Integrated Community Therapists, LLC
Client Rights and Responsibilities
As a client of Integrated Community Therapists, LLC, you have the following rights:
1. To be treated with courtesy, and respect by your therapist, her staff and colleagues.
2. To make recommendations regarding your therapist's responsibilities.
3. To receive appropriate therapeutic counseling.
4. To obtain information about your therapist's services and fees.
5. To receive information about your insurance company's clinical guidelines and member's rights and responsibilities from your provider when available.
6. To participate in the planning of your treatment, including the option to consult with outside personal acquaintances and other professionals at your own expense.
7. To refuse treatment.
8. To participate in experimental research, but only when you have provided written, informed consent to do so.
9. To be free from mental and physical abuse as defined by law. This includes the freedom from any act that constitutes assault, sexual exploitation, or sexual misconduct. It also includes the intentional and non-therapeutic infliction of physical pain or injury, or any conduct intended to produce mental or emotional distress.
10. To confidential therapeutic counseling and the confidentiality of your treatment record. This includes your right to approve or refuse the release of information in this record to anyone outside of your provider's office.
11. To voice complaints about the care that is provided according to the provider's grievance procedure. A copy of the procedure can be obtained from your provider.
As a client of Integrated Community Therapists, LLC, you have the following responsibilities:
12. To give to your therapist, the information necessary for your counseling.
13. To follow the treatment plan and instructions for care that you and the therapist have agreed upon.
14. To understand your mental health issues to the best of your ability and develop with your therapist mutually agreed upon treatment goals.
FEE AND COLLECTION POLICIES
1. The counselor and client before the first appointment agree upon fees.
2. UNKEPT APPOINTMENTS, not cancelled 24 hours prior to the appointment, will be billed at $125.00. Insurance companies will not pay for cancelled appointments. Call 319-337-3357 to cancel.
3. Occasions may arise during which clients must contact their counselor between appointments. Telephone contact, which exceeds ten minutes, will be billed at the regular hourly rate. This does not apply to scheduling concerns.
4. Method of Payment: Fees are dictated by the Insurance Companies, based on the billing codes used by the Therapist. Clients are urged to pay the fee or insurance copay at the time of each appointment.
I will pay the fee 1) each visit, 2) each month, 3) $ ______per month until the total fee is paid.
Informed Consent:
I have read the policies outlined above and agree to follow said policies.
Date: ______Client/Parent Signature
Date: ______
Signature of Therapist
INTEGRATED COMMUNITY THERAPISTS, LLC
CONSENT FOR CONSULTATION AND TREATMENT
Consultation
I, the undersigned, hereby authorize Darcie D. Yamada, Amanda A. Goodrich , Megan LaVelle, Kathleen A Ruyle and Louise Gisolfi to consult with one another concerning my counseling. I understand that the consultants will maintain confidentiality. Information shared may include clinical notes, termination summaries, and/or written or verbal communication.
I acknowledge that the data to be released may include material that is protected by federal law and is applicable to either mental health information, drug/alcohol use and or abuse (including physical, mental or sexual).
I further understand that I may revoke this consent at any time by a written notice. I understand that any release which has been made prior to my revocation and which was made in reliance upon this authorization shall not constitute a breach of my rights to confidentiality. I understand that I may review any written materials that are disclosed by contacting my counselor.
Consent for Treatment
I ______(name of patient), agree and consent to participate in behavioral health care services offered and provided by ______(name of provider), a behavioral health care provider. I understand that I am consenting and agreeing only to those services that the above named provider is qualified to provide within: (1) the scope of the provider’s license, certification, and training; or (2) the scope of license, certification, and training of the behavioral health care providers directly supervising the services received by the patient. If the patient is under the age of eighteen or unable to consent to treatment, I attest that I have legal custody of this individual and am authorized to initiate and consent for treatment and/or legally authorized to initial and consent to treatment on behalf of this individual.
** I hereby acknowledge that I have received and have been given an opportunity to read a copy of Integrated Community Therapist’s Notice of Privacy Practices. I understand that if I have any questions regarding the Notice or my privacy rights, I can contact my therapist at 123 N. Linn Street, Suite 2a, Iowa City, Iowa 52245, (319) 337-3357.
