Please note that Journey Healthcare does not perform neuropsychological evaluations, which are necessary before an ADHD/ADD diagnosis or treatment can be provided.

In accordance with the Health Insurance Portability and Accountability Act of 1996, as of April 14, 2003 all health care providers are required to provide their patients with a "Notice of Privacy Practice' statement.

 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Journey Healthcare is required, by law, to maintain the privacy and confidentiality of your protected health information and to provide our clients with notice of our legal duties and privacy practices with respect to your protected health information

Disclosure of Your Health Care Information

Treatment

We may disclose your health care information to other healthcare professionals within our practice for the purpose of treatment, payment or healthcare operations. For example, on occasion, it may be necessary to seek consultation regarding your condition from other health care professionals associated with Journey Healthcare.

Payment

We may disclose your health information to your insurance provider for the purpose of payment of health care operations. For example, as a courtesy to our clients, we will submit an itemized billing statement to you and/or your insurance carrier for the purpose of payment to Journey Healthcare for health care services rendered. The billing statement contains medical information, including diagnosis, date of condition and codes that describe the health care services rendered.

Workers' Compensation

We may disclose your health information as necessary to comply with State Workers' Compensation Laws.

Emergencies

We may disclose your health information to notify or assist in notifying a family member, or another person responsible for your care, about your medical condition, or in the event of an emergency or your death.

Public Health

As required by law, we may disclose your health information to public health authorities for purposes related to: preventing or controlling disease, injury or disability, reporting child abuse or neglect, reporting domestic violence, reporting to the Food and Drug Administration problems with products and reactions to medications and reporting disease or infection exposure..

Public Safety

It may be necessary to disclose your health information to appropriate persons in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or to the general public.

 Appointment Reminders

We may contact you for the purpose of reminding you that you have an appointment for treatment at our office.

Change of Ownership

In the event that Journey Healthcare is sold or merged with another organization, your health information/record will become the property of the new owner.

Your Health Information Rights

You have the right to request restrictions on certain uses and disclosures of your health information. Please be advised, however, that Journey Healthcare is not required to agree to the restriction that you request. You have the right to have your health information received or communicated through an alternative method or sent to an alternative location other than the usual method of communication of delivery, upon your request. You have the right to inspect and copy your health information. You have the right to request that Journey Healthcare amend your protected health information. Please be advised, however, that Journey Healthcare is not required to agree to amend your protected health information. If your request to amend your health information has been denied, you will be provided with an explanation of our denial reason(s) and information about how you can disagree with the denial. You have a right to receive an accounting of disclosures of your protected health information made by Journey Healthcare. You have a right to a paper copy of this Notice of Privacy Practices at any time upon request.

Changes to this Notice of Privacy Practices

Journey Healthcare reserves the right to amend this Notice of Privacy Practices at any time in the future, and will make the new provisions effective for all information that it maintains. Until such amendment is made, Journey Healthcare is required by law to comply with this Notice.

Journey Healthcare is required by law to maintain the privacy of your health information and to provide you with notice of its' legal duties and privacy practices with respect to your health information. If you have questions about any part of this notice or if you want more information about your privacy rights, please contact the HIPAA Privacy Practice Officer by calling our office at the number listed in the Client Handbook.

HIPAA Disclaimer

Releases of information permitted by HIPAA regulations which are prohibited by the Federal and State Confidentiality Laws for substance abuse treatment, continue to be prohibited and will require the client's written consent.

Complaints

Complaints about your Privacy rights or how Journey Healthcare has handled your health information should be directed to the HIPAA Privacy Practice Officer at Journey Healthcare. If s/he is not available, you may make an appointment for a personal conference in person or by telephone within two working days. If you are not satisfied with the manner in which this office handles your complaint, you may submit a formal complaint to:

DHHS
Office of Civil Rights
200 Independence Avenue, S.W.
Room 509F HHH Building
Washington, D.C. 20201

As a client of Journey, you are entitled to the following:

1. You shall retain all civil rights and liberties except as provided by law. No client shall be deprived of any civil rights solely by reason of involvement treatment.
   Journey shall not discriminate on the basis of age, race, creed, ethnicity, national origin, marital status, sexual orientation, handicap, or religious preference.
2. You have the right to inspect your record. The Program Manager may temporarily remove portions of your record prior to your inspection when she/he determine that the information may be detrimental to you if presented. The reason for the removal will be documented as part of your record. The following procedure is to be followed when requesting review of your record:
3. Submit a written request to a staff member stating the reason(s) you are requesting to review your record. Sign and date the request.
4. This request will be presented to the Program Manager, along with your record to the Program Manager. All such requests will be honored within 7 days. You may request a correction or removal if the information is inaccurate, irrelevant, or incomplete. Appeals related to the retention or destruction of record contents are to be mediated by the Program Manager. You may submit rebuttal data or a memorandum to your record.

