RBH COMMUNITY CARE CLINIC -
PSYCHOLOGICAL SERVICES INFORMED CONSENT FORM
Many people are struggling with stress, depression, anxiety, relational difficulties, and trauma. While RBH offers many therapists who are in network with your health plan, there may be times that a patient is in need of services sooner than a credentialed clinician’s schedule allows. There may be other times that a patient is in need of discounted counseling rates for financial reasons. RBH is pleased to offer the periodic availability of Post-Doctoral Psychology Residents (under the supervision of a Psychologist), LPC Associates (under supervision of an LPC), as well as fully licensed clinicians who are in the process of credentialing with health plans to help you or your family member in a time of need. The RBH Community Care Clinic is offered at the cash-discounted Fee-For-Service rates listed below which are due at the time of service delivery. No claims are submitted to Health Plans for this program and costs occurred with services under this clinic are not eligible to be counted toward meeting Health plan deductibles. Please note that once clinicians complete the credentialing process with health insurance companies, they are no longer available to participate in the Community Care Clinic, and continuation of care with that clinician would then apply to the standard RBH Fee Schedule and/or patient’s health insurance benefit coverage. The patient/legal guardian will have to determine directly if these services would qualify for any Health Savings benefit coverage. The program does not cover services that are covered with a credentialed provider under your health plan.
Cash Discounted Fee-For-Service Rate Schedule:
|
Service
|
LPC Associate
(Masters)
|
Licensed Masters Clinician
(LPC, LCSW) -Pending Insurance Credentialing
|
Post-Doctoral (Ph.D./Psy.D.) Psychology Resident
|
Licensed Psychologist
(PHD/PsyD) – Pending Insurance Credentialing
|
| Individual Therapy - 45 min |
$30.00 |
$40.00 |
$50.00 |
$70.00 |
Cancellation Policy: Patients are asked to keep their appointments, as this time as been specifically reserved for you. Please notify the office of any need to cancel your appointment with 72 hours notice in order to avoid the cancellation fee.
*$15.00 Cancellation Fee - (Mon.-Sat.) Therapy Appointments
*** If there are three or more cancellations, we will be unable to accommodate scheduling recurring appointments;
Confidentiality: All records will be kept confidential and will be held in accordance with the state and federal regulations regarding the confidentiality of such records and Personal Health Information. Privileged information will only be released upon the client’s written authorization. The following are exceptions to the privilege of confidentiality:
1) All situations involving abuse or neglect, or suspicion thereof, of a child or elderly person must be reported to the appropriate protective agency.
2) If there is an imminent danger of harm to self or others, information may be released to the medical and/or law enforcement personnel for the coordination of emergency care.
3) Records must be released in accordance with any court proceedings, subpoenas, qualified audits, program evaluations or investigations authorized by state or federal regulations. RBH does NOT accept court-related cases or conduct custody evaluation & can provide a referral for these cases.
Release of Information: RBH may release information with your consent for the reasons noted on your signed HIPAA notice. RBH may be required to release information regarding your assessment and/or treatment with your insurance company pertaining to authorization or medical necessity determinations. Clinical case information may be communicated to other health care professionals for the purposes of consultation and/or training, and such communications will be bound by the same professional and ethical guidelines regarding confidentiality. Releasing information to another health care professional or family member for the purpose of coordination of care will take place only with your specific authorization.
Emergency/On-Call Services: In the event of an emergency after hours please call 9-1-1- or proceed to the nearest hospital. Restore Behavioral Health does NOT offer after hour’s on-call services.
Access of Records: The laws and standards of the profession of psychology require maintenance of treatment records. Adult clients and legal guardians or minors, including managing and possessory conservators, have the right to access the record of the services provided to them or their child. If such access is determined to be of potential harm to a client, the information will instead be summarized or shared directly with an authorized health care professional.
Treatment of a Minor: Treatment of children under the age of 18 will be provided with the consent of the Parent or Legal Guardian. For divorced parents, managing conservators are required to provide consent for treatment of the minor. A copy of the divorce decree or court order designating conservatorship is required at the time of intake. In some emergency situations, a minor may consent to his/her own treatment.
I have read and understand this statement of informed consent. I voluntarily consent to treatment at Restore Behavioral Health with the knowledge of the above conditions.
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