental handicap, developmental disability, genetic information, human immunodeficiency virus status, or in any manner prohibited by local, state, or federal laws.
The right to know the cost of services.
The right to be verbally informed of all client rights and to receive a written copy upon request.
The right to exercise one's own rights without reprisal, except that no right extends so far as to supersede health and safety considerations.
The right to file a grievance.
The right to have oral and written instructions concerning the procedure for filing a grievance and to assistance in filing a grievance if requested.
The right to be informed of one's own condition.
The right to consult with an independent treatment specialist or legal counsel at one's own expense.
I hereby acknowledge that I have been given or had my Client Rights made available to me.

RISKS AND BENEFITS OF THERAPY

People seek therapy for various reasons, but ultimately, it’s about wanting to improve or feel better. Therapy can be very effective in helping individuals accomplish this, providing a space to learn about yourself, gain new perspectives, and adopt healthier ways of interacting with the world. While therapy is generally beneficial, it’s important to understand that it can come with some risks. Below, we outline a few of these risks, followed by the potential benefits, which often far outweigh the risks.

Risks:

Therapy can sometimes feel uncomfortable (initially):
Therapy often involves discussing past events or difficult topics that may bring up unwanted feelings and emotional pain. This discomfort may linger beyond the session, but it’s often a sign that real healing is taking place. Emotional pain sometimes gets worse before it gets better.
Therapy promotes change:
Therapy often leads to personal growth and positive changes, but these changes can also impact other areas of your life, such as relationships or career choices. While the goal is improved functioning, change—even positive change—can sometimes lead to resistance from others and difficult decisions.
Self-discovery can be challenging:
As you explore your strengths and weaknesses, you might gain insights that are difficult to accept. These insights are necessary for personal growth, but they can be emotionally challenging to process.
You might hear things you don’t want to hear:
Honesty is crucial in therapy. Sometimes, your therapist may offer observations that challenge your current way of thinking. This can create discomfort, but it’s an essential part of the growth process.
You might not find the right therapist immediately:
It’s important to find a therapist you feel comfortable with. However, it may take a few sessions to know if the therapist is the right fit for you. This can be frustrating, but finding the right therapist is critical for success in therapy.
You may form a strong connection with your therapist:
Therapy often involves sharing deeply personal information, which may lead to a strong bond with your therapist. While this connection is beneficial for the therapeutic process, it may bring a sense of loss when therapy ends.
Benefits:

Improved mood
Increased self-esteem and confidence
Better relationships
Greater ability to achieve personal and professional goals
New and improved perspectives on life
Better stress management skills
Resolution of past emotional issues
Increased self-awareness
Improved overall health
Cathartic relief through having a neutral, supportive person to talk to
Decreased anxiety and depression
A stronger sense of purpose and fulfillment
Healthier ways of coping with life’s difficulties
Better sleep
Increase in good habits and reduction of harmful ones
Resolution of feelings of shame, guilt, and regret
Potential to overcome fears
Greater satisfaction in your career
Increased assertiveness
Better management of anger in a healthy way
By signing, I acknowledge that I have been informed of the potential risks and benefits of therapy. I also understand that this is not an exhaustive list of risks and benefits.

TELEHEALTH SERVICES INFORMED CONSENT

What is Telehealth?

Telehealth refers to the provision of mental health services where the provider and the recipient are in different locations, with services delivered through electronic means. This often includes videoconferencing software, email, text messaging, virtual environments, and specialized mobile health ("mHealth") apps. HWS Best Health, LLC provides telehealth services through Doxy, Zoom or another HIPAA compliant telehealth platform and the modality used will be documented in each note. You will need internet access, and a link will be sent to enter our virtual waiting room. If you have any concerns or questions about telehealth tools, please address them directly with your provider to discuss their risks, benefits, and specific application to your treatment.

Consent to Participate

I, the undersigned, a citizen of Ohio, or my designee(s) on my behalf, agree to participate in phone or video-conference counseling with my assigned provider(s) at HWS Best Health, LLC. I authorize the transmission of medical and mental health information, including voice, images, and data, to and from the provider, other persons involved in my care, and staff operating the phone/video-conferencing equipment.