Client Responsibility 

• I agree to adhere to the payment policy outlined by this program. If I have medical coverage that will cover the cost of my treatment, I agree to provide Journey with the necessary documents that will allow them to bill my medical coverage provider.
• I agree to conduct myself courteously in the Journey Healthcare offices.
• I agree not to give any of my medication to another person for any reason.
• I agree that my prescription can only be given to me at my regular treatment visit. A missed visit may result in my not being able to get my prescription until the next scheduled treatment visit.
• I understand that my provider will not fill any prescriptions early if I run out of controlled substances before my scheduled refill or appointment.
• I agree that the medication I am prescribed by Journey Healthcare is my responsibility and I agree to keep it in a safe, secure, place. I agree that lost medication will not be replaced, regardless of why it was lost.
• I agree to present my medication the staff at Journey Healthcare at their request for random medication counts. When I am requested to bring my medication for a medication count, I agree to allow that medication to be stored by the program staff in a secure place.
• I agree not to obtain medications from any doctors, pharmacies, or other sources without telling my treating physician. If I am prescribed another medication, I agree to disclose that information to the physician at Journey.
• I understand that mixing respiratory suppressants such as Buprenorphine with other medications, especially benzodiazepines or alcohol, can be dangerous. I also recognize that several deaths have occurred among persons mixing Buprenorphine and benzodiazepines (especially if taken outside the care of a physician or in higher than recommended therapeutic doses).
• I agree to take my medication as my doctor has instructed and not to alter the way I take my medication without first consulting my doctor.
• I acknowledge that I have a complete understanding of the risks of consuming alcohol while taking controlled substances. To receive a prescription for any controlled substances, I agree to provide urine drug screen samples and breath alcohol tests if ordered by my provider.
  I understand that violations of the above may be grounds for termination of treatment.
• Clients are expected to follow all treatment recommendations provided by the treatment staff.
• Please be on time for all scheduled appointments.  Any client who is more than 15 minutes late will be required to reschedule for the next available appointment.  
• No violent behaviors or acts will be tolerated on Journey Healthcare property.
• Clients and those accompanying them are responsible for being respectful of all healthcare providers, staff, and other patients. This applies to us as well; we strive to treat all our clients with the respect and kindness they deserve. 
• Any patient found to be inappropriate or abusive to staff or providers will be discharged from Journey Healthcare and will be ineligible to return to the practice.  Extreme instances of abuse or assault of staff may be cause for criminal charges under Pennsylvania Consolidated Statutes Title 18 S 2702

 

No Show Fees

Psychiatric Evaluation with Psychiatrist: $250Psychiatric Evaluation (All Other Providers): $150
Psychiatric Follow-Up: $75
Therapy Intake (First Appointment): $125
Therapy Follow-Up: $100

 Three no-shows will result in a discharge from our practice.

Late Cancel Fee:

We require at least 24 hours notice to cancel your appointment without charge. We do our best to fill spaces so our providers can serve those in need promptly. I agree to attend my scheduled appointments, and if there is a need to reschedule, I am required to provide timely notice of at least 48 hours. Failure to allow for 24 business hours will result in a $75 late cancel fee.

 Client Medication Refills

Before contacting the office, please call the pharmacy directly to ensure that you do not have any additional refills on file. Please note that we do not respond to pharmacy-generated automated refill requests. If you require additional medication before your next appointment, please get in touch with the office as soon as possible. It may take up to five business days to refill your prescription, and you must have a follow-up appointment scheduled. Please do not expect that the medication will be filled on the same day as the request.

Certain medications cannot be prescribed electronically or via telephone and must be provided through a scheduled visit at Journey Healthcare. Prescriptions will not be mailed to you for any reason. Please ensure that you have an adequate supply of medication to last until your next scheduled appointment.

If you or your child are prescribed a controlled substance, including stimulants or benzodiazepines, the medication must be stored securely and taken as directed. If appointments are canceled/changed, refill requests may not be honored until you are seen in the office. Misuse or sale/distribution of medication will result in discontinuation of treatment or termination of care.

Refill requests made after a missed or cancelled/changed appointment, or those with repeated requests for refills, will incur a $50 fee at the time the refill is processed.

I have carefully reviewed this form and I also agree to the uphold my share of patient responsibility.

