INFORMED CONSENT FOR TREATMENT
I understand that the goal of Aspen Ridge Counseling Centers. is to provide the best possible service. While I expect benefits from this treatment, I fully understand and accept that because of factors beyond our control, such benefits and desired outcomes cannot be guaranteed. A variety of methods will be used to provide relief of my symptoms, and to improve coping and problem-solving skills. I understand that counseling requires a lot of effort on my part to receive the best outcomes of treatment.
I understand that I can talk with my therapist if I feel my treatment needs modified. This may be a simple case of updating treatment goals with therapist or referring to other services or providers. It is also important to find a good fit for each client, you are welcome to ask for a referral from your therapist or contact the office to schedule with a different provider. Therapists are also able to refer to treatment providers outside of Aspen Ridge Counseling Centers. Therapists understand that each person may require a different style or personality and are open to discussing this with you.
I understand that counseling sessions are approximately 50 minutes in length depending on insurance. I understand that frequency of sessions, length of sessions and treatment goals may change as discussed in treatment planning with my therapist. I understand that if I am late for my appointment, it will still end at the regular appointment time. I understand it is important to communicate with my therapist if I’m running late to make sure appointment does not need rescheduled.
As a courtesy, Aspen Ridge Counseling Centers will contact your insurance to learn about health plan benefits as it relates to counseling. However, I understand it is my responsibility to be familiar with my own insurance coverage as it relates to outpatient counseling.
I understand that the fee for the initial consultation for a Mental Health Assessment is $200.000 and following sessions are $160.00 for each office visit. *These are the rates that are billed to insurance companies. I understand that Aspen Ridge has a contractual obligation to bill any in-network insurance company and that the self-pay option is only available if 1) I have no insurance coverage, or 2) Aspen Ridge is not in network with my insurance. I understand that by providing my insurance information, I give Aspen Ridge Counseling and affiliated agencies permission to bill my insurance for services rendered. I agree to make my payment or co-payment at the time of service. If you are a self-pay client, you will be quoted our self-pay rates before your first appointment and you will be notified of any self-pay rate change prior to upcoming appointments. I understand that Therapists update Mental Health Assessments once per year and thus the Mental Health Assessment rate is often charged once yearly.
Medicaid consumers cannot be charged for services or billed for the remainder not covered by Medicaid (balance billed).
Phone calls more than 10 minutes in length, written reports, and other professional contacts will be billed at the same rate. I fully understand that I am responsible to pay all charges not covered by my insurance carrier.
In the event payment under this agreement is not made at the time and in the manner required, I agree to pay all costs of collection, including attorney fees, court costs, and collection agency charges and fees. This includes but is not limited to a 25% collections fee of total balance owed on account. I authorize the release of my identifying information to a collection agency if that should become necessary.
There will be a service charge of $25.00 added to my account for any returned check. There is also a $65 fee for appointments that are considered no-shows or late-cancellations (see no-show/late cancellation form). This fee is not covered by insurance companies and is still payable by clients including those on Medicaid.
I understand that if I’d like to set up a payment plan to pay off my total balance, or have my credit/debit card charged automatically for my amount owed each session by placing my card on file, I can request this. In order to request ongoing charges, please contact the office to obtain a form to do so.
I understand that it is my responsibility to ensure my contact information is kept up to date (including phone number, mailing address, and email address.)
I understand that I will receive statements via email at no cost each billing cycle. However, if I’d like to receive mailed statements, I can do so by completing a written form at the office. There will however be a $2 charge added to mailed statements. I understand that if I disagree with any statements received, I must contact the office within 30 days to dispute. If the account is sent to collections and no disputes are filed, I understand that I am responsible for the balance. I understand it is my responsibility to request a receipt for all card, cash and check payments and keep them for my records. Receipts will be required from the client upon any invoice disputes.
Records/Coordination of Care
I understand that for mental health services to be most effective, it is essential to have these services coordinated with other health care providers. Aspen Ridge Counseling Centers uses a secure electronic medical records system to house your information. Information will only be shared in accordance with the Privacy Policies of Aspen Ridge Counseling Centers. For any person or institution that is not directly related to treatment, payment of services or health care operations of Aspen Ridge Counseling Centers, all protected health information will be kept confidential UNLESS you sign a specific authorization. However, all health care providers are legally required to report and release the following information without specific authorization: Suspected physical/sexual abuse and/or neglect of a child or elderly person, to prevent injury to self or others, in a medical emergency to save lives, or if ordered by the court.
In the event of an emergency I will call: 1) University of Utah Neuropsychiatric Institute at (801)587-3000; 2) Salt Lake County Mental Health Suicide Prevention and Crisis Services at (801) 483-5444; or 3) 911 or the nearest hospital emergency room.
Divorce & Custody Issues
Although it is common for clients to seek counseling services during times of divorce and separation, it is important to note that Aspen Ridge Counseling does not get involved in custody issues and does not make recommendations for custody or visitation.
This is a different service that can be found by looking for Custody Evaluators in other agencies. This is outside of Aspen Ridge Counseling’s scope of practice and we want to separate individual and family counseling from this function in order to work with your family more effectively.
Aspen Ridge Counseling does not attend court unless required to do so by a Judge’s court order. If there is an instance where an employee does so, there is a charge of $200 per hour plus travel time to appear and this is not covered by insurance. If you are involved in a court case, you can talk with your therapist about providing a report to the court in lieu of testifying or make other arrangements.
Aspen Ridge Counseling Centers works closely with Froerer Counseling and C. Hakes LLC. There is a Business Service Agreement in place to protect both clients and businesses above. These three entities may share administrative costs and storage and thus everyone working for the entities above are required to follow the rules set forth in this form along with HIPAA including payment and confidentiality rules. Thus, you may receive a bill or explanation of benefits from any of the above listed agencies for services rendered. This is all information covered within the Business Service Agreement with the three above entities and is done so to provide better range of service for clients.