I confirm that I am using my own equipment for the session and not any equipment owned by another party, such as my employer.
I will be informed of the identities of all individuals present during the phone or video-conference counseling and their purpose.
I will inform my provider of all parties present during the session and their reasons for attending.
Understanding Telehealth

My provider has explained how tele-behavioral health counseling is performed and how it differs from in-person services, including potential emotional reactions generated by technology. I understand that my provider will not be physically present, and some information typically gathered in face-to-face counseling may not be available, which could impact the treatment. My provider will be unable to offer physical assistance in emergencies.

Recognized Risks:

Telehealth is a new treatment method, not yet fully validated by research, and has potential risks, including:

Technology failures before or during the session
Unclear or inadequate transmission of information
Unauthorized access to the transmitted information
Release of Information:

I authorize the release of relevant information, including my name, Social Security number, birth date, and medical records, to my provider, health care providers, and insurance carrier for counseling and insurance claims processing.

Client Rights:

I understand that:

I can discontinue telehealth counseling at any time without affecting my continued treatment.
I can refuse to answer any question or participate in any portion of the session.
Diagnosis and treatment depend on the information provided. Withholding information may lead to incorrect diagnoses and less successful treatment outcomes.
My provider may be required by law to report information indicating that I may endanger myself or others.
Alternatives to Telehealth:

The alternatives to phone/video-conference counseling, including their risks and benefits, have been explained to me. I understand that I can pursue in-person counseling and that telehealth does not eliminate the need for seeing a specialist in person. No guarantees have been made about the effectiveness of telehealth.

Confidentiality and Safety:

I understand that my phone or video-conferenced sessions will not be recorded by me, my provider, or my designee(s). Counseling, test results, and disclosures will be held in confidence according to state and federal law.

If my provider concludes that releasing my records could threaten my safety or the safety of others, they may withhold the records. I will remain responsible for the confidentiality of any records released to me and may be charged a reasonable fee to obtain copies.

I also understand that my records may be used for tele-behavioral health program evaluation, education, or research without personal identification.

Compensation and Emergency Plan:

I understand that I am not entitled to royalties or compensation for participating in tele-behavioral health counseling.

I have received a copy of my provider’s contact information and an emergency action plan. If I believe I am in a situation that could result in harm to myself or others, I will seek immediate care through my local health provider or the nearest hospital emergency department or by calling 911.

I release and discharge HWS Best Health, LLC, its affiliates, agents, employees, and my provider from liability related to my participation in tele-behavioral health video-conference counseling.

Benefits of Telehealth:

Access to services at times and locations where they may not otherwise be available
Convenience and fewer delays compared to in-person meetings
Access to care when travel to the provider’s office is not possible
Telehealth media may facilitate progress on health goals that may not have been achievable otherwise
Risks of Telehealth:

Technical Failures: Internet or device malfunctions may interrupt the session.
Privacy Risks: Cloud-based services, personnel, or malicious actors may access your private information.
Service Limitations: Providers may be unable to help in emergencies due to the remote nature of the service.
While telehealth is validated by research, it may not be suitable for every individual. Your provider will assess the fit for telehealth on an ongoing basis. You may stop receiving telehealth services at any time without prejudice.

Creating a Safe Telehealth Environment:

You are responsible for creating a safe and confidential space during sessions. The space should be private, and others should not be able to overhear or observe your session. Please contact your provider if you need assistance setting up a secure space.

Communication Plan:

At our first session, we will establish a plan for backup communications in case of technology failures and a plan for responding to emergencies. Key points include:

The best way to contact your provider between sessions is via phone. Messages will generally be returned within 24 hours or the next business day (excluding weekends and holidays).
Between-session contact should be limited to urgent information.
Appointment scheduling or billing inquiries should be directed to administrative staff.
All communication (emails and texts) with your provider will become part of your health record.
Your provider may coordinate with other professionals involved in your care, ensuring that communications are secure and that your privacy is safeguarded.
Safety and Emergency Plan:

Your provider will require an emergency contact and permission to communicate with this person during emergencies. You will also develop a plan for handling mental health crises and maintaining safety during sessions. In an emergency, dial 911 or visit your nearest emergency room.

