Consent for Billing
Client's Responsibilities:
- I understand that I am responsible for providing accurate credit card information to MBMHW before services are rendered. I further understand that MBMHW does not bill my insurance and I am responsible for the entire balance of services rendered.
- I understand that my lack of cooperation in submitting any necessary information regarding a valid credit card information constitutes a refusal to cooperate and may result in the termination of services.
- I understand that it is my responsibility to notify MBMHW should I have a change of address, phone number, and/or email address as soon as possible for billing purposes.
- I understand that providing false information to avoid financial liability can result in termination of services or my responsibility for the full-service fee.
- I understand that MBMHW services have the right to enforce collection procedures, legal action, and/or refusal of services at the time service charges become delinquent.
- I hereby certify that I have read and understand the information stated above and certify that all information given is true and accurate.
Consent and Acknowledgment of receipt of Notice of Privacy Practices
I understand that as part of the provision of healthcare services, Mind Balance Mental Health and Wellness (MBMHW) may create and maintain health information and other information pertaining to my health history, progress toward goals, evaluation and assessment results, crisis events, services of treatment, and any plans for future care or treatment (PHI - Protected Health Information I have been provided with a Notice of Privacy Practices that provides a more complete description of the uses and disclosure of certain health information. I understand that I have the right to review the Notice of Privacy Practice before signing this consent. I understand that MBMHW reserves the right to change the Notice of Privacy Practices and before implementation will give me a copy of any revisions if requested. I understand that I have the right to object to the use of PHI for directory purposes. I understand that I have the right to request restrictions as to how my PHI may be used or disclosed to carry out treatment, payment, or healthcare operations (quality assessment and improvement activities, underwriting, premium rating, conducting or arranging for medical review, legal services, and auditing functions, etc. I also understand that the organization is not required to agree to the restrictions requested. By signing this form, I consent to the use and disclosure of PHI for the purpose of treatment, payment, and health care operations. I have the right to revoke this consent at any time, in writing, except where disclosure has already been made in reliance on my prior consent. This consent is given freely with the understanding that:
- Any and all records, whether written, oral, in electronic format, are confidential and cannot be disclosed for reasons outside of treatment, payment or healthcare operations, without my prior written authorization, except as otherwise provided by law.
- A photocopy or fax of this consent is as valid as this original.
- I have the right to request that the use of my PHI, which is used or disclosed for the purposes of treatment, payment or healthcare operations are restricted. I also understand that MBMHW andI must agree to any restrictions in writing that I request on the use and disclosure of my PHI and agree to terminate any restrictions in writing on the use and disclosure of my PHI, which have been previously agreed upon.
Disclosure of Business Affiliate Organization:
All administrative tasks including office management, billing, maintenance of medical records, human resource management, advertisement, etc., are completed by MBMH Management LLC (MBMH MBMH is a sister company of Mind Balance Mental Health and Wellness, PLLC (MBMHW) and there is a contract agreement between the two entities to ensure that our patient's confidentiality information is protected based on federal and state confidentiality/HIPAA guidelines.
Authorization to Approve Emergency Medical Care
In the event of a serious medical emergency where immediate medical care is needed for me (or client), and where the individual, legal guardian, or other responsible person is not immediately available to authorize medical care:
- Seek emergency medical care from EMS, hospital or physician.
- Authorize the provision of emergency medical procedures as recommended by a licensed physician, and
- Release verbally or in writing such medical information about the individual as may be requested by the attending physician.
- This authorization is good for one year from the signature date unless otherwise I specify period (not to exceed one year)
- I understand that:
- MBMHW staff will make every effort to contact family or emergency contact designee immediately.
- MBMHW is not responsible for any charges that are incurred as a results of emergency medical services.