 Informed Consent Telemedicine Services

1. I understand that it is my obligation to notify Journey Healthcare of my location at the beginning of each treatment session. If, for some reason, I change locations during the session, it is my obligation to notify Journey Healthcare of the change in location.
2. I understand that it is my obligation to notify Journey Healthcare of any other persons in the location, either on or off camera, who can hear or see my sessions. I understand that I am responsible for ensuring privacy at my location. I will notify Journey Healthcare at the outset of each session and am aware that confidential information may be discussed.
3. I agree that I will not record either through audio or video any of the sessions.
   I understand there are potential risks to using telehealth technology, including but not limited to interruptions, unauthorized access, and technical difficulties. I understand some of these technological challenges include issues with software, hardware, and internet connection, which may result in interruptions.
4. I am aware that alternative care options, including in-person visits, are available for any services I receive.
5. I have been trained on how to use telehealth technology by Journey Healthcare. I understand that Telehealth is NOT an emergency service. In the event of an emergency, I will use a phone to call 911.
6. To maintain confidentiality, I will not share my telehealth appointment link or information with anyone not authorized to attend the session.

I understand that either I or Journey Healthcare can discontinue the telehealth services if those services do not appear to benefit me therapeutically or for other reasons, which will be explained to me. I have read, understood, and agree to this consent to treatment and the associated telehealth policies. 

Emergency and Psychiatric Consent:

I consent to allow Journey to procure for me in the event of a medical or psychiatric emergency and release Journey from all liability related to any injury that may occur during my treatment at this facility.

Acknowledgement of Receipt of Client Handbook

I acknowledge that I have received a copy of the Journey Healthcare Client Handbook at the time of my admission and that I have been informed that I am free to ask questions about it at any point throughout my treatment. Fees were also discussed with me at the time of my intake.

This consent is subject to my revocation at any time. It will expire at the conclusion of my treatment stay. My signature indicates that I have been provided with and understand the above information regarding my rights, responsibilities and treatment.

I also understand:

1. That regulation 164.508 ensures my right to treatment, payment or enrollment in a health program regardless of whether I sign this authorization, and that I may refuse to sign.
2. That when either federal or state laws afford me more a stringent level of privacy protection than those regulated by 164.508, Journey Healthcare will always abide by the more stringent law.
3. Journey Healthcare will only disclose my health information gathered through treatment by our internal healthcare clinicians, and will not re-disclose my PHI received from any other external healthcare provider.
4. That although Federal Law (42 CFR Part 2) prohibits re-disclosure of your PHI, recipients of your information could potentially disregard these and other laws.
5. That this authorization expires 30 days after discharge from treatment episode.

I understand that I may revoke all or part of this authorization verbally or in writing.
Please contact the office if you wish to revoke this consent.

This Consent/Authorization complies with the Privacy Regulations contained within Federal Register Vol. 65, Part II, Part 164; SubPart E 164.508.

PROHIBITION OF REDISCLOSURE: This information has been disclosed to you from records whose confidentiality is protected by Federal Law.  Federal regulations prohibit you from making any further disclosures of this information except with the specific written consent of the person to whom it pertains or as otherwise permitted by such regulations.  A general release of medical or other information is NOT sufficient for this purpose.

I also understand:

1. That regulation 164.508 ensures my right to treatment, payment or enrollment in a health program regardless of whether I sign this authorization, and that I may refuse to sign.
2. That when either federal or state laws afford me more a stringent level of privacy protection than those regulated by 164.508, Journey Healthcare will always abide by the more stringent law.
3. Journey Healthcare will only disclose my health information gathered through treatment by our internal healthcare clinicians, and will not re-disclose my PHI received from any other external healthcare provider.
4. That although Federal Law (42 CFR Part 2) prohibits re-disclosure of your PHI, recipients of your information could potentially disregard these and other laws.
5. That this authorization expires 30 days after discharge from treatment episode.

I understand that I may revoke all or part of this authorization verbally or in writing.
Please contact the office if you wish to revoke this consent.

This Consent/Authorization complies with the Privacy Regulations contained within Federal Register Vol. 65, Part II, Part 164; SubPart E 164.508.

PROHIBITION OF REDISCLOSURE: This information has been disclosed to you from records whose confidentiality is protected by Federal Law.  Federal regulations prohibit you from making any further disclosures of this information except with the specific written consent of the person to whom it pertains or as otherwise permitted by such regulations.  A general release of medical or other information is NOT sufficient for this purpose.

•  The fee schedule is posted in the main lobby of the facility and in your initial client paperwork. If you need an additional copy, you may request one, and it will be given to you.
• I understand that if the credit card charge is denied, I will be billed separately for the appointments. I know that I must pay for any outstanding balance in full before receiving further services.
• I agree to call and notify the receptionist in advance of my next scheduled appointment if my address, phone number, or responsible party has changed.
• I agree to provide Journey Healthcare with an active credit card to bill during the utilization of telehealth services or for any incurred balance.
• I agree to keep an active credit card on file at all times. I agree to call and notify the receptionist if my credit card expires, and will provide a current one before my next service.
• The undersigned authorizes Journey Healthcare to charge account balances to the provided credit card for Services Rendered at Journey Healthcare.