If I am unable to attend my child’s appointments, I designate the following person as my substitute for my child’s medical care. I understand that my health care surrogate may attend my child’s appointments on my behalf which is valid for (1) year unless I revoke it in writing beforehand.

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 an authorization must be separate from an authorization to release other medical records.

THIS NOTICE DESCRIBES HOW MENTAL HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN ACCESS 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 these notices 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 INFORMATIONFOROTHER 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.
In JUDICIAL PROCEEDINGS in response to court/ administrative orders, subpoenas, discovery requests, or other legal processes
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 SENATEOR ASSEMBLYRULESCOMMITTEES for legislative investigations.
FOR RESEARCHPURPOSES subject to a special review process and the confidentiality requirements of state and federal law.
TO PREVENT A SERIOUS THREAT TO THE 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.

Authorization and Signature
I understand that my health information is protected and confidential, as described in my instructions above. I understand that the information is protected by law and that use/ disclosure will be in accordance with my instructions. The recipient may re-disclose the information that is used and/ or disclosed accordingly, unless the recipient is covered by state laws limiting the use or disclosure of my protected health information. 

I acknowledge that I have received and read the notices of privacy practices with my rights, responsibilities and obligations by Hands of Hope Texas, LLC. I am aware that if I have any questions regarding privacy practices and HIPAA law, I will contact Hands of Hope office.

Protected Health Information: Hands of Hope TEXAS, LLC. You have a policy procedure for a client who believes that information in his or her medical record is incorrect or incomplete and wishes to have the information modifies or changed and I understand this policy and my rights under HIPAA law.

HIPAA Law: Hands of Hope TEXAS, LLC. You agree to follow federal and state HIPAA and will not use or disclose the client's information for any reason other than necessary for the benefit of the client's treatment.

I chose Hands of Hope Texas, LLC. Located at 13140 Coit Rd Ste.200, Dallas TX 75240 and certify that: a) I have freely chosen this location for my child to receive mental health services; b) I understand that I have the right to choose the provider of my choice; c) I understand that I have the right to change providers at any times under any circumstances; d) I certify that I have read the clients rights and responsibilities and the confidentiality and security of medical records policy regarding the services provided to me.

Individual Evaluation of 60 minutes $175 dollars.

Individual session of 60 minutes $125 dollars.

Psychiatric Evaluations of 60 minutes $175 dollars.

Medication management of 20 minutes $150 dollars.

Evaluation management for Immigration process $1,200 dollars.

Family sessions of 90 minutes $180 dollars.

An additional amount of $15 dollars will be charged for each extra 15 minutes. And an amount of $25 dollars per appointment missed or not canceled within 24-hour notice period.

Our staff is available to meet with clients via Telehealth video conferencing. Please note that the confidentiality and exceptions thereto that have been described in this Hands of Hope Texas, LLC Services Consent also applies to Telehealth services.
This informed consent to receive Telehealth services contains information focused on psychotherapy and psychiatry services that use the telephone or internet. Please read carefully.

Benefits and risks of Telehealth services
Telehealth refers to the provision of psychotherapy and psychiatric services remotely using telecommunications technology through video conferencing. One of the benefits of Telehealth is that the client and professional can provide services without being in the same physical location. Telehealth however, requires a good technical connection on both sides to be useful. Although there are benefits to Telehealth, there are some differences between in-person services, as well as some risk. For example:

Condidentiality Risk: Because the telehealth session takes place outside of the practitioner's private office, there is a chance that others may overhear the session if the client is not in a private location during the session. The professional will take reasonable measures to ensure the client's privacy. It is important that the client finds a private place for the session where there will be no interruptions. It is also important for the client to protect the privacy of the session via cell phone or other electronic devices. The client should participate in the session only while in a room or area where other people are not present and cannot hear the conversation. We strongly suggest that you only communicate through a device that you know is secure and is technologically secure (for example, has a firewall, antivirus software installed, is password protected, does not access the Internet over a public network wireless, etc.) during a session with a client, the professional will make all the reasonable efforts to ensure the client’s privacy in the space in which he or she provides services, as well as on the device used to provide the service.

Technology Issues: There are many ways that technology issues can impact Telehealth services. For example, there may be difficulties with hardware, software, equipment and/or services provided by a third party that may result in service interruptions; technology may stop working during a session; other people could have access to the private conversation; could be accessed by unauthorized person or companies. Hands if Hope Texas, LLC is taking all reasonable measures to ensure the confidentiality of customer information on devices and systems used by HOH to provide services; Please read the Confidentiality Section below for additional information.

Crisis Management and Intervention: The professional will not engage in Telehealth with clients who are currently in crisis and require heigh levels of support and intervention. Prior to participating in Telehealth, the client and practitioner will develop an emergency action plan to address potential crisis situations that may arise during the use of Telehealth. The professional will determine if a client is in crisis using his or her professional knowledge to evaluate the general circumstance presented.

Electronic communication: The client and the professional will decide together what type of Telehealth services they are going to use. The client may be required to have certain computer or cell phone systems to use Telehealth services.

Confidentiality: The professional has the legal and ethical responsibility to make the best efforts to protect all communications that are part of the Telehealth services. However, the use of technology for electronic communications is such that the professional cannot guarantee that the communication will be kept confidential or that others will not be able to access them. The professional will try to use encryption methods, firewalls, and backup systems to help keep the client information private, but there is a risk that the electronic communication may be compromised, unsecured, or accessed by others. The client must also take responsible steps to ensure the security of communications (for example, only using secure networks for Telehealth sessions and having a password to protect the device used for Telehealth).

