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  • Adult Intake Form

    Keys To Communicate LLC

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  • HIPAA POLICY NOTICE OF PRIVACY PRACTICES

    This notice describes how medical information about you may be used and disclosed andhow you can get access to this information. Please review it carefully.

  • The Health Insurance Portability & Accountability Act of 1996 (HIPAA) is a federal programthat requires that all medical records and other individually identifiable health informationused or disclosed by us in any form, whether electronically, on paper, or orally, are keptproperly confidential. This Act gives you, the patient, significant new rights to understand andcontrol how your health information is used. We are required by law to maintain the privacyof your protected health information and to provide you with notice of our legal duties andprivacy practices with respect to protected health information. HIPAA provides penalties forcovered entities that misuse personal health information.As required by HIPAA, we have prepared this explanation of how we are required to maintain theprivacy of your health information and how we may use and disclose your health information.Treatment means providing, coordinating, or managing health care and related services, by oneor more health care providers. An example of this would include a physical examination.Payment means such activities as obtaining reimbursement for services, confirming coverage,billing or collections activities, and utilization review. An example of this would be sending abill for your visit to your insurance company for payment.Health care operations include the business aspects of running our practice, such as conductingquality assessment and improvement activities, auditing functions, cost-management analysis,and customer service. An example would be an internal quality assessment review.We may create and distribute de-identified health information by removing all references toindividually identifiable information.We may contact you to provide appointment reminders or information about treatmentalternatives or other health-related benefits and services that may be of interest to you.Any other uses and disclosures will be made only with your written authorization. You mayrevoke such authorization in writing and we are required to honor and abide by that writtenrequest, except to the extent that we have already taken actions relying on your authorization.You have the following rights with respect to your protected health information, which youcan exercise by presenting a written request to the Privacy Officer:The right to request restrictions on certain uses and disclosures of protected health information,including those related to disclosure to family members, other relative, close personal friends,or any other person identified by you. We are, however, not required to agree to a requestedrestriction. If we do agree to a restriction, we must abide by it unless you agree in writing toremove it.The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternative locations.The right to inspect and copy your protected health information.The right to amend your protected health information.The right to obtain a paper copy of this notice from us upon request.This notice is effective as of April 14, 2003 and we are required to abide by the terms of theNotice of Privacy Practices currently in effect. We reserve the right to change the terms of ournotice of Privacy Practices and to make the new notice provisions effective for all protectedhealth information that we maintain. We will post and you may request a written copy of arevised Notice of Privacy Practices from this office.You have recourse if you feel that your privacy protections have been violated. You have theright to file written complaints with our office, or with the Department of Health & HumanServices, Office of Civil Rights, about violations of the provisions of this notice or the policesand procedures of our office. We will not retaliate against you for filing a complaint.Please contact the following for more information:The U.S. Department of Health & Human ServicesOffice of Civil Rights200 Independence Avenue, S.W.Washington, D.C. 20201(202) 619-0257Toll Free: 1-877-696-6775

  • Acknowledgement That You Have Received Our HIPAA Privacy Notice

    Keys To Communicate is required by law to keep your health information and records safe. This information may include: Notes from your doctor, teacher or other healthcare provider, Medical history, Test results, Treatment notes, Insurance information. We are required by law to give you a copy of our privacy notice. This notice tells you how your health information maybe used and shared. The below signature shows that you acknowledge that you have received a copy of Keys To Communicate's HIPAA Notice of Privacy Practices that fully explains the uses and disclosures they will make with respect to my individually identifiable health information. It acknowledges you have had the opportunity to read the notice and to have any questions regarding the notice answered to my satisfaction. You understand Keys To Communicate cannot disclose my health information other than as specified in the notice. By signing below, you understand that Keys To Communicate reserves the right to change the notice and the practices detailed therein if it sends a copy of the revised notice to the address I have provided.
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  • Policies and Agreements

  • Attendance 

    We value your commitment to the therapy process and aim to provide consistent and reliable support. Regular attendance is essential to achieving your therapeutic goals.

    If a client cancels or misses more than 4 sessions within a 2-month period, it may impact the continuity of care. Repeated absences without valid reason may result in the reassignment of your time slot or, in some cases, the discontinuation of services.

    If you anticipate any scheduling challenges, please inform us as soon as possible so we can work with you to find a solution.

    Thank you for your understanding and cooperation.

    DDD Sessions

    DDD sessions include 10 minutes embedded for parent
    communication, session notes, and DDD billing. 

    Cancelled Appointments
    To ensure effective scheduling and service delivery, we require a minimum of 24 hours' notice for any appointment cancellations. If a cancellation occurs without 24 hours' notice after one instance, a cancellation fee of $25.00 will be charged to your account. Exceptions will be made for unavoidable circumstances, such as sudden illness.

    No Show Policy
    If you miss an appointment without prior notice, you will be charged at the private pay rate for your session. This fee reflects the time reserved for your session and our commitment to serving all clients effectively.

    Make-Up Sessions
    We will make every effort to reschedule sessions canceled by the therapist. However, please note that make-up sessions may not necessarily be conducted by your current therapist.

    Therapist Changes
    Due to scheduling demands, your therapist may change at any time during your treatment. We will strive to maintain continuity of care, but please be aware that circumstances may require a different therapist to be assigned.

    Consent to treat via Teletherapy
    1. I have the right to withhold or withdraw my consent to teletherapy, in
    writing at any time without affecting my right to future care or treatment.
    2. The laws that protect the confidentiality of medical information (HIPAA) also
    apply to teletherapy as all other company policies e.g. Payment agreement.
    3. I understand that there are certain unavoidable associated risks with
    teletherapy including transmission of information that could be interrupted
    by unauthorized persons and internet/Wi-Fi technical difficulties.
    4. I understand that I am responsible for providing the necessary computer,
    ensuring information security on my computer, and arranging a sufficient
    location with lighting and privacy that is free of distractions.

    By signing below, you acknowledge that you have read and understood these policies and agreements.

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  • Media Release

  • I (parent/guardian) hereby grant Keys To Communicate LLC, the right to photograph, and/or video record my dependent and use the photo and/or other digital reproduction of him/her for website, social media or education purposes. I understand and agree that these materials will become the property of Keys To Communicate LLC and will not be returned.

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  • Payment

  • IVY PAY (Private Pay Clients)

     

     

     


    Keys To Communicate, utilizes IVY PAY, which is a payment system designed specifically for therapists and their clients. This payment vehicle can be used for times of forgotten check books, phone or video sessions, missed sessions, or sessions that are cancelled with less than the required 24 hours notice (nonemergency) as per the agency’s policies. Ivy Pay works with your debit card, credit card, HSA or FSA account. It is HIPAA secure and it keeps our therapeutic relationship confidential. It is easy to use and provides a completely touchless payment process. Ivy Pay is a HIPPAA-compliant app that uses encryption, two-factor authentication, and adheres to payment card industry data security standards. Ivy Pay creates a mobile invoice for easily processing credits cards and tracking payment by cash or check. Ivy Pay is very easy to navigate and requires a mobile
    number (no landlines) for every client listed and mobile numbers cannot be duplicated.
    If you are in agreement to this form of payment, I will send you an invitation text to set up your account after your first appointment.

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  • Signature and Submission

  • Please type your name below to indicate consent to treatment. 

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    If patient is a minor, the parent or guardian must sign below to consent to the minor receiving treatment.

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