Contact: (860)663-8131 Fax: 1-(888)918-2702. Email: Yourpeaceofmindprovider@gmail.com
AGREEMENT FOR PAYMENT AND FINANCIAL RESPONSIBILITIES
Marital Status
Marital Status:
May Your therapist acknowledge the referral?
Contact: (860)663-8131
Fax: 1-(888)918-2702.
Email: Yourpeaceofmindprovider@gmail.com
Please list any additional people who will be attending the counseling session
Race:
Race:
Race:
Household Income: (We need this information whether or not you use insurance or pay a subsidized fee.)
Insurance (The office will need a copy of both sides of your insurance card.)
If I fail to obtain authorization, I am responsible for payment to Your Peace of Mind Therapeutic Services, LLC.
the denied session.
Contact: (860)663-8131
Fax: 1-(888)918-2702.
Email: Yourpeaceofmindprovider@gmail.com
*If I fail to obtain authorization, I am responsible for payment to Your Peace of Mind Therapeutic Services, LLC
denied session.
1. I am responsible for obtaining all authorizations and for all charges not covered. I understand that I am responsible for
charges not covered or reimbursed by the above agents. I agree, in the event of non-payment, to assume the costs of
interest, collection and legal action (if required and waive confidentiality for this purpose).
2. My therapist may discuss accommodations in special circumstances (i.e. video therapy, phone sessions); it is my
responsibility to determine insurance coverage for these sessions or to cover the cost of the service at the agreed-upon
rates.
3. I authorize Your Peace of Mind Therapeutic Services, LLC staff to communicate with my insurance company for the
purpose of claim verification and authorization for services, including a diagnosis code, and for my insurance carrier to
release information regarding my coverage to Your Peace of Mind Therapeutic Services, LLC. I authorize the release of
any medical or other information necessary to process this claim.
4. My right to payment for all services are hereby assigned to Your Peace of Mind Therapeutic Services, LLC. This
assignment covers any and all benefits under Self Pay, Medicare, other government sponsored programs, private insurance
and any other health plans. I acknowledge this document as a legally binding assignment to collect my benefits as payment
of claims for services. In the event my insurance carrier does not accept Assignment of Benefits, or if payments are made
directly to me or my representative, I will endorse such payments to For Your Peace of Mind Therapeutic Services, LLC.
5. I understand that I have a right to request and receive a Notice of Privacy Practices from Your Peace of Mind Therapeutic
Services, LLC.
THIS AGREEMENT/CONSENT WILL REMAIN IN EFFECT UNLESS REVOKED BY ME IN WRITING.
By signing I indicate that my therapist has discussed my fees for co-pay/session rate, late cancellation (<48 hours’
notice) and no shows, and any phone consultation fees I may be responsible for, and that I agree to pay those
promptly
I have read the above statements and accept the terms.
Contact: (860)663-8131 Fax: 1-(888)918-2702. Email: Yourpeaceofmindprovider@gmail.com
HEALTH HISTORY FORM
Any hospitalizations?
Have you ever been treated for depression/anxiety?
CONSENT FOR SERVICES
Confidentiality
Policies about confidentiality, as well as other information about your privacy rights, are fully described in a separate document
entitled Notice of Privacy Practices. It is our policy here at Your Peace of Mind, LLC. to protect the privacy of every client to
the maximum extent possible. Generally, information about you or services furnished to you will not be released without your
prior written consent. There are, however, some circumstances which require the disclosure of information without your
consent, such as when:
a) Mandated by state or federal law due to suspicion or knowledge of child abuse and/or neglect or elder abuse and/or neglect,
b) There is an imminent risk or serious threat of physical harm to self or to others, and
c) Specifically ordered by a court of law.
In accordance to For Your Peace of Mind Therapeutic Services, LLC. quality assurance standards, The Counseling’s
accrediting purposes may review your file to ensure record keeping compliance. Also, your therapist may anonymously
discuss your treatment with a supervisor to ensure the provision of quality care. Clinical supervisors and staff are mandated to
follow laws of confidentiality.
Appointments that are no show or missed without the 24-48-hour notice will be billed to your account in the amount that
would collect if the service had been provided as scheduled. Insurance does not reimburse for missed appointments;
therefore, you are responsible for full payment of this fee. Please discuss with your therapist any questions about the
cancellation policy.
Messages
Please discuss with your therapist how to handle emergencies. If you experience a mental health crisis outside of a session
there are several resources for help. These resources are available 24 hours per day, 365 days per year. Please call 211 for
mobile crises, Suicide prevention line 1800-272-8255. Alternatively, you may go to the nearest Emergency Room or call 911.
Fees and Insurance
The fee for your first appointment is determined by a Client Service Specialist during the intake process. At the first
appointment, you and your therapist will establish the ongoing appointment fee. Payment is expected at the time of your
appointment. Your Peace of Mind Therapeutic Services, LLC accepts cash, checks, MasterCard, Discover, and Visa.
Termination of Services
Clients have the right to end treatment at any time. Please notify your therapist of your desire to complete therapy. She/he
may request to have a final session with you to allow for therapeutic termination and to provide aftercare planning. Services
through For Your Peace of Mind Therapeutic Services, LLC. may be terminated for a variety of other reasons, including but
not limited to:
Client Consent
My signature below indicates that I reviewed this document, agree to the policies, and authorize the services. I accept financial
responsibility for payment of services received, and for payment of late cancellations. If I use insurance to pay all or a portion
of the charges, I hereby authorize the release of information necessary to process insurance claims filed on my behalf. I
acknowledge that I am financial and legally responsible for the full payment of charges for services received in the event my
health insurance policy does not cover my claim. I am 18 years of age or older or I have legal custody of this minor child(ren).
