Please Note

If you are seeking assistance for a minor under 18, please use our Minor Registration Form.

Guarantor Information

This person assumes financial responsibility for payments.

Please list an emergency contact.

Informed Consent for Treatment

I consent that I am at least 18 years old and signing to each and every term in this agreement, with full and complete authority to act for Patient on whose behalf I am signing, consent to treatment services provided by Family & Addiction Counseling LLC located at 1888 Kalakaua Ave. Suite C312, Honolulu, Hawaii 96815.

The Treatment Process

In order for care to be effective, it is necessary for both provider and patient to take an active role in the treatment process.

Participation involves being open to each other's thoughts and ideas, being honest with each other, discussing concerns about the process, completing outside assignments when appropriate, and providing ongoing feedback to the provider about the process.

While treatment is often beneficial for many people, some people may not find services helpful. The treatment process can also evoke strong feelings and sometimes produce unanticipated change in one’s behaviors, thoughts, and feelings, family members, and friends.

In order for you to maximize your experience, it is helpful to discuss with your provider any questions or discomfort you may experience during therapeutic process. You have the right to ask any questions, at any time, about what occurs during treatment.

You have the right to refuse the use of any treatment technique at any time.

Emergency Situations

Counseling and medical appointments are available throughout the week. If for some reason you are unable to contact your provider, you may obtain assistance by calling 911, the Crisis Help Line at (808) 832-3100 (Oahu) or 1-800-753-6879 (off-island), or by going to your local hospital emergency room.

Scheduling

You and your provider will collaborate on your frequency of sessions, number of sessions, goals, and type of treatment throughout the care process.

You and your provider may re-evaluate the frequency of your sessions as situations arise and/or as you move towards your goals.

We routinely check for voice and text messages during regular business hours and usually all calls are returned within 24 hours.

If your provider is not available immediately by phone, messages may be left at (808) 494-6066. Text messages may also be sent to through our SMS scheduling system.

Confidentiality

Under most circumstances, all information about you, in written or verbal form, obtained in the treatment process (including your identity as a client) will be kept ethically and legally confidential. Information will not be disclosed to any outside person(s) or agency without your written permission except in certain situations, which include, but are not limited to:

• If you are determined to be in imminent danger of harming yourself or someone else.
• If you disclose abuse or neglect of children, the elderly, or a disabled person(s).
• Diagnosis and services shared with your insurance company to collect payments.
• To qualified personnel for certain kinds of audits or evaluations.
• In cases where the client signs a release of information form.
• In court proceedings and where otherwise legally required.
• Information necessary for supervision or consultation.
• Information for business operations including accounting, data management, and laboratory testing systems.

Any information that you also share outside of treatment, willingly and publicly, will not be considered protected or confidential by a court. The above is considered a summary. If you have questions about specific situations or any aspects of confidentiality, please feel free to discuss your concerns with your provider.

Termination

• You have the right to decide not to enter treatment with your provider and to end treatment at any time.
• Your provider reserves the right to deny services to individuals whose concerns are beyond the scope of competence as well as to any individual that abuses or misuses services in any manner, e.g. non-compliance with treatment, frequent missed appointments, delinquent payment, etc.
• If your provider is unable to offer you services for your specific needs, we will discuss other local treatment options and possible referrals with you. Alternative medical and counseling providers may be found by contacting your insurance company directly.

Since this may be different than the type of consultation with which you are familiar, it is important that you understand and agree to the following statements.

Expected Benefits

• Improved access to care.

Possible Risks

There are potential risks associated with the use of telemedicine. These risks include, but are not limited to:

• Information transmitted may not be sufficient (e.g. poor resolution of images) to allow for care.
• The transmission of patient’s medical information could be interrupted by unauthorized persons; and/or the electronic storage of my medical information could be accessed by unauthorized persons; and a lack of access to complete medical records may result in adverse reactions or other judgment errors.

Key Understandings

• I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine.
• I understand that I have the right to withhold or withdraw my consent to the use of telemedicine.
• I understand that I have the right to inspect all information obtained and recorded in the course of a telemedicine interaction, and may receive copies of this information for a reasonable fee.
• I understand that a variety of alternative methods of medical care may be available to me, and that I may choose one or more of these at any time. I understand that I may ask my Provider this.
• I understand that telemedicine may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including out of state.
• I understand that it is my duty to inform my Provider of electronic interactions regarding my care that I may have with other healthcare providers.
• I understand that telemedicine based services and care may not be as complete as face-to-face services. I also understand that if my Provider believes I would be better served by another form of service (e.g. face-to-face services), I will be referred to a Provider who can provide such services in my area.
• I understand that there are potential risks and benefits associated with any form of treatment, and that despite my efforts and the efforts of my Provider, my condition may not improve, and in some cases may even get worse.
• I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.
• I understand that in the event of an adverse reaction to the treatment, or in the event of an inability to communicate as a result of a technological or equipment failure, I shall seek follow-up care or assistance at the recommendation of my Provider.

