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, Genesis Counseling Center, and Genesis Psychiatric Medicine (GPM) are 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, $85 fee for missed medication management appointments not covered by insurance), 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. 

GENESIS PSYCHIATRIC MEDICINE TREATMENT POLICIES AND PROCEDURES 

Thank you for choosing Genesis. To provide you with the utmost quality of care, it is imperative that we set proper expectations within our policies and procedures. Enforcing our policies will not only benefit you as a patient but also us as your providers. We appreciate everyone's efforts in adhering to these guidelines.  

I UNDERSTAND AND AGREE TO THE FOLLOWING:  

I understand that 2 or more missed appointments within a year could result in my discharge of treatment with Genesis Psychiatric Medicine (GPM).  

• I agree to keep my regularly scheduled appointments with my provider, as they are necessary for medication management.
• I understand that if I miss my appointments, my provider will not send in my prescription refills until my missed appointment fee of $85 is paid AND a 4 to 6-week follow-up is scheduled.
• I agree to the Controlled Substance policy.
• I understand that I must keep my medication in a safe place, and I must take my medications exactly as they are prescribed to me, unless first consulting with my medication provider to make necessary/documented changes.
• I understand that if my controlled medication is stolen/lost, it is at my provider's discretion to replace my medication. If the medication is stolen, I understand that a police report is required for replacement.
• I agree to random urine drug screenings.

I understand if I have forms that need to be completed (FMLA, Long/Short Term Disability, Accommodation Letters, etc., I must give them to GPM as soon as possible and promptly schedule an appointment with my provider to review the forms. I understand an appointment to review the forms is required so my provider can gain an understanding of my situation and properly assess what is needed and/or required. I understand this could take up to 5-10 business days with holidays excluded. There will be associated fees with this service.  

I acknowledge that if I, or an outside entity request my medical records, it may take up to 30 days to receive the requested records.  

I acknowledge that if my medication requires a prior authorization, it can take up to 72 hours to be completed. Authorizations are handled by GPM staff in the order in which they are received.  

I understand that if my child has an appointment (in-office or virtual), I must be present during the appointment so that information can be exchanged between parent and provider.  

I agree that any infractions to any of the above statements could result in immediate dismissal/discharge from care at GPM. 

I will treat the staff at GPM respectfully. If I am disrespectful to staff or disrupt the care of other patients, this could lead to termination of treatment from GPM.  

GPM is strictly an outpatient practice. While the staff will do their best to accommodate my needs, in the event I need immediate emergency care, I will call 911 or go to the nearest emergency room.  

I agree to only having one psychiatric medication management provider, if multiple providers are prescribing psychiatric medications, you will be discharged from GPM.

I agree, if I am admitted to the hospital for any mental health concerns or conditions, I will release medical records to GPM prior to my post hospitalization appointment. 

I agree, if I am admitted to the hospital for any mental health conditions, I will release hospital medical records to GPM prior to my post hospitalization appointment. 

I understand that if my symptoms become more severe at any time, my provider may determine that I need a higher level of care. This could include a referral to a psychiatrist or the Emergency Room. The decision will be made based on my provider's professional judgment of what is best for my health and safety.

I am responsible for my own appointments; reminders from the office are system generated and a courtesy but may not always go out. I can view my appointments in my MYIO portal. Therefore, missed appointment fees will be charged without providing at least 24 hours’ advance notice.

I may lose my right to treatment in this office if I violate any of the policies of GPM.  

If I do not wish to sign this document, GPM has the right to REFUSE and/or DISCONTINUE my treatment. 

Controlled Substance Medication Policy

To receive controlled substance medications from providers at Genesis Psychiatric Medicine, each patient must adhere to the following guidelines:

Routine and Random Drug Screenings

1. Routine and random drug screenings will be conducted. If the use of illicit or unprescribed medications is detected, eligibility for controlled substance prescriptions will be discontinued.
2. Virginia Prescription Monitoring Program (VPMP) Verification
3. Your provider will complete a Virginia Prescription Monitoring Program (VPMP) verification before refilling prescriptions to ensure there are no active conflicting prescriptions.

