To simplify billing and reduce the need for refunds or additional statements, Genesis Counseling Center typically requires a credit card on file prior to scheduling psychological testing appointments.

Your card will be securely stored in our electronic health record system and used as part of a structured billing process.

Before Testing Begins

• After your initial appointment, we will provide a cost estimate based on your insurance benefits and the planned testing services
• The estimated out-of-pocket cost will be charged to your card on file prior to continuing the testing process

After Testing is Complete

• Once insurance has processed all claims, we will reconcile your account
• If your estimate was higher than the final cost, a refund will be issued to your card
• If there is any remaining balance, it will be charged to your card on file

Additional Notes

• Some services (such as educational testing) may not be covered by insurance and will be discussed with you in advance
• Applicable no-show or late cancellation fees may be charged to your card on file in accordance with our policy

To help avoid delays, clients are responsible for ensuring that a valid credit card remains on file throughout the testing process.

Insurance-Specific Notes:

• Some plans (such as Medicaid) do not allow patient balances or no-show fees, so a credit card will not be required
• Our team will review your specific coverage and let you know what applies to you

This process allows us to provide clear cost expectations upfront, minimizes billing delays, and eliminates additional statements or mailing of refund checks.

If you have any questions, our team is happy to help.

Thank you for choosing Genesis. We are honored you have entrusted us to walk with you through this journey. As with any medical appointment, there are a few documents to sign. Note that Genesis and Genesis Counseling Center is used interchangeably throughout this document. 

Professional Services Agreement: This outlines our Privacy Policy and how we protect you and your records. It gives us authorization to bill your insurance on your behalf, if applicable, outlines our Cancellation Policy (please call to cancel appointments at least 24 hours in advance or there is a $75 fee for missed therapy and testing appointments), and allows us to securely store your payment information for copays and any portion of your bill that is your responsibility.  

Treatment Policies and Procedures: This document outlines our policies and procedures to help you understand our expectations for treatment. Our clinical standards include appointment information and clinical management criteria that provide clarity on what is expected of you as a patient of Genesis.  

Payment Processing: It is our policy that a payment method be saved in the secure vault during your account setup, so we can collect payment each time you check in for your appointment. Please chat with our care coordinators from our website (www.genesiscounselingcenter.com) or call our main office at 929-GENESIS (929-436- 3747) or your local office (http://genesiscounselingcenter.com/locations/) for assistance or questions about payment. 

Informed Consent for Telehealth Services: This form is intended to review and inform you of your rights regarding in-person and Telehealth services. Please electronically sign this document. This form provides your consent to participate, whether in-person or online services will be provided. 

Notice of Privacy Policy: If you are a Telehealth Client, you will not check in at a physical office location, so you will not be interacting directly with a Client Care Coordinator at each appointment. Please know we have Client Care Coordinators in our offices who can schedule appointments, assist with payments, and answer any questions you may have. Please connect through your MYIO portal in secure messaging, chat from our website, or call us between 9 a.m. and 5 p.m. Monday through Friday for all your administrative needs at 929-GENESIS (929-436-3747). We also encourage you to leave a message at any time, and one of our Client Care Coordinators will return your call.  

Please note: These forms must be completed and submitted prior to your first appointment. A client Care Coordinator may designate a due date. If the forms are not completed by that date or the first appointment (whichever comes first), my appointment may be cancelled. See the Online Info page of our website for more information and Online Check-in to select your provider's name and connect to their Online Virtual Lobby. 

Receipt of Notice of Privacy Practices, Informed Consent, Confidentiality Release to Contact Payor(s), and Payment Agreement Form 

Notice of Privacy Practices: I understand that the Genesis Notice of Privacy Practices provides information about how Genesis we may use and disclose protected health information about me. 

I acknowledge that I have received a copy of Genesis Counseling Center, Inc. Notice of Privacy Practices (included at the end of this document) and that a copy is available upon request. * 

Informed Consent:  

This agreement indicates my commitment to enter treatment for counseling, psychological testing/assessment and/or psychiatric medicine services, and my understanding of the basic ideas and personal growth goals of treatment and/or counseling. I agree to keep my physician and/or therapist up to date about any changes in my symptoms or any situation that may impact the success of treatment. I understand that effective counseling is a process that unfolds cyclically, from exploration to understanding, and finally, to action. The process may necessitate periodic evaluation of goals and new goals may be agreed upon to serve my long-term best interest. At times, counseling may arouse unpleasant feelings and emotional experiences, particularly in the initial phase of treatment. I understand that my therapy may include periodic case consultations with Genesis’ clinical staff when necessary. I acknowledge and give informed consent to begin counseling, psychological testing/assessment, and or psychiatric medicine services. 