Your Rights
and why. We will include all the disclosures except for those about
treatment, payment, and health care operations, and certain other
disclosures (such as any you asked us to make). We’ll provide one
accounting a year for free but will charge a reasonable, cost-based fee if
you ask for another one within 12 months.
Ask us to correct your medical record
You can ask us to correct health information about you that you think is
incorrect or incomplete. Ask us how to do this. We may say “no” to
your request, but we’ll tell you why in writing within 60 days.
• Request confidential communications
You can ask us to contact you in a specific way (for example, home or
office phone) or to send mail to a different address. We will say “yes” to
all reasonable requests.
• Choose someone to act for you
If you have given someone medical power of attorney or if someone is
your legal guardian, that person can exercise your rights and make
choices about your health information. We will make sure the person has
this authority and can act for you before we take any action.
• Ask us to limit what we use or share
You can ask us not to use or share certain health information for
treatment, payment, or our operations. We are not required to agree to
your request, and we may say “no” if it would affect your care. If you
pay for a service or health care item out-of-pocket in full, you can ask us
not to share that information for the purpose of payment or our
operations with your health insurer. We will say “yes” unless a law
requires us to share that information.
• File a complaint if you feel your rights are violated
complain if you feel we have violated your rights by contacting our
Clinical Director and Privacy Officer, Julia Pickup, LCSW at
314.336.1041. You can also file a complaint with the U.S. Department
of
Health and Human Services Office for Civil Rights by sending a letter to
200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-
877696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
We will not retaliate against you for filing a complaint
Your Choices
For certain health information, you can tell us your choices about what
we share. If you have a clear preference for how we share your
information in the situations described below, talk to us. Tell us what you
want us to do, and we will follow your instructions. In these cases, you
have both the right and choice to tell us to:We are allowed or required to share your information in other ways –
usually in ways that contribute to the public good, such as public health
and research. We have to meet many conditions in the law before we can
share your information for these purposes. For more information see:
www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
Our Uses and Disclosures
We typically use or share your health information in the following ways.
• Help with public health and safety issues
We can share health information about you for certain situations such as:
Preventing disease, reporting suspected abuse, neglect, or domestic
violence, and preventing or reducing a serious threat to anyone’s health
or safety.
• Treat you
We can use your health information and share it with other professionals
who are treating you. Example: A doctor treating you for an injury asks another
doctor about your overall health condition.
• Do research
We can use or share your information for health research
• Comply with the law
We will share information about you if state or federal laws require it,
including with the Department of Health and Human Services if it wants
to see that we’re complying with federal privacy law.
• Run our organization
We can use and share your health information to run our practice,
improve your care, and contact you when necessary. Example: We use
health information about you to manage your treatment and services.
• Work with a medical examiner or funeral director
health information with a coroner, medical examiner, or funeral
director when an individual dies.
• Address workers’ compensation, law enforcement, and other
government requests
We can use or share health information about you for workers’
compensation claims, for law enforcement purposes or with a law
enforcement official, with health oversight agencies for activities
authorized by law, and for special government functions such as military,
national security, and presidential protective services
Respond to lawsuits and legal actions
We can share health information about you in response to a court or
administrative order, or in response to a subpoena.
Our Responsibilities
may change your mind at any time. Let us know in writing if you
change your mind.
Contact: (860)663-8131 Fax: 1-(888)918-2702
Email: Yourpeaceofmindprovider@gmail.com
This is to acknowledge that I have received
Your Peace of Mind Therapeutic Services, LLC
HIPPA FORMS
Contact: (860)663-8131 Fax: 1-(888)918-2702 Email: Yourpeaceofmindprovider@gmail.com
Appointment Reminders
Your Peace of Mind Therapeutic Services, LLC. offers the option to receive an appointment reminder the day prior
to your scheduled appointment by email (up to 2 email addresses) and/or by phone (only 1 phone number
permitted). If you choose the reminder by phone, you have the option of a text message or a computer-generated
voice message.
Please select ONE of the following options:
Automated Voice Messages: I authorize Your Peace of Mind Therapeutic Services, LLC to send
computer generated voice phone message appointment reminders to me on my provided phone number
I authorize Your Peace of Mind Therapeutic Services, LLC to send an email message
appointment reminders to me on my provided email address.
Example of email message from ValantApptReminder@reminderXchange.com
This is a reminder of your appointment on Monday – 01/11/2016 scheduled for 4:00 PM with Name of Counselor.
Email address(es) to send reminder messages to (up to 2)
Signature
EMAIL CONSENT
After reviewing the risks of email communication, you may authorize (client initials next to selected
method):
Contact: (860)663-8131 Fax: 1-(888)918-2702 Email: Yourpeaceofmindprovider@gmail.com
CLIENT GUIDE TO TELEHEALTH SERVICES
SETTING UP FOR VIDEO THERAPY
PRIVACY
WHAT TO EXPECT IN YOUR TELEHEALTH SESSIONS
TROUBLE SHOOTING TECHNICAL ISSUES IN VIDEO THERAPY
BACK UP PLAN
CONSENT TO TELEHEALTH SERVICES
INTRODUCTION
STATEMENT OF POTENTIAL RISKS AND BENEFITS
Potential Benefits of Telehealth Services
Potential Risks of Telehealth Services
By accepting this Consent to Telehealth Services, you acknowledge your understanding and agreement to the
following:
CLIENT CONSENT TO THE USE OF VIDEO THERAPY
Your Peace of Mind Therapeutic Services, LLC