Phone Calls

FAC LLC will call clients to schedule treatment and discuss care. By signing below, you are saying that you have considered and understand the limitations of confidentiality and agree that you are responsible for keeping your phone calls and voice messages private to the extent that you desire them to be private. You request that FAC LLC provide you treatment related communications via phone.

Text Messages

FAC LLC will text message clients to schedule treatment and discuss care. By signing below, you are saying that you have considered and understand the limitations of confidentiality and agree that you are responsible for keeping your text messages private to the extent that you desire them to be private. You request that FAC LLC provide you treatment related communications via text message.

Email

It is our normal practice to email message clients. You agree and request that FAC LLC provide you with electronic billing, schedule reminders, and treatment related communications and information via email. Your provider cannot guarantee that your e-mail will remain confidential. Although your provider may keep your e-mail message private, your provider cannot ensure administrators of networks and experienced computer users may be able to access e-mail. When communicating via email, it is important to remember that confidentiality is limited. By signing below, you are saying that you have considered and understand the limitations of confidentiality and agree that you are responsible for keeping your email account private to the extent that you desire it to be private.

Purpose

We understand the importance of privacy and are committed to maintaining the confidentiality of your medical information. We make a record of the medical care we provide and may receive such records from others. We use these records to provide or enable health care providers to provide quality medical care, to obtain payment for services provided to you as allowed by your health plan and to enable us to meet our professional and legal obligations to operate our practice properly. We are required by law to maintain the privacy of protected health information and to provide individuals with notice of our legal duties and privacy practices with respect to protected health information. In the event of a breach of your unsecured personal health information, we are required to notify you. This notice describes how we may use and disclose your medical information. It also describes your rights and our legal obligations with respect to your medical information. If you have any questions about this Notice, please contact our Privacy Officer at the number or email address listed at the end of this Notice of Privacy Policies.

How We May Use or Disclose Your Health Information

We collect health information about you and store it in an encrypted electronic record. By law, we are required to ensure that your protected health information (referred to in this Notice of Privacy Practices as “PHI,” “medical information” or “health information”) is kept confidential. PHI consists of information created or received by us that can be used to identify you. It contains data about your past, present or future health or condition, the provision of health care services to you, or the payment for such services. Under the Health Information Portability and Accountability Act (“HIPAA”), we can use or disclose your PHI under the following circumstances:

1. Treatment. We may use or disclose your PHI in order to provide, coordinate or manage your medical care. For example, we disclose medical information to our employees and others within our practice who are involved in providing the care you need. In addition, we may share your medical information with other physicians, pharmacists, laboratories, medical technology companies, or other health care providers who are not part of our practice and who will provide services to you and may provide you with their Notice of Privacy Practices.

2. Payment. We may use and disclose PHI to obtain payment for the services we provide. For example, we might send PHI to your insurance company, credit card processor, or accounting software vendor to obtain payment for services that we provide to you.

3. Health Care Operations. We may use and disclose your PHI as needed to operate our practice. For example, we may use and disclose this information to review and improve the quality of care we provide, or the competence and qualifications of our professional staff. We may also use and disclose this information as necessary for medical reviews, legal services and audits (including fraud and abuse detection and compliance programs) and business planning and management. Under HIPAA, we may share your PHI with our "business associates" that perform administrative or other services for us. An example of a business associate is Google, Inc, which offers document storage and applications enabling the delivery of our mental health care services through the internet. We have a written contract with each of these business associates that contains terms requiring them to protect the confidentiality of your PHI.

4. Notification and Communication with Family. We may disclose to a family member, your personal representative, or another person responsible for your care, the PHI directly relevant to that person’s involvement in your care or about your location, your general condition or death. In the event of an emergency, we may disclose information to public service organizations to facilitate your care. We may also disclose information to someone who is involved with your care or helps pay for your care. If you are able and available to agree or object, we will give you the opportunity to object prior to making these disclosures, although we may disclose this information in the event of a disaster even over your objection if we believe it is necessary to respond to the emergency circumstances. If you are unable or unavailable to agree or object, our health professionals will use their best judgment in communication with your family and others.

5. Required by Law. As required by law, we will use and disclose your PHI, but we will limit our use or disclosure to the relevant requirements of the law. For example, we may use or disclose PHI when the law requires us to report abuse, neglect or domestic violence, respond to judicial or administrative proceedings, respond to law enforcement officials or report information about deceased patients.

6. Public Health Activities. We may, and are sometimes required by law to, disclose your health information to public health authorities for public health activities such as: preventing or controlling disease, injury or disability; reporting child, elder or dependent adult abuse or neglect; reporting domestic violence, reporting communicable disease or infection exposure, and reporting to the Food and Drug Administration problems with products and reactions to medications. Such disclosures shall be made consistent with the requirements of applicable federal and state law.