I consent to receive automated and personalized text and email messages from Genesis including third-party Genesis contracts for reasons that include appointment reminders, requests for feedback, promotional reasons, etc. Consent is not a condition of any services. You have the right to stop or cancel at any time. You can opt out of this at any time by calling a Genesis office. On certain occasions, a member of the Genesis clinical team may utilize text or email to facilitate communication with you. Your privacy is important to us, and we take many safeguards to protect it. There are certain risks, however, associated with text and email communication. By signing below, you agree to the use of text or email messages by the Genesis clinical team recognizing the following risks: text and email messages can be intercepted during transmission, and unencrypted messages (and any attachments) can be read, and potentially copied and forwarded, by anyone. Unencrypted text and email messages can also be easily viewed by someone other than the recipient if, for example, someone has access to a device that the Client uses to access their messages.  

If you do not wish to receive text or email messages from a Genesis clinical team member, please contact our office to ensure that your choice is documented in your record. 

CHECK-IN PROCESS FOR VIRTUAL/IN OFFICE APPOINTMENTS 

Appointment Preference  

If you are scheduled for an appointment, a note is added to your appointment that indicates whether you prefer an in-office, virtual, or phone appointment. PLEASE NOTE: Virtual appointments must be conducted in a safe, secure, and private environment without distractions (e.g., not while driving, shopping or in the presence of other people If you do not have the ability OR capability to have a virtual appointment, please inform the Genesis staff so an in-office or phone appointment can be scheduled. Phone appointments are a last resort and may not be covered by your insurance plan which will result in Client responsibility for payment.  

Checking In  

When checking in for a virtual appointment or an in-office appointment, please check-in or arrive 10 minutes early. This allows us to make any necessary updates to your chart, collect payment, and get you connected to your provider. Arriving early helps with keeping you, your provider, and other Clients on schedule and on track.  

Payment Process 

It is our policy that a payment method be saved in our secure system during your account setup so we can collect payment each time you check in for your appointment. We will also charge your card for balances due and no-show fees.  

Minor Clients  

Regardless of the appointment type (in-office or virtual), Clients under 18 years old must be accompanied by a parent or legal guardian for any testing or therapy appointments, unless the provider requests otherwise. This allows the parent or guardian to inform their child's provider of any changes, issues, updates, or concerns. It also allows the staff to collect appropriate payment for the scheduled appointment.  

APPOINTMENT INFORMATION 

New Client Appointment  

Please be mindful and aware of the length of your scheduled appointment. New Client appointments are scheduled for 45 minutes, depending on the Client age and provider. ALL new Clients MUST confirm their first appointment with the staff 48 hours (2 Business Days) ahead of your scheduled appointment. If your appointment is NOT confirmed within that timeframe, then your appointment may be cancelled by the Genesis staff. This not only ensures your commitment to your treatment, but it allows the opportunity for someone else to be seen.  

CANCELLATIONS AND MISSED APPOINTMENTS 

Appointment Cancellations  

If an appointment needs to be canceled and/or re-scheduled, please make sure to call our office 24 hours in advance to cancel. Make sure to leave a detailed message about your cancellation to include the reason, as our staff monitors the voicemail frequently. This allows the staff enough time to schedule someone else who may need to be seen. If your appointment is canceled within the appropriate timeframe, you will not be charged. 

Missed Appointments  

If an appointment is missed and you do not provide a 24-hour notice of cancellation, you will still be required to pay for your missed appointment except in cases of true emergencies. 2 or more missed appointments may result in scheduling restrictions or even discharge.

INFORMED CONSENT FOR TELEHEALTH SERVICES

Telehealth involves the use of electronic communications to enable Genesis Counseling Center's health professionals to connect with individuals using interactive video and audio communications. Telehealth includes the practice of psychological health care delivery, diagnosis, consultation, treatment, referral to resources, education, and the transfer of medical and clinical data.  I understand that I have rights with respect to Telehealth:

1. The laws that protect the confidentiality of my personal information also apply to telehealth. As such, I understand that the information disclosed by me during my sessions is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited to, reporting child, elder, and dependent adult abuse; expressed threats of violence toward an ascertainable victim; and where I make my mental or emotional state an issue in a legal proceeding. I also understand that the dissemination of any personally identifiable images or information from the online therapy interaction to other entities shall not occur without my written consent.

