409 7th Street
Safford, AZ 85546
Phone 1-928-428-2952
Fax 1-928-428-2016
Consent to Treatment
1. Consent to Treatment:
I have retained Jeffrey C. Jorgensen D.BH, to provide mental health treatment. The nature of the treatment to be provided will be explained including expected benefits, any risk that may be involved, and any alternative treatments that may be available. I also understand that the improvement expected, is not guaranteed. If I wish to withdraw from treatment, I will be provided an appropriate referral.
2. Confidentiality and Release of Information
I understand that information regarding my treatment will be held strictly confidential and Jorgensen Counseling Inc. will protect my right to privacy. I also understand that any information will not be disclosed without my written consent (or consent of my legal guardian), except under the following circumstances:
a. I threaten to injure myself or another person.
b. Information required by law to be reported is revealed, such as information concerning abuse, neglect, molestation or exploitation of a minor or incapacitated adult, or in the case of a court order or subpoena.
c. A medical emergency.
d. Any information that would be necessary for reimbursement from a third party payer.
The Health Insurance Portability and Accountability Act (HIPAA) provide safeguards to protect your privacy. Specifically, there are rules and restrictions on who may see or be notified of your Protected Health Information (PHI). These restrictions do not include the normal interchange of information necessary to provide you with office services. HIPAA provides certain rights and protections to you as the patient.
3. Fees/Payment
Payment or co-pays are expected at the time services are rendered, by cash, check, or credit. Additional fees may apply for letters/completion of forms. Dr. Jorgensen is not available for custody evaluations, competency hearings/ evaluations, or any other court services. If a court subpoena requires documents or appearance, patients will incur additional charges. These services must be pre-paid and are not covered by insurance. Any disability or work leave paperwork completed by our office requires a charge of $75.00. This cost is not covered by insurance. Whether they will be filled out will depend upon the clinical judgment of Dr. Jorgensen. The client (or responsible party) is considered responsible for payment of professional services. When a third party is used for payments, such as an insurance company, and that third party fails to make payment within 60 days from the billing date, payment is expected from the client or responsible party within 30 days of receipt of bill. Bills not paid within 60 days will from the date of billing will be sent to collections.
***If you are unable to keep an appointment, please notify the office immediately. If an appointment is cancelled or missed without 24 hours prior notice, you will be charged for the missed session at the rate of $35. We require a credit card on file for all Jorgensen Counseling clients. By signing you authorize use of this credit card for missed sessions and/or unpaid balances on your account *** INITIAL______
CREDIT CARD#______-______-______-______EXP______CVV#______
4. Client Rights
Initial that you have received a copy of the Client Rights form and that you understand your rights: ______.
______
Client or Legally Authorized Guardian/Parent (if under 18) Date