7. Health Oversight Activities. We may, and are sometimes required by law to, disclose your health information to health oversight agencies during the course of audits, investigations, inspections, licensure and other proceedings, subject to the limitations imposed by federal and state law.

8. Judicial and Administrative Proceedings. We may, and are sometimes required by law to, disclose your PHI in the course of an administrative or judicial proceeding to the extent expressly authorized by a court or administrative order. We may also disclose information about you in response to a subpoena, discovery request, or other lawful process if reasonable efforts have been made to notify you of the request and you have not objected, or if your objections have been resolved by a court or administrative order.

9. Law Enforcement. To the extent authorized or required by law, we may disclose your PHI to a law enforcement official for purposes including (1) those required by law such as the reporting of certain types of wounds or other physical injuries, (2) compliance with legal processes including requirements of a court order, warrant, grand jury or administrative subpoena and other judicial or administrative summons, (3) limited information requests for identification and location purposes, (4) pertaining to victims of a crime, (5) suspicion that death has occurred as a result of criminal conduct, (6) where PHI constitutes evidence of criminal conduct that has occurred on the premises of our practice, and (7) medical emergencies where it is likely that a crime has occurred. If you are an inmate of a correctional institution or under the custody of law enforcement, we may release PHI about you to the correctional institution as authorized or required by law.

10. Coroners, Medical Examiners and Organ Donation. We may disclose your PHI to coroners or medical examiners for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose protected health information to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties. We may disclose such information in reasonable anticipation of death. Protected health information may be used and disclosed to organizations involved in procuring, banking, or transplanting organs and tissues for cadaveric organ, eye or tissue donation purposes.

11. Public Safety. We may, and are sometimes required by law to, disclose your PHI to appropriate persons in order to prevent or lessen a serious and imminent threat to the health or safety of a reasonably foreseeable victim or victims and for other public safety purposes. We may also disclose your PHI if it is necessary for law enforcement authorities to identify or apprehend an individual.

12. National Security/Protective Services. To the extent authorized or required by law, we may disclose your PHI for purposes including (1) military and veteran activities, (2) national security or intelligence activities, (3) protective services for the President or other authorized persons or foreign heads of state, (4) medical suitability determinations such as national security clearance, (5) correctional institutions and other law enforcement custodial situations, and (6) eligibility determinations for provision of public benefits under government programs.

13. Worker’s Compensation. We may disclose your health information as necessary to comply with worker’s compensation laws.

14. Minors. If you are an unemancipated minor, there may be circumstances in which we disclose health information about you to a parent, guardian, or other person acting in loco parentis, in accordance with our legal and ethical responsibilities.

15. Change of Ownership. In the event that our practice is sold or merged with another organization, we will transfer your medical records to the new owner, although you will maintain the right to request that copies of your health information be transferred to another health care provider or group. Please note that although certain disclosures described above do not require your prior authorization under HIPAA, under state law we may not be able to make certain disclosures listed above unless you authorize the disclosure.

When We May Not Use or Disclose Your Health Information

Except as described in this Notice of Privacy Practices, we will not use or disclose PHI without your written authorization. Most uses and disclosures of psychotherapy and medical notes require an authorization. If you do authorize us to use or disclose your PHI, you may revoke your authorization in writing at any time by emailing help@familyaddictioncounseling.com.

Your Health Information Rights

1. Right to Request Special Privacy Protections. You have the right to request restrictions on certain uses and disclosures of your health information, by a written request specifying what information you want to limit and what limitations on our use or disclosure of that information you wish to impose. We reserve the right to accept or reject your request, unless you paid in full out of pocket for a healthcare item or service and you request that we do not notify your health plan that you have obtained such items or services. In that case, we must comply with your request. To the extent we have the right to accept or reject your request, we will notify you of our decision.

2. Right to Request Confidential Communications. You have the right to request that you receive your health information in a specific way or at a specific location. For example, you may ask that we send information to a post office box or to your work address. We will comply with all reasonable requests submitted in writing which specify how or where you wish to receive these communications.

3. Right to Inspect and Copy. You have the right to inspect and copy your health information, with limited exceptions. To access your medical information, you must submit a written request detailing what information you want access to and whether you want to inspect it or get a copy of it. We will charge a reasonable fee, as allowed by state law. We may deny your request under limited circumstances. In such an event, we will notify you in writing of the reason for the denial, whether you have the opportunity to have the denial reviewed and, if so, the process for reviewing the denial. In most cases there is an opportunity to review the denial. We will comply with the outcome of the review.