2. I understand that I have the right to withhold or withdraw my consent to the use of telehealth during my care at any time, without affecting my right to future care or treatment.

3. I understand that there are risks and consequences from telehealth, including, but not limited to, the possibility, despite reasonable efforts on the part of the provider, that: the transmission of my personal information could be disrupted or distorted by technical failures, the transmission of my personal information could be interrupted by unauthorized persons, and/or the electronic storage of my personal information could be unintentionally lost or accessed by unauthorized persons. Genesis Counseling Center utilizes secure, encrypted audio/video transmission software to deliver online therapy.

4. I understand that telehealth sessions are not recorded, and I agree that I will not record telehealth sessions on a mobile or other recording device.

5. I understand that if my provider believes I would be better served by another form of intervention (e.g., face-to-face services), I will be referred to a mental health professional that can provide such services in my area. Finally, 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.

 6. I understand the alternatives to treatment through telehealth as they have been explained to me, and in choosing to participate in telehealth, I agree to participate using video conferencing technology. I also understand that at my request or at the direction of my provider. I may be directed to "face-to-face" treatment.

7. I understand that I may expect the anticipated benefits such as improved access to care and more efficient evaluation and management from the use of telehealth in my care, but that no results can be guaranteed or assured.

8. I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. Others may also be present during the consultation other than my counselor to operate the video equipment. The above-mentioned people will all maintain confidentiality of the information obtained. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history that are personally sensitive to me, (2) ask non-clinical personnel to leave the telehealth room, and/or (3) terminate the consultation at any time.

9. I understand that my express consent is required to forward my personally identifiable information to a third party.

10. I understand that I have a right to access my medical information and copies of my medical records in accordance with the laws pertaining to the state of my legal residence.

11. By signing this document, I agree that certain situations, including emergencies and crises, are inappropriate for audio-/video-/computer-based services. If am in crisis or in an emergency, I should immediately call 9-1-1 or seek help from a hospital or crisis-oriented health care facility in my immediate area.

PAYMENT FOR TELEHEALTH SERVICES: Payment for telehealth services is due at the time of service and must be paid by credit card. Credit cards will be stored in our secure electronic vault that is PCI-DSS compliant. Card may automatically be charged at the time of appointment for payments due.

CLIENT CONSENT TO THE USE OF TELEHEALTH: I have read and understand the information provided above regarding telehealth, have discussed it with my provider, and all my questions have been answered to my satisfaction. I have read this document carefully and understand the risks and benefits related to the use of telehealth services and have had my questions regarding the procedure explained. I hereby give my informed consent to participate in the use of telehealth services for treatment under the terms described herein. By my signature below, I hereby state that I have read, understood, and agree to the terms of this document.

Updated: February 2026

Genesis Counseling Center is committed to maintaining the privacy of all client information and adheres to the requirements of the Health Insurance Portability and Accountability Act (HIPAA). The Notice of Privacy Practices explains the ways in which Genesis Counseling Center safeguards each client’s protected health information (PHI). If you have questions or comments, please contact the Director of Operations, Rondell Davis, at 757-827-7707. You may also email our Privacy Officer at care@genesiscounselingcenter.com.

We respect the privacy of your personal health information and are committed to maintaining our clients’ privacy and confidentiality. This Notice applies to all information and records related to your care that our Provider has received or created. We need these records to provide you with quality care and to comply with certain legal requirements. It extends to information received or created by our employees, staff, and/or volunteers. This Notice informs you about the possible uses and disclosures of your personal health information. It also describes your rights and our obligations regarding your personal health information. Some health information we maintain may be subject to additional federal confidentiality protections for substance use disorder (SUD) treatment records under 42 CFR Part 2. When Part 2 applies, it may limit or prohibit certain uses and disclosures that would otherwise be permitted under HIPAA.

We are required by law to:

• maintain the privacy of your protected health information.
• provide to you this detailed Notice of our legal duties and privacy practices relating to your personal health information; and
• abide by the terms of the Notice that are currently in effect.

 
I. How Genesis Counseling Center may use & disclose health information about you. The following categories describe different ways that we use and disclose health information. Following each use or disclosure, there will be a brief description further explaining it. All the ways we are permitted to use and disclose information will not be listed but will fall within one of these categories.