Dated ______
______
Signature of Client Signature of Parent or Guardian
Signature of Therapist
Patient Name ______
- Insurance, payment information and assignment of benefits
- I request Integrated Community Therapists, LLC to submit claims on my behalf to my insurance company, Medicare, or other third party payor for my care and authorize disclosure of health information to the extent necessary to obtain payment for these services.
- In consideration of the health care services provided to the Patient, I assign and authorize my insurance company, Medicare, or other third party payor to make payments directly to Integrated Community Therapists, LLC or the individual partners.
- I have been informed that:
- I must pay all charges, co-payments, deductibles, and coinsurance not covered by my insurance company, Medicare or third party payor,
- I must pay all charges incurred if I lack insurance coverage and will also contact Integrated Community Therapists, LLC to work with them to identify financial options available for me.
- I may revoke this consent to release medical information at any time by sending a written notice to Integrated Community Therapists, LLC, 123 N. Linn Street, Suite 2A, Iowa City, Iowa 52245. Except as provided below * this release is valid until revoked.
- I agree to pay for non-covered services or services not covered as a result of my failure to obtain pre-authorization for treatment as required by any such payor or agreed upon services deemed as medically unnecessary by the payor.
- Integrated Community Therapists, LLC will use good faith efforts to protect patient’s right to confidentiality in appropriately providing health information to payers.
- Specific Authorization for Release of Information
- I specifically authorize Integrated Community Therapists, LLC to submit medical information to regarding diagnoses, treatment, consultations, prescriptions, and medical history to my insurance company, Medicare, or other third party payor or its authorized agents or representatives for the purpose of determining benefits and facilitating payment. This authorization is valid for one (1) year* Disclosures may only be made pursuant to the written authorization of an individual or an individual’s legal representative. The unauthorized disclosure of this information in unlawful and civil damages and criminal penalties may be applicable to the unauthorized disclosure of said information pursuant to the Iowa code. I may revoke this specific consent to release information at any time by sending a written notice to, Integrated Community Therapists, LLC, 123 N. Linn Street, Suite 2A Iowa City, Iowa 52245. I understand that the information to be released may include information in the following categories unless I specifically deny the release (initial any category not to be released).
______Substance Abuse
______Acquired Immune Deficiency Syndrome (AIDS) includingHuman Immune-deficiency Virus (HIV)
______Mental Health
______
Patient Signature/Responsible Person Date SignedRelationship/Legal Title (if not patient)
______
Witness Date SignedWitness Date Signed
INTEGRATED COMMUNITY THERAPISTS, LLC
AUTHORIZATION FOR RELEASE OF CONFIDENTIAL INFORMATION
I, ______of
(name of client) (address)
authorize ______
to disclose to and gather from ______
the following information:
dates of service
assessment information
______alcohol and Other Drug History
recommendations for treatment
social/family history
verbal exchange of information to review treatment or refer for services
summary of progress
for the purpose of:
case consultation or collaboration
assistance in assessment or treatment
billing
I understand that my alcohol and/or drug treatment records are protected under the Federal regulations governing Confidentiality and Drug Abuse Patient Records, 42 C.F.R. part 2, and the Health Insurance Portability and Accountability Act of 1996(HIPPA), 45 C.F.R. pts 160 & 164, and cannot be disclosed without my written consent unless otherwise provide for by the regulations. I understand that I may revoke this consent by a written request at any time; otherwise consent expires automatically as specified below. I also understand my right to inspect the disclosed material at any time.
Specification of the date, event, or condition upon which this consent is based expires one year from date of signature. This consent is only renewable upon a new signature and date. I further acknowledge that the information to be released was fully explained to me and this consent is given of my own free will.
Mental health and substance abuse information is protected by Federal law. I am releasing:
Mental Health Information______
Substance Abuse Information______
HIV Related Information______
Executed this day of ______, 2016
Signature of Client
______
Signature of Client/Parent or Guardian
Signature of Therapist