Your Security and Privacy:

Your provider uses software and hardware tools that follow security best practices and applicable legal standards to protect your privacy and ensure that your healthcare records are secure. However, you also have a role in maintaining your security during telehealth sessions. Please follow these security protocols to protect your healthcare information:

Use devices and service accounts that are secured with unique passwords only you know.
Use the secure tools provided by your provider for communication.
PROHIBITION OF RECORDING COUNSELING SESSIONS

Notice to Clients: 

It is strictly prohibited to records, in any form, the content of any counseling session absent the express, written consent of the counsel, HWS, and all other participants involved in the counseling session. This includes, but is not limited to, audio recordings, video recordings, and any other means of capturing or transmitting the session.

Legal Implications. The unauthorized recordings of counseling sessions are a violation of privacy and confidentiality laws. Any client or parent or agent of a client found to be recording a session without express written consent may be subject to immediate termination of services and potential legal action.  This may include, but is not limited to, civil penalties, criminal charges, and the pursuant of damages for any harm caused by the unauthorized recording.

Privacy and Confidentiality.

The privacy and confidentiality of HWS clients are of paramount importance in the therapeutic process.  Unauthorized recordings undermine the trust and safety essential to effective counseling.  Clients and their families and agents are expected to respect the boundaries and privacy of the counseling relationship.

By participating in a counseling session, you acknowledge and agree to comply with this prohibition.  Failure to adhere to this policy may result in legal consequences.

VIDEO AND AUDIO PRIVACY ADDENDUM

Confidentiality. All video and audio recordings of counseling sessions are strictly confidential.  These recordings are created solely for the purpose of providing the best possible care and will not be shared, distributed, or used for any purpose other than those explicitly stated in this Addendum.
Recording Consent. Video and audio recordings will only be made with the express consent of the client. The client has the right to refuse recording without affecting the quality of continuity of their care.
Use of Recordings. If consent is given, recordings may be used for the following purposes:
Internal review by the counsel and/or supervising staff to enhance the quality of care;
Supervision and training purposes, provided the client’s identity is protected;
Legal and regulatory requirements, only when compelled by law.
Storage and Security. All recordings will be securely stored in encrypted files with access limited to authorized personnel only Recordings will be retained for a period of two (2) years, after which they will be permanently deleted unless required for ongoing treatment or legal purposes.
Client Access. Clients have the right to request access to their recordings at any time during the retention period. Such requests must be made in writing, and access will be provided within a reasonable time frame.
Third-Party Disclosure. No recordings will be shared with third parties without the client’s express written consent, except where required by law (i.e. court order, mandatory reporting requirements).
Termination of Recording Consent. The client has the right to withdraw consent for recording at any time.  Upon withdrawal, no further recordings will be made, and existing recordings will be handled in accordance with this Addendum.
Client Rights and Responsibilities. The client is responsible for notifying the counselor if they do not wish to be recorded. The counselor is responsible for respecting the client’s decision and ensuring that all privacy measures are upheld.
ACKNOWLEDGEMENT

By signing below, I acknowledge that I have read, understand, and agree to all the terms and conditions outlined in the Service Agreement & Consent Version: 091224. I have had the opportunity to ask questions or request clarification on any clause and am satisfied with the information provided.

MESSAGE FROM OUR FOUNDER & CEO, LAURI PIERCE

Dear Valued Client,

Welcome to HWS Best Health Counseling & Psychiatry. We are honored that you have chosen us as a partner in your mental health journey. At HWS, we are deeply committed to providing compassionate, high-quality care to individuals and families, with a focus on accessibility and holistic wellness.

Our mission is to empower you with the tools and support needed to navigate life's challenges while fostering growth and wellness in mind, body, and spirit. We believe that mental health is a vital part of overall health, and we strive to create a safe and supportive environment where healing and transformation can thrive.

Since our founding in 2021, we have remained dedicated to reducing barriers to mental health care and tailoring our services to meet the unique needs of each client. Whether you are here for individual counseling, family therapy, medication management, or case management services, our multidisciplinary team is here to guide and support you every step of the way.

At HWS Best Health, we are not just a mental health provider; we are your partners in building a healthier and more fulfilling life. We look forward to working with you to achieve your goals and celebrate your progress.

Thank you for trusting us with your care.

Warm regards,

Lauri C. Pierce | Founder & CEO
Personal Phone Number: (330) 442-2664

MISSION STATEMENT

HWS Best Health’s mission is to provide compassionate, high-quality mental health care for individuals and families, emphasizing accessibility and holistic wellness.