For Treatment. We may use and disclose health information for your treatment and to provide you with treatment-related health care services which may include periodic case consultation with Genesis’ clinical staff with de-identified demographics when necessary. We may disclose health information to doctors, nurses, technicians, or other personnel, including people outside our office or facility, who are involved in your medical care and need the information to provide you with medical care. If your information includes SUD treatment records protected by 42 CFR Part 2, we generally will not use or disclose those Part 2 records for treatment, payment, or health care operations unless you give written consent, except as permitted by Part 2.

For Payment. We may use and disclose health information so that we or others may bill and receive payment from you, an insurance company or a third party for the treatment and services you received. If your information includes SUD treatment records protected by 42 CFR Part 2, we generally will not use or disclose those Part 2 records for treatment, payment, or health care operations unless you give written consent, except as permitted by Part 2.

For Appointment Reminders, Treatment Alternatives and Health Related Benefits and Services.  We may use and disclose health information to contact you to remind you that you have an appointment with us.  We also may use and disclose health information to tell you about treatment alternatives or health-related benefits and services that may be of interest to you. We may also call out your name when we are ready to see you.

Individuals Involved in Your Care or Payment for Your Care.  We may share health information with a person who is involved in your medical care or payment for your care, such as your family or a close friend.  We also may notify your family about your location or general condition or disclose such information to an entity assisting in a disaster relief effort.  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 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.

Research. Under certain circumstances, we may wish to use and disclose health information about you for research purposes. If this is the case, we will request ahead of time that you sign an authorization form allowing us to use and disclose this information. If you wish not to participate, you can let us know at that time.

Business Associates.  We may disclose health information to our business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services.  All our business associates are obligated to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.

As Required by Law. We will disclose health information about you when required to do so by federal, state, or local law.  This includes using or disclosing your health information to provide legally required notices of unauthorized access to or disclosure of your health information.

Redisclosure Notice. Information disclosed under this Notice may be subject to redisclosure by the recipient and may no longer be protected by HIPAA. However, SUD treatment records protected by 42 CFR Part 2 have additional federal confidentiality protections, and certain uses (including use in proceedings against you) remain restricted unless Part 2 requirements are met.

To Avert a Serious Threat to Health or Safety. We may use and disclose health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.

Military & Veterans. If you are a member of the armed forces or separated / discharged from military services, we may release health information about you as required by military command authorities or the Department of Veterans Affairs as may be applicable. We may also release health information about foreign military personnel to the appropriate foreign military authorities.

Workers’ Compensation. We may release health information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.

Public Health Risks. We may disclose health information about you for public health activities. These activities generally include disclosures to prevent or control disease, injury or disability; to report births or deaths; to report abuse or neglect; to report reaction to medications or problems with products; to notify people of recalls of products they may be using; to notify person or organization required to receive information on FDA-regulated product; to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; and to notify the appropriate government authority if we believe a resident has been the victim of abuse, neglect, or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.

Lawsuits & Disputes. If you are involved in a lawsuit or a dispute, we may disclose health information about you in response to a court or administrative order. We may also disclose health information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested. Special protection for certain SUD treatment records (42 CFR Part 2). SUD treatment records received from programs subject to 42 CFR Part 2 (or testimony relaying those records) may not be used or disclosed in civil, criminal, administrative, or legislative proceedings against you unless you give specific written consent or there is a court order that meets Part 2 requirements. A court order authorizing use or disclosure must be accompanied by a subpoena or other legal requirement compelling disclosure before the record is used or disclosed.

Psychotherapy Notes. We must receive your written authorization to disclose psychotherapy notes, except for certain treatment, payment or health care operations activities. If we deny your request to access your psychotherapy notes, you will have the right to have them transferred to another mental health professional.

Marketing and Sale of Personal Health Information. We must receive your written authorization for any disclosure of personal health information for marketing purposes or for any disclosure which is a sale of personal health information.

Change of Ownership.  If this organization is sold or merged with another organization, your health information/record will become the property of the new owner, although you will maintain the right to request that copies of your health information be transferred to another Provider.

Not Otherwise Permitted.  In any other situation not described above, we may not disclose your personal health information without your written authorization. 

II. SMS Text Communication

Phone numbers collected with SMS consent, will not be sold, rented, or shared with third parties or affiliates for marketing purposes under any circumstances.

Consent for SMS Communication: The information (Phone Numbers) obtained as part of the SMS consent process will not be shared with third parties for marketing purposes.