Aspen Ridge Counseling Centers uses different methods of electronic communication as a convenience for staff and clients.
This is including but not limited to:
Text messages Emails Faxes Video Chat/Telehealth
I understand that many forms of electronic communication may not be secure methods to communicate about my treatment.
I understand that Aspen Ridge Counseling therapists are not allowed to communicate via Social Media outlets with their clients or their supervisee’s clients.
I understand that telehealth options are available for situations where travel is impacted, health issues limit contact and scheduling conflicts. Telehealth options are offered in a variety of user-friendly platforms although many are not considered secure methods of communication. This is to help with issues with missing appointments and therefore delaying treatment. You may contact your therapist to discuss options for Telehealth/Video Chat. Telehealth is typically used to supplement face-to-face sessions and it is still important to try to find a calm environment with little to no distractions to gain the most benefit from this service. Telehealth options may be limited based on client insurance stipulations, licensure rules and or location of services being provided.
I understand that I can talk with my therapist about which electronic methods of communication, I feel comfortable with and can opt out of electronic communication at any time by completing a form at the office advising as such.
I have read and understand the above information and I consent to treatment by Aspen Ridge Counseling Centers under the described conditions.
This notice describes how medical information about you may be used and disclosed and how you can get access to it. Please review carefully.
1. Your medical records are used to provide treatment, bill and receive payments, and conduct health care operations. Examples of these activities include but not limited to review of treatment records to ensure appropriate care, electronic or mail delivery of billing for treatment to you or other authorized payers, appointment reminder telephone calls, and records review to ensure completeness and quality of care. Use and disclosure of medical records is limited to the internal used outlined above except required by law or authorized by the patient or legal representative.
2. Federal and State laws require abuse, neglect, domestic violence and threats to be reported to social services or other protective agencies. If such reports are made they will be disclosed to you or your legal representative unless disclosure increases risk of further harm.
3. Disclosed information will be limited to the minimum necessary. You may request an account for any uses or disclosures other than those described in Sections 1 and Sections 2.
4. You, or your legal representative, may request your records to be disclosed to yourself or any other entity. Your request must be made in writing, clearly identify the person authorized to request the release, specify the information you want disclosed, the name and address of the entity you want the information released to, purpose and the expiration date of the authorization. Any authorization provided may be revoked in writing at anytime. Psychotherapy notes are part of your medical records. We have 30 days to respond to a disclosure request and 60 days if the records is stored off site.
5. You may request corrections to your records.
6. A request for disclosure may be denied under the following circumstances: disclosure would likely endanger the life or physical safety of you or another person, requested information references other persons, except another healthcare provider, or if released to a legal representative would likely result in harm.
7. If a request for disclosure is denied for reasons outlined in Section 6, you or your legal representative may request review of the denial. A review will be conducted by another licensed healthcare provider appointed by the original reviewer, who was not involved in the original decision to deny access. A review will be concluded within 30 days.
8. You may request that we restrict uses and disclosures outlined in Section 1. However, we are not required to agree to the restrictions. If an agreement is made to restrict used or disclosure, we will be bound by such restriction until revoked by you or your legal representative orally or in writing except when disclosure is required by law or in an emergency. We may also revoke such restrictions but information gathered while required by law or in a emergency. We may also revoke such restrictions but information gathered while the restriction was in place will remain restricted by such an agreement.
9. If you wish to complain about privacy related issues you may contact the Secretary of the Department of Health and Human Services, Hubert H. Humphrey Building, 200 Independence Avenue SW, Washington DC, 20201. In any case there will not be any retaliation against you or your legal representative for filling a complaint.
10. This agreement may be modified or amended as required by law or in the course of health care operations.
I HAVE READ AND UNDERSTOOD THIS PRIVACY NOTICE AND MY RIGHTS CONCERNING USE AND DISCLOSURE OF PROTECTED HEALTHCARE INFORMATION.
There is a $65 fee for No-shows or Late Cancellations of scheduled appointments. Late-Cancellation/No-show fees are an out of pocket expense that insurances or other agencies will NOT cover. Please review the definitions below:
· Appointments are approximately 53 minutes long. If you are late, the appointment will still end based on the scheduled appointment time. Please call us if you are running late.
We understand that there are extenuating circumstances where you are not able to attend.
· Severe illness or hospitalization
· Miscellaneous--- Please contact your therapist if there is an extenuating circumstance for the owners of Aspen Ridge Counseling to consider in order to either be issued a refund or if timely enough to avoid charge completely.
· You may be required to present proof of extenuating circumstance in order to receive a refund or avoid charge.
Please review each section:
Medical Coordination of Care Form
At Aspen Ridge Counseling, we feel it is important to work with your Primary Care Physician/ Medication Prescriber to provide the best care possible. Please complete as much of this information as you can for your provider. We will be notifying the provider of your therapist information in case there is a need to coordinate care. If you have more than one main provider, you may complete additional Release of Information forms at the office.
For Medicaid Consumers Only:
I acknowledge that I have received a Medicaid Member Handbook and Provider Directory (either in the mail or from my provider). I understand that the purpose of this book is to insure I have information about my benefits, rights and responsibilities. The handbook also provides information on how to receive covered services, access to emergency services, transportation and how to choose a provider. The handbook also addresses procedures for filing grievances and appeals.
I also understand that if I have been treated unfairly or discriminated against for any reason, I may file a complaint by contacting Optum Health at 1-877-370-8593
By signing this page, I acknowledge that I have completed this intake packet truthfully to the best of my ability. I am also acknowledging that I've read the information provided in each section. *Please save a copy for your records.