VISION STATEMENT

HWS envisions a community where mental health is prioritized and accessible to all, promoting wellness of mind, body, and spirit.

 

INSURANCE – PAYMENT AND HOURS OF OPERATION

We accept all Medicaid/Medicare Products.  We accept most private insurances.  We are able to make arrangements for self-pay. Our self-pay rates generally reflect the current fee schedule for community mental health center providers set by the Ohio Department of Medicaid.

Our Counselors and Support Team are available:  Monday – Friday 7 am – 7 pm and other hours by appointment.  

PROGRAM OVERVIEW AND DESCRIPTION

Founded and incorporated in 2021, HWS Best Health, LLC is a private, for-profit organization dedicated to providing mental health treatment services to children, adults and families who are impacted or affected by mental health challenges.  

 

HWS Best Health, LLC provides treatment services to individuals ages 3 years and older.  The company provides services in the school setting, home setting, community and via telehealth.

Inherent in HWS Best Health, LLC ’s mission is the fact that mental health issues are treatable and that its attendant medical, psychological and social problems can be treated in an effective manner such that individuals may enjoy a satisfying, healthy life.  

To establish a foundation for ongoing healthy living, the individual must not only recognize and accept the need for mental health intervention but also undergo changes in his or her behavior, attitude, values, beliefs, and lifestyle. Such changes are explored within the client’s cultural and ethical worldview.

The psychodynamic approach utilized by HWS Best Health clinicians and staff provides principles and tools as well as a support network for the client both during and following treatment. Within a structured, supportive therapeutic milieu, the client is assisted to develop goals to improve his or her quality of life.  Clients learn new ways to cope, function and improve relationships. 

Prospective clients can be a self-referral, referred by their school counselor, referred by Child Protective Services, DJFS, and other community providers/stakeholders.

The admission process begins with an initial assessment with a counselor at HWS which allows staff to determine the level of medical necessity. If the person is accepted, a follow-up appointment is scheduled where the treatment plan is then created. The continued stay/transitions in programming/discharge criteria are monitored for each person served throughout the provision of care. Where treatment plan updates occur as needed, but at a minimum of every 90 days. As with admissions, any transition or discharge of a person served is determined based on client need, client preference and medical necessity.

Every effort is made to respond to an individual’s needs, e.g., financial, medical, legal, etc. Initial and ongoing assessments and evaluations provide a basis for formulating individualized treatment plans as well as identifying the need for any external services. Linkages with other community‐based agencies are established and referrals to ancillary services are facilitated as needed. The development of the individual treatment plan takes into consideration the client’s lifestyle, ethnic and cultural background, strengths, needs, abilities, preferences, and the support systems that will enhance the person’s treatment outcomes. 

Clients and staff collaboratively assess a client’s strengths, needs, abilities, and preferences to develop a treatment plan designed to reduce or eliminate emotional, behavioral, and situational obstacles to   enhance his or her skills and abilities.  The client’s progress and needs are continuously evaluated and assessed throughout the treatment process with modifications made to treatment and continuing care/discharge plans.

Clients are assisted in addressing key issues critical to the maintenance of improving mental health functioning through an integrated approach utilizing recognized counseling methods and other treatment modalities and strategies including individual and group counseling, trauma services such as psychoeducation, intra‐ and inter‐personal skill development. 

The therapeutic environment provides an arena for clients to internalize concepts and tools, implement newly acquired skills, while fostering “personal empowerment” as clients learn to take responsibility for their actions and attitudes. A combination of supportive, insight oriented, motivational interviewing, and cognitive behavioral approaches are utilized depending upon the individual client. Additionally, where feasible, the client’s family and educational support system are engaged in the treatment process through individual family sessions and educational sessions facilitated by a licensed therapist.

The multi‐disciplinary treatment team is comprised of Clinical Director, clinical staff, interns, licensed professionals such as LSW, LPC, QMHS etc. 

A full spectrum of outpatient treatment services are offered to clients, based upon their individual needs as assessed at intake and throughout their participation in the program.

The assignment to, and frequency of, services, corresponds to individualized treatment plans within the context of the level of care and treatment intensity level.