Types of SMS Communications: If you have consented to receive text messages from Genesis Counseling Center, you may receive messages related to the following:

• Appointment reminders
• Follow-up messages
• Billing inquiries
• Requests for feedback
• Information about services, Genesis staff, etc.

Message Frequency: Message frequency may vary depending on the type of communication. For example, you may receive up to 10 SMS messages per week related to your appointments, etc.

Potential Fees for SMS Messaging: Please note that standard message and data rates may apply, depending on your carrier’s pricing plan. These fees may vary if the message is sent domestically or internationally.

Opt-In Method: You may opt-in to receive SMS messages from Genesis Counseling Center in the following ways:

• Verbally, during a conversation with one of the Genesis staff
• On our website, during a secure webchat with one of the Genesis staff
• By submitting an online form
  
  

Opt-Out Method: You can opt out of receiving SMS messages at any time. To do so, simply reply “STOP” to any SMS message you receive. Alternatively, you can contact us directly by phone at 929-GENESIS or by webchat on our website to request removal from our messaging list.

Help: If you are experiencing any issues, you can get help directly from us by connecting with a Genesis staff member on our website using secure webchat or by calling us at 929-GENESIS.

Additional Options: If you do not wish to receive SMS messages, you can choose not to check the SMS consent box on our forms.

Standard Messaging Disclosures:

• Message and data rates may apply.
• You can opt out at any time by texting “STOP.”
• For assistance, contact us by secure webchat from our website or call us at 929-GENESIS.
• Message frequency may vary
  
  

III. Your rights regarding health information about you. You have the following rights regarding health information we maintain about you:

Right to Inspect and Copy: You have the right to inspect and copy health information that may be used to make decisions about your care. This includes health and billing records, but not psychotherapy notes.  To inspect and copy health information that may be used to make decisions about you, you must complete a written request to Genesis Counseling Center detailing what information you want access to, whether you want to inspect it or get a copy of it, and if you want a copy, your preferred form and format. We will provide copies in your requested form and format if it is readily producible, or we will provide you with an alternative format you find acceptable, or if we can’t agree and we maintain the record in an electronic format, your choice of a readable electronic or hardcopy format. We will also send a copy to any other person you designate in writing.  If you request a copy of the information, we will charge a reasonable fee for the costs of copying, mailing or other supplies and services associated with your request. We may deny your request to inspect and copy in limited circumstances. If you are denied access to health information, you may request that the denial be reviewed.

Right to Amend: If you feel that health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as we keep the information. 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 and will provide you with information about this medical practice's denial and how you can disagree with the denial.  If we deny your request, you may submit a written statement of your disagreement with that decision, and we may, in turn, prepare a written rebuttal. All information related to any request to amend will be maintained and disclosed in conjunction with any subsequent disclosure of the disputed information. We may deny your request if you ask us to amend information that was not created by us, unless the person or entity that created the information is no longer available to make the amendment; is not part of the health information kept by or for our community; is not part of the information which you would be permitted to inspect and copy; or is accurate and complete. Any amendment we make to your health information will be disclosed to those with whom we disclose information as previously specified.

Right to an Accounting of Disclosures. You have the right to request a list accounting for any disclosure of your health information we have made, except for uses and disclosures for treatment, payment, and healthcare operations, as previously described. To request this list of disclosures, submit your request in writing to our office. Your request must state a time period which may not be longer than six years. We may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred. We will mail you a list of disclosures in paper form within 30 days of your request or notify you if we are unable to supply the list within that time period and by what date we can supply the list; but this date will not exceed a total of 60 days from the date you made the request. For certain SUD treatment records protected by 42 CFR Part 2, you may have additional accounting rights, including an accounting of disclosures of electronic records for the past three years as required by federal law.

Right to Request Restrictions. You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment, or health care operations. You also have the right to request a limit on the health information we disclose about you to someone who is involved in your care or the payment for your care, such as a family member or friend. We are not required to agree to your request for restrictions if it is not feasible for us to ensure our compliance or believe it will negatively impact the care we may provide you with. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. To request a restriction, you must complete the form that can be attained from the clinic. The form will require the information you want to limit and to whom you want the limits to apply. The form must then be submitted to the office manager.

Right to Restrict Disclosure for Services Paid by You in Full. You have the right to restrict the disclosure of your personal health information to a health plan if the personal health information pertains to health care services or items for which you or anyone other than your health plan paid in full.