Medication Refills

• Refills of all medications will be processed only after follow-up appointments have been conducted, and lab results have been reviewed.
• All refills are at the provider’s discretion.
• Patients must be seen in person for medication management at least once a year. The provider will determine the frequency and need for in-person appointments.
• For telemedicine appointments, the patient’s Individual Service Plan (ISP) location must reflect the state of Virginia and not any out-of-state location.

Single Provider for Prescription Refills

• Patients are required to obtain prescription refills from only one provider.
• Patients with a history of or active substance abuse, misuse, or addiction (with or without treatment) are not eligible for controlled substances at Genesis Psychiatric Medicine. Non-stimulant and non-benzodiazepine medications will be considered as alternatives.

Pharmacy Guidelines

• Patients must contact their pharmacy to confirm medication availability before submitting prescriptions.
• Providers will not send prescriptions for controlled substances to multiple pharmacies.
• Benzodiazepines will be prescribed strictly on an as-needed basis. If a patient is currently taking benzodiazepines daily, a tapering plan will be initiated to reduce the dose to 5–10 tablets per month (if necessary and at the provider's discretion).
• If there are concerns regarding dependence, tolerance, and/or addiction, the patient will be referred to an addiction clinic for further care and medication management.

I AGREE TO COMPLY WITH THE GENESIS PSYCHIATRIC MEDICINE TREATMENT POLICIES AND PROCEDURES FOR MY MENTAL HEALTH CARE.

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.

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. If you have questions or comments please contact the Vice-President of Operations, Cameron Ashworth, at 757-827-7707.

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, volunteers and clinical director. 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.

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 of 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.

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.

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 use and disclose medical information about you by having you sign in when you arrive at our office. 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 of 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.

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.

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. In the event that this Provider 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. 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.

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. 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.

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. To obtain a copy, please request it from our office.

You may also obtain a copy of this notice either from the front desk at Genesis Counseling Center or our website. If we know that the electronic message has failed to be delivered, a paper copy of this notice will be provided. Even if you have received a copy electronically, you still retain the right to receive a paper copy upon request.

III. 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 in our Provider. In addition, each time you register for treatment or health care services, you may ask for a copy of the current notice in effect.

IV. 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 Cameron Ashworth, Director of Operations. If you are not satisfied with the manner in which 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 Complaint Form. Again, you will not be penalized in any way for filing a complaint.

V. 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.

VI. Acknowledgment of Receipt of Notice.

Your signature in this online form acknowledges that you received 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 given to Genesis by the insurance company, if applicable, and only represents an estimate. Genesis Counseling Center, Inc. is not responsible for co-pays and/or deductibles that may differ from what Genesis is told when verifying benefits. The Client/Guarantor gives permission to Genesis 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 which Genesis is contracted with.

• 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 and $85 for medicine management appointments not canceled 24 hours prior to the scheduled appointment time, except in cases of true emergencies. Although reminders are sent, I understand they are a courtesy, and I am ultimately responsible for remembering my appointments. I understand that I am responsible for all charges incurred during my treatment, including any portion of charges not covered by insurance, case management fees as explained and/or court related fees should a Genesis employee be subpoenaed on my behalf.  A fee schedule is available upon request.  Unpaid balances that are more than 90 days may necessitate the initiation of collections procedures, including possible legal action to recover the amount owed.  My signature below represents my understanding of this payment agreement.

• Credit Card on File Policy: We require storing your credit card or debit card information on file as a convenient method of payment for services that your insurance doesn’t cover, but for which you are liable. Your card information is kept confidential and secure according to PCI standards. I authorize Genesis to charge my credit card the portion of my bill that is my responsibility, including missed appointment fees of $75 or $85.

• 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.