Individual Counseling - Depending on length of treatment, client’s needs, and level of care, sessions may be initially scheduled for once a week; as the client progresses through treatment the frequency of sessions may be reduced. The focus of sessions is based on the treatment problems and goals as outlined in the client’s treatment plan.
Family Therapy – Counseling for the family led by a licensed therapist such as a social worker, professional counselor, etc. which work toward client treatment plan goals and allow clients to learn how to improve functioning within their family of origin. 
Medication Management (Medsom) - Medication management services are provided exclusively through telehealth to ensure clients have convenient and accessible care. Sessions with a licensed medical provider, such as a psychiatrist or psychiatric nurse practitioner, are tailored to address the specific mental health needs of each client. During these sessions, providers evaluate the effectiveness of prescribed medications, monitor for any side effects, and make adjustments to enhance therapeutic outcomes. The goal of medication management is to support the client’s overall treatment plan, helping them achieve mental health stability and improved quality of life through safe and effective use of medication.
Case Management Services - HWS Best Health offers a community psychiatric supportive treatment (CPST) program to individuals and families who are struggling with mental health challenges and certain co-occurring conditions. Our expert CPST team provides case management and advocacy services that help people access the care they need so that they can start their better health journey.
Therapeutic Behavioral Services: HWS Best Health offers TBS or Therapeutic Behavioral Services based on the “Social Support Theory,” which indicates that social support can have positive effects on an individual’s overall well-being. Social skills are important because they allow children and adults to have positive experiences at home, school, and in the community.  In addition, the program uses Cognitive-Behavioral Therapy (CBT) to help client’s change their thoughts and behaviors as it relates to social, communication, problem solving, conflict-resolution, and independent living skills.  
 

By the time a client is ready to complete the program, it is anticipated that the client’s awareness and acceptance of his/her diagnosis and commitment to treatment is sufficient to expect maintenance of an improved way of living. Clients will utilize his/her strengths, skills, and coping strategies s/he learned in treatment. Other evidence of one’s readiness for completion include:

The client has met all goals identified in the individualized treatment plan.
 

PROGRAM RULES

As a participant in services at HWS Best Health Counseling & Psychiatry, I agree to abide by the following rules:

I will be on time for my scheduled appointments. If I am more than ten (10) minutes late, I understand I may not be seen and may need to reschedule the appointment.
I will adhere to the agreed-upon terms of my financial agreement. I understand that payment is expected at the time of service unless other arrangements have been made.
I agree to abstain from the use of alcohol or other drugs not prescribed for me while participating in programs. I will inform my counselor or care team of any prescribed or over-the-counter medications I am taking. Verification may require a release of information from the prescribing provider.
I will not possess, sell, or use any illicit drugs, alcohol, or drug paraphernalia while on HWS premises or in the parking lot.
For clients receiving medication management services through HWS, I agree to submit to a urine drug screen or breath screen if requested.
I understand that smoking, vaping, or using tobacco products is permitted only in designated areas.
I will not sexually, physically, or verbally assault, threaten, or abuse any HWS staff member or other program participants.
I will not willfully damage or steal the property of HWS, its staff, or other program participants.
I will not carry or conceal any weapons, including pocketknives, on HWS premises.
I understand that prescription medication should not be brought onto the premises unless deemed medically necessary. If I am required to have prescription or over-the-counter medication with me, I agree to bring it in the original container and keep it in my possession at all times while on the premises.
I understand that loitering on HWS premises is not permitted for safety reasons.
I agree to respect the confidentiality of all other program participants. I will not discuss any participant's name or case outside of my scheduled sessions or groups. Violating confidentiality may result in dismissal from services.
I am responsible for providing childcare when attending appointments or group sessions. Children may not attend sessions without prior permission from my counselor or care team. If a child is left in the lobby, I must provide a responsible caregiver to supervise them. HWS cannot assume responsibility for the safety and well-being of children.
I will comply with the HWS dress code and refrain from wearing clothing with alcohol, drug, violent, or offensive messages.
I agree to provide at least 24 hours' notice to cancel any appointments. Failure to do so may result in the appointment being considered unexcused.
I understand that after three (3) unexcused absences (missed appointments, canceled appointments without 24-hour notice, or no call/no show), I may be discharged from services due to non-compliance.
I will register to use the HWS client portal to complete consent forms, access billing statements and receipts, make payments, and communicate with providers and administrative staff at HWS.
I understand and agree that violations of these rules may result in dismissal from services, and my referral source may be notified. I also understand that serious violations may require HWS to notify local law enforcement, which could result in criminal charges.
 