Right to Request Confidential Communications. You have the right to request that we communicate with you about health matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail to a post office box. To request confidential communications, you must submit your request to our office. We will not ask you the reason for the request and we will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted. In certain occasions, a member of the Genesis clinical team may utilize text or email to facilitate communication with you. Your privacy is important to us, and we take many safeguards to protect it. There are certain risks, however, associated with text and email communication. Text (SMS) and email messages can be intercepted during transmission, and unencrypted messages (and any attachments) can be read, and potentially copied and forwarded, by anyone. Unencrypted text and email messages can also be easily viewed by someone other than the recipient if, for example, someone other than the patient has access to a device the patient uses to access their messages. If you do not wish to receive text or email messages from a Genesis clinical team member, please contact our office to ensure that your choice is documented in your record.

Right to Notice of Breach. You have the right to be notified if we or one of our business associates become aware of a breach of your unsecured personal health information.

Right to a Paper Copy of This Notice. You have the right to obtain a paper copy of this notice at any time. You may obtain a copy of this notice either from the front desk at Genesis Counseling Center or our website.

IV. Changes to This Notice.

We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for health information we already have about you as well as any information we receive in the future. We will post a copy of the current notice on our website. In addition, each time you register for treatment or health care services, you may ask for a copy of the current notice in effect.

V. Complaints.

If you believe your privacy rights have been violated, you may file a complaint with us. You will not be penalized in any way for filing a complaint. To file a complaint with us, contact Rondell Davis, Director of Operations.  If you are not satisfied with the way this office handles a complaint, you may submit a formal complaint with the Secretary of the Department of Health and Human Services. The complaint form may be found at www.hhs.gov/ocr/privacy/hipaa/complaints/hipcomplaint.pdf.  Again, you will not be penalized in any way for filing a complaint.

VI. Other Uses of Health Information.

Other uses and disclosures of health information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose health information about you, you make revoke that permission, using the form obtainable from the clinic, at any time. If you revoke your permission, we will no longer use or disclose health information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you. If your information includes SUD treatment records protected by 42 CFR Part 2, many disclosures require your specific written consent unless Part 2 permits the disclosure without consent.

VII. Acknowledgment of Receipt of Notice.

As part of the client registration process with Genesis Counseling Center, we will ask you to sign a Professional Services Agreement which denotes you have reviewed and understand this Notice.

By signing below you confirm the following statements:

• Privacy Practices – I acknowledge that I have received a copy of Genesis Counseling Center, Inc.’s Notice of Privacy Practices and that an additional copy is available upon request.

• Benefit Information – Benefit information is provided to Genesis by the insurance company, if applicable, and represents an estimate only. Actual patient responsibility may vary. I understand that I am responsible for all co-pays, deductibles, and amounts not covered by insurance. I give Genesis permission to contact any third-party payer for payment.

• Insurance Claims – I understand that Genesis will submit claims to my insurance company if I have insurance with which Genesis is contracted.

• Payment Due at Time of Service – I understand that my payment is due at the time services are rendered.

• Cancellation Fee – I understand that I will be billed a fee of $75 for testing appointments not canceled at least 24 hours prior to the scheduled appointment time, except in cases of true emergencies. Although reminders are sent as a courtesy, I am ultimately responsible for remembering my appointments. I understand that I am responsible for all charges incurred during my treatment, including any portion not covered by insurance. Unpaid balances may be subject to collections procedures if not resolved in a timely manner.

• Credit Card on File Policy – I understand that Genesis requires a credit or debit card to be stored securely on file as a method of payment for amounts I am responsible for. I authorize Genesis to charge my card for estimated costs, final balances after insurance processing, and applicable fees (including missed appointment fees), in accordance with this agreement. I understand that I am responsible for maintaining a valid card on file throughout my services and will provide updated information if needed.

• Client Email & Mobile Phone Number – By providing my e-mail address and/or mobile phone number to Genesis, I permit them to use my e-mail address and/or mobile phone number to send me messages on appointments, behavioral health-related issues, and Genesis behavioral health services. I also permit them to send requests for feedback which may include the option for me to post reviews and/or comments publicly (e.g., Google, Facebook, etc.). I understand I can choose not to receive such messages from Genesis by contacting them. Genesis does not share client contact information outside of trusted third-party providers where Business Associate Agreements are established to help protect privacy.

• For More Information – I understand if I desire more detailed information regarding Genesis’ policies related to privacy, informed consent, professional services, and payment, I may request more information from a Genesis Client Care Coordinator.