Emergencies and Technology: If the session is interrupted for any reason, such as a connection failure, and the client has an emergency, do not call your clinician; call 911 or go to the nearest emergency room. If the session is interrupted and the client does not have an emergency, please log out of the session and the practitioner will wait (2) minutes and then contact you again via the Telehealth platform on which we agreed to conduct the therapy.

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

Informed consent

I understand that this is a modification to my previously signed consent for treatment – HOH Consent to Receive Services and I hereby consent to the provision of services. 

If my child has a crisis, Hands of Hope TEXAS LLC must be notified immediately. If the crisis occurs during non-working hours, on weekends, or holidays, you should call 911. Understand what crisis behaviors may include:

A. Physical assault.
B. Verbal threats
C. Self-harm
D. Destruction of property

 

Crisis Plan

In case of crisis please do the following:

1. Try to stay calm.
2. In case of an emergency that endangers your life, call 911.
3. In case of a mental health crisis, contact the crisis number 988.
4. In case of minor crises contact your LPC or QMHP/CSSP.
5. If you are unable to contact your provider, please contact out office at 469-      480-9021.

I understand that normal routine services will be provided during business hours including medications refills, appointment changed, and other non-emergency situations.

I affirm that I have read the crisis and emergency procedure of Hands of Hope Texas, LLC. And I understand the steps I should take in the event of an emergency crisis. I understand that my child will receive a personalized crisis plan after the evaluation and I will attempt to use this crisis plan for crisis or emergency intervention. I will inform my child’s therapist or QMHP the next business day. Hands of Hope provides assistance with any problems or difficulties, but we cannot help if we are not notified of the problems the client is experiencing.

At Hands of Hope TEXAS, LLC. We provide open and productive communication between clients and staff; However, we recognize that sometimes miscommunication and misunderstanding can occur. Each client and/or family has the right to express their opinions and air any perceived or actual grievances through a formal grievance procedure.

I. Policy: Recipients and/or parents/ legal guardian have the right to complain if they believe they have been treated incorrectly. They will not be subject to disciplinary action or retaliation of any kind for filling complaints.
II. Procedures: 

a) Recipients will request a meeting with the staff member providing their services to discuss the issue.
b) If the recipient and staff are unable to resolve the issue, the recipient must request a meeting with the staff member’s supervisor (QMHP), who will meet with the recipient within three (3) days.
c) If the issue remains unresolved, the recipient has five (5) days to file a formal written complaint and forward it to the office manager. If the recipient/ recipient’s family needs assistance with the written complaint, staff members who are not involved are available to assist.
d) The program director and clinical director (if necessary) will meet with the recipient to attempt to resolve the issue. The program and/ or clinical director will issue a written response to the recipient within five (5) business days.
e) If the issue has not yet been resolved, a meeting will be scheduled with the Executive Director. A formal written response will then be sent to the recipient within five (5) business days.
f) While the complaint process specified above has been developed as a means of cooperatively resolving complaints, the recipient may at any time register a complaint with the following agencies and seek their assistance in achieving a resolution:

 

Call the Texas Health and Human Services Commission at: 1-866-566-8989 Send your complaint in writing to:
Texas Health and Himan Services Commission
Medicaid/CHIP Health Plan Management (Mail Code H-320)
P.O. Box 85200 4900 N. Lamar, Austin TX 78708-5200

Other reasons for termination of treatment, client discharge, or case transition may include, but are not limited to, the following:

1. The recipient moved and/ or lost contact.
2. The recipient is admitted to a correctional facility or group home.
3. The recipient is admitted to a mental health institution or long-term inpatient treatment nursing facility.
4. The recipient is not available for services.
5. The recipient has passed away.
6. Administrative closure.
7. The beneficiary no longer meets the Medicaid/ eligibility criteria.
8. The recipient requires a level of care beyond what Hands of Hope can safely provide.
9. The safety of the recipient and/or staff is at risk.
10. Support systems are in place to maintain the client in a less restrictive environment.
11. The recipient or guardian has transferred services to another agency or care provider for treatment.
12. Non-compliance with treatment.

In the event that a recipient is discharged, the following procedures will be followed:

1. The LMHP will complete the following discharge/ transition planning form.
2. Hands of Hope Texas, LLC will send a certified letter to the client or parent/ guardian confirming discharge or transition of services and indicating any necessary referral information.
3. LMHP will follow up with the discharge beneficiary within 72 hours of discharge for unplanned discharges and within 30 days for planned discharges/ transitions.
4. If the termination occurred for aggressive behavior, LMHP and authorized family members will meet within 72 hours to discuss available options within the community or state.
5. If the recipient has caused harm to Hands of Hope Texas, LLC staff, the procedure is to immediately contact local authorities and remove the client from the facility. In this circumstance the law enforcement agency and judicial system will be notified immediately
6. If the recipient transfer services to another agency or provider, Hands of Hope Texas will make their records available once the recipient or parent/ legal guardian has signed the appropriate consent to release information.

 

The policy and procedure for termination of treatment case closure and/ or transition has been explained to me and I understand the reasons why I may be terminated from services.