DRESS CODE

UNACCEPTABLE ATTIRE

To maintain a professional and respectful environment, the following types of clothing are not permitted while attending appointments, groups, or other services at HWS Best Health Counseling & Psychiatry:

T-shirts with logos promoting alcohol, drugs, or containing offensive, violent, or inappropriate messages
Spandex or Lycra clothing, such as biker shorts
Underwear worn as outerwear
Beachwear, including swimsuits
Midriff tops or crop tops that expose the stomach
Clothing made of mesh or sheer materials that expose undergarments or private areas.
 

If you choose to wear questionable or inappropriate attire, your counselor or a supervisor may hold a personal, private discussion with you to address the inappropriateness of the attire and provide guidance on acceptable dress moving forward.

 

CLIENT RIGHTS

Each HWS BEST HEALTH, LLC client has all of the following rights: (except for clients receiving forensic evaluation services as defined in rule 5122-29-07 of the OAV from a certified forensic center, or attending a driver intervention program as defined in rule 5122-29-12 of the OAC-

The right to be treated with consideration and respect for personal dignity, autonomy and privacy;
The right to reasonable protection from physical, sexual or emotional abuse, neglect and inhumane treatment;
The right to receive services in the least restrictive, feasible environment;
The right to participate in any appropriate and available service that is consistent with an individual service plan (ISP), regardless of the refusal of any other service, unless that service is a necessity for clear treatment reasons and requires the person's participation;
The right to give informed consent to or to refuse any service, treatment or therapy, including medication absent an emergency;
The right to participate in the development, review and revision of one's own individualized treatment plan and receive a copy of it;
The right to freedom from unnecessary or excessive medication, and to be free from restraint or seclusion unless there is immediate risk of physical harm to self or others;
The right to be informed and the right to refuse any unusual or hazardous treatment procedures;
The right to be advised and the right to refuse observation by others and by techniques such as one-way vision mirrors, tape recorders, video recorders, television, movies, photographs or other audio and visual technology. This right does not prohibit an Organization from using closed-circuit monitoring to observe seclusion rooms or common areas, which does not include bathrooms or sleeping areas;
The right to confidentiality of communications and personal identifying information within the limitations and requirements for disclosure of client information under state and federal laws and regulations;
The right to have access to one's own client record unless access to certain information is restricted for clear treatment reasons. If access is restricted, the treatment plan shall include the reason for the restriction, a goal to remove the restriction, and the treatment being offered to remove the restriction;
The right to be informed a reasonable amount of time in advance of the reason for terminating participation in a service, and to be provided a referral, unless the service is unavailable or not necessary;
The right to be informed of the reason for denial of a service;
The right not to be discriminated against for receiving services on the basis of race, ethnicity, age, color, religion, gender, national origin, sexual orientation, physical or mental handicap, developmental disability, genetic information, human immunodeficiency virus status, or in any manner prohibited by local, state or federal laws;
The right to know the cost of services;
The right to be verbally informed of all client rights, and to receive a written copy upon request;
The right to exercise one's own rights without reprisal, except that no right extends so far as to supersede health and safety considerations;
The right to file a grievance;
The right to have oral and written instructions concerning the procedure for filing a grievance, and to assistance in filing a grievance if requested;
The right to be informed of one's own condition; and,
The right to consult with an independent treatment specialist or legal counsel at one's own expense.
 

YOUR OTHER RIGHTS INCLUDE:

The nature of any intended treatment (including medications where applicable) including expected benefits, risks, or side effects.
Alternative and additional treatment and your right to request aid in referral.
The program’s responsibilities, should you refuse treatment, to help you seek alternative treatment or to terminate our relationship with you in a professional manner with reasonable notice. 
Basic rate changes (30-day notice), charges for additional services, or any conditions regarding reimbursement for services that may affect the duration of care.
You have the right to personal privileges consistent with health and safety factors. This includes the right to (these apply specifically to inpatient clients) wear your own clothing and maintain your personal effects.  Keep, use and have unrestricted access to your personal property within facility regulations.  Keep and spend reasonable sums of money.
Be protected from abuse and/or neglect.
Maintain individual and cultural identity.
Refuse to act as a research subject.
Supervised social interaction with members of either sex unless therapeutically contraindicated.
Receive and review itemized bills for charges.
Be free from transfer or discharge except for therapeutic reasons or violations of the program rules.
With your consent, have your presence and any change in your status acknowledged to family and guardians.
Have all reasonable requests and questions responded to promptly.
 