4. Right to Amend or Supplement. You have a right to request that we amend your health information that you believe is incorrect or incomplete. You must make a request to amend in writing, and include the reasons you believe the information is inaccurate or incomplete. We are not required to change your health information. If we deny your request, we will provide you with information about our denial and how you can disagree with the denial. We may deny your request if we do not have the information, if we did not create the information (unless the person or entity that created the information is no longer available to make the amendment), if you would not be permitted to inspect or copy the information at issue, or if the information is accurate and complete as is. You also have the right to request that we add to your record a statement of up to 250 words concerning any statement or item you believe to be incomplete or incorrect.

5. Right to an Accounting of Disclosures. You have a right to receive an accounting of certain disclosures of your health information made by us for a period of up to six years. We are not required to provide you with an accounting of disclosures made to you for treatment purposes, made with your authorization and for certain other purposes. To obtain an accounting of disclosures, you must submit your request in writing. You are entitled to one accounting within any 12-month period. If you request a second accounting in a 12- month period, we may assess a reasonable fee.

6. Paper Copy. You have a right to a paper copy of this Notice of Privacy Practices. If you would like to have a more detailed explanation of these rights or if you would like to exercise one or more of these rights, contact our Privacy Officer at the number or email address listed in Section E below.

Changes to this Notice of Privacy Practices

We reserve the right to amend this Notice of Privacy Practices at any time in the future. Until such amendment is made, we are required by law to comply with this Notice of Privacy Practices. After an amendment is made, the revised Notice of Privacy Practices will apply to all protected health information that we maintain, regardless of when it was created or received. We will offer you a copy at each appointment following any change whether through telemedicine or in our offices.

Contact Us

If you have questions about any part of this notice, complaints or if you want more information about your privacy rights, please contact our Privacy Officer by phone at 1-808-494-6066, or by email at help@familyaddictioncounseling.com. If you are not satisfied with the manner in which this office handles a complaint, you may submit a formal complaint to:

Department of Health and Human Services
Office of Civil Rights
Hubert H. Humphrey Bldg.
200 Independence Avenue, S.W. Room 509F
Washington, DC 20201
(202) 619-0403

You will not be penalized for filing a complaint.

Provider Name

Family & Addiction Counseling LLC located at 1888 Kalakaua Ave. Suite C312, Honolulu, Hawaii 96815. NPI # 1427413707, EIN # 81-0928947

Expected Cost

If you have selected to use an insurance carrier we accept (HMSA PPO, HMSA Quest, HMSA Akamai, UHA, HMAA), we will bill your plan directly. Co-payments charged to your credit card on file average $15 per session plus tax. Please ask your insurance company if you have any questions about your coverage plan.

Treatment services are typically recommended at a frequency of one to three sessions per week, depending on your individual needs and therapeutic goals. The duration of treatment is flexible and tailored to your progress, with no mandatory commitment to a specific time frame. While some individuals may benefit from a shorter course of therapy, others may find ongoing support helpful.

The estimated annual cost for services for a patient attending therapy one time a week with three psychiatric appointments is approximately $10,000 ($1,000 out-of-pocket copay), excluding holidays, vacations, and any unforeseen cancellations.

If your insurance has an unmet deductible or denies payment for any reason, you are responsible for any outstanding payments for services received. Psychological and medical treatment is a significant personal and financial commitment. Do not hesitate to discuss financial matters with us and let them know if there are any change with your insurance.

Primary Diagnosis

Diagnostic coding used for treatment services are billed at the same rate, and do not vary based on diagnosis. If you have questions about your diagnosis, please discuss this directly with your provider.

Primary Service

Family & Addiction Counseling LLC providers offers comprehensive outpatient care, primarily providing individual and family therapy, behavioral, integrative, and psychiatric treatments. Our providers collaborate to ensure high-quality care tailored to your needs. Psychiatric services are available to prescribe medicine and address medical and psychological concerns.

If you would like more information, your provier will gladly explain any therapeutic style, technique, or treatment approach used in your care.

Disclaimer

If you are billed for more than this Good Faith Estimate, you have the right to dispute the bill. You may contact the health care provider or facility listed to let them know the billed charges are higher than the Good Faith Estimate. You can ask them to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available. You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill. There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on this Good Faith Estimate. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount. To learn more and get a form to start the process, go to www.cms.gov/nosurprises. Keep a copy of this Good Faith Estimate in a safe place or take pictures of it. You may need it if you are billed a higher amount.

Canceling Appointments

Appointment reminders will be sent to your phone 48 hours before each session. If you need to cancel your appointment, please provide more than 24 hours notice to your provider using our text message notification system.

If you miss your scheduled appointment without notifying your provider at least 24 hours in advance, you agree to a missed appointment fee, which will be charged to your credit card on file. The fee will correspond to your provider's hourly rate: Physician = $200, Nurse Practicioner = $150, Psychologist = $100, Therapist = $65.