The following individual has been designated by this HWS BEST HEALTH, LLC as the Clients Rights Advocate who is responsible to accept and oversee the process of any grievance filed by a client or other person or HWS BEST HEALTH, LLC (complainant) on behalf of a client. The Client Rights Advocate may assist in filing and investigating the grievance and may represent the complainant at the HWS BEST HEALTH, LLC hearing on the grievance, if desired by the complainant. The Client Rights Advocate shall take all necessary steps to assure compliance with the grievance procedure.

 

Upon admission each client will be provided with a copy of the client rights. Upon written request any other person may receive a copy of the policy and procedure regarding client rights. Documentation is maintained with dated signatures by the clients, which is kept in each client’s record to indicate receipt.
The client rights procedure will be posted. This policy and procedure is posted prominently at each HWS BEST HEALTH, LLC location where clients and visitors may review them.
In a crisis or emergency situation the client will at a minimum be advised of their immediate relevant rights.
Annually the Client Rights Advocate will arrange for mandatory staff training.
HWS BEST HEALTH, LLC promotes maximum integration and inclusion of the persons served through regular evaluation of the following: any restrictions placed on the rights or privileges of the persons served; method to reinstate restricted or lost privileges and rights; and the purpose or benefit of any type of restriction on rights or privileges.
Privileges can be lost through violation of program rules or a failure to demonstrate progress in treatment. Should restrictions on privileges occur; the purpose of the restriction will be fully explained to the client and will be documented in the case record. The client will also be informed regarding the methods to reinstate restricted or lost privileges. This will also be documented in the case record.
The rights of clients are non-negotiable, i.e. they cannot be lost by the client or taken away by the organization. In contrast, privileges may be extended to clients as a result of exceptional conformance to program rules or due to extraordinary progress. Privileges, unlike client rights, can be lost through violations of program rules or a failure to demonstrate progress in treatment.
HWS BEST HEALTH, LLC maintains the rights and dignity of the persons served at all times and makes appropriate arrangements available to persons served to meet their need for privacy and safety.
When persons served participate in research, HWS BEST HEALTH, LLC adheres to all governmental regulations, professional ethics, and is approved by the Owner. HWS BEST HEALTH, LLC ensures that the confidentiality of the person served is protected. Written consent from each client participating is required. Documentation that the client made an informed choice and that he/she had the right to cease participation with no penalty is required. A written consent from clients to use, disposition, and release of the data is required.
HWS BEST HEALTH, LLC provides policies and procedures governing the rights of the person served that apply to all applicable federal and state regulations. This adherence is demonstrated in its clinical records, code of ethics, and other practices.
 

CLIENT GRIEVENCES

Information regarding the HWS BEST HEALTH, LLCs grievance procedure may be obtained from any staff person. 

 

The Client Rights Advocate for HWS BEST HEALTH, LLC is the COO, and they are available to assist you in filing and investigating your grievance. In their absence, or if they are the subject of a grievance, this grievance may be filed with the Corporate Compliance Officer.

 

The client rights advocate may be reached at:

JEFFREY BONCHEK, COO CLIENTS RIGHTS ADVOCATE 

PHONE: 760-310-3611 

JEFFREYBONCHEK@HWSBESTHEALTH.COM 

1303 W. MAPLE ST. STE. 102 NORTH CANTON, OH 44720 

AVAILABLE: MONDAY-FRIDAY 8AM-6PM 

The client rights advocate will explain the grievance procedure including the following:

Grievances are required to be in writing.
Grievances must be signed and dated.
Grievances must include (to the best of your knowledge) the date, time, description, and/or names of individuals involved in the incident or situation being grieved.
You will be notified of the name of the staff person to whom to give the grievance.
You have the option at any time to file with an outside organization including the Cuyahoga County Mental Health and Recovery Board, OhioMHAS, Disability Rights Ohio, the U.S. Department of HHS, Civil Rights regional office in Chicago.
Upon your written request, information concerning your grievance will be forwarded to any outside HWS BEST HEALTH, LLC you identify.
Written acknowledgment of receipt of the grievance will be provided within three (3) working days and includes:
Date grievance received
Summary of grievance
Overview of investigation process
HWS BEST HEALTH, LLC contact person ‘s name, address, and phone number
The Client Rights Advocate will attempt to bring about a resolution to your complaint and provide you with a written and oral explanation of the resolution within seven (7) working days of your initiation of the complaint.
If after following this step you are still not satisfied, you may appeal to the Executive Director/Executive Director within five (5) working days of receiving the decision of the Client Rights Advocate.
Within five (5) working days of your appeal, the Executive Director will schedule time to meet with you to discuss your complaint.
Within four (4) working days of your meeting with the Executive Director, you will be provided, in writing, the Executive Director's determination regarding your complaint.
A final resolution decision will be made within 20 business days of receipt of the complaint.
Any extenuating circumstances that necessitate a need for an extension will be given to you in writing.
If the hearing by HWS BEST HEALTH, LLC does not settle the grievance to your satisfaction, or you do not want to bring your grievance to HWS BEST HEALTH, LLC, then you may take it to the County Mental Health and Recovery Board.
The Client Rights Advocate will be available to help you prepare and present your grievance if you so desire. 
You have the right to initiate a grievance outside HWS BEST HEALTH, LLC. This could involve the following:

Stark County ADAMH’s Board 

121 Cleveland Ave SW 

Canton, OH 44702 

(330) 455-6644 

 

OhioMHAS

30 East Broad Street

36th Floor Columbus, Ohio 43215-3430

(614) 466-2596

 

Attorney General's Office

30 E. Broad Street, 14th Floor

Columbus, Ohio 43215

(614) 466-4986

 

Disability Rights Ohio

200 S Civic Center Dr #300,

Columbus, OH 43215

(614) 466-7264

 

CSWMFT Board

50 West Broad Street #1075

Columbus, Ohio 43215-3344

(614) 466-0912 Office

(614) 728-7790 Fax

               

Ohio State Medical Board

30 East Broad Street 3rd floor

Columbus, Ohio 43215-6127

(614) 466-3934 Office

(614) 728-5946 Fax

 

Ohio Board of Nursing

17 South High Street #400

Columbus, Ohio 43215

(614) 466-3947 Office

U.S. Dept of Health and Human Services

200 Independence Avenue, S.W.

Room 509F HHH Bldg.

Washington, D.C. 20201

(877) 696-6775 Office

 

Ohio State Board of Psychology

77 South High Street #1830

Columbus, Ohio 43215-6108

(614) 466-8808 Office

(614) 728-7081 Fax

 

OCDP Board

77 South High Street, 16th Floor

Columbus, Ohio 43215

(614) 387-1110 Office

(614) 387-1109 Fax

 

YOUR CIVIL RIGHTS ARE GUARANTEED BY LAW. In agreement with the letter and spirit of the Civil Rights Act of 1964, all the programs operated by HWS BEST HEALTH, LLC admits and provides services without discrimination due to race, ethnicity, age, color, religion, sex, na­tional origin, sexual orientation, handicap or developmental disability, or any person with HIV infection, whether asymptomatic or symptomatic, or AIDS.  This policy includes (but is not limited) to the following: a) admission b) assignment of staff to client services c) provision of treatment d) use of facilities f) client transfer or discharge.

AFTER HOURS RESOURCES IN THE COMMUNITY

Your local County Mental Health and Recovery Board
Online helplines and resources such as:
Suicide and Crisis Lifeline; Call or Text 988
The National Suicide Prevention Lifeline; Call 1-800-273-TALK (8255)
The Trevor Project Website; The leading LGBTQ youth suicide prevention organization with a “Reach a Counselor Button” including a quick exit feature for safety.
Alcoholics Anonymous: (510) 839-8900
Poison Control: (800) 222-1222

ADVANCE DIRECTIVES

For more information on end of life decisions including durable power of attorney and living wills, see a counselor, case manger, or the client rights advocate. Or you can access the information at http://www.caringinfo.org/files/public/ad/Ohio.pdf