CONSENT TO TREATMENT AND DIAGNOSTIC
SERVICES
Client:
_____________________________________________________________________
Welcome to our practice. This document contains important information about our professional services and business policies. You will also be given a Notice of Privacy Practices. Please take the time to read both of these documents in depth. We will be happy to discuss with you their contents and to answer any of your questions. You may revoke this consent in writing at any time. That revocation will be binding on us unless we have taken action in reliance on it; if there are obligations imposed on us by your health insurer in order to process or substantiate claims made under your policy; or if you have not satisfied any financial obligations you have incurred.
The services provided to you or your dependent will be based on currently accepted practice in the fields of mental health or substance abuse. We cannot guarantee the outcome of treatment and any services continue only with your voluntary consent. You or your dependent may be asked to consult with a physician or a psychiatrist, when this is considered necessary by your therapist.
Your or your dependent’s records are confidential. Specific policies and rights are given in the Notice of Privacy Practices.
We may attempt to contact you by mail or telephone during or after your or your dependent’s contacts with Relationship Center of Michigan for the purpose of confirming or scheduling appointment, billing and payment issues, completing of forms and any necessary follow-up. You have the right to request and receive confidential information by alternative means and at different locations.
We normally conduct an evaluation that will last from 2 to 4 sessions. During this time, we can decide if your therapist is the best person to provide the services that you need in order to meet your treatment goals.
Due to our work schedule, we are not often immediately available by phone. When we are unavailable, please leave a voice mail message on our telephone. We frequently monitor our messages. We will make every effort to return your call on the same day you make it, with the exception of weekends and holidays. If there is an emergency after hours, please call 810-772-1649. The answering service will work to contact your therapist. If you feel you cannot wait for a return call, contact your family physician, psychiatrist, or the nearest emergency room. If your therapist is unavailable for an extended time, we will provide you with the name of a colleague to contact, if necessary.
The law allows parents to examine their dependent’s records, unless the child is over 18 year old or is emancipated. Clients over 14 can consent to their own treatment, although that treatment cannot extend beyond 12 sessions or 4 months. We ask that parent respect their child’s privacy and not question them about treatment. However, we are willing to meet with parents periodically to share general information about the progress of treatment. Any other communication will require the child’s authorization. If we feel that the child is in danger or is a danger to someone else, or if other legal responsibilities become apparent (as defined in the Notice), we will notify the parents of our concerns.
If you have insurance which will pay for these services and if we have a service agreement with this company, we will accept the contracted fee screen. In addition to weekly appointments, we may charge the professional fee for other services not generally covered by insurance, such as, report writing, extended telephone conversations, preparations of records or treatment summaries, consulting with other professionals with your permission, and court appearances, including travel time.
By signing this document, you give us permission to bill your insurance company and to give them information, such as diagnosis and Protected Health Information (as defined in the Notice), necessary to obtain payment for services. But you are responsible for the full payment of our fees. It is very important that you find out exactly what services your insurance policy covers and what your deductibles and co-pays are. We cannot be responsible for quoting any benefit information.
You will be expected to pay co-pays and fees for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage which will pay for all or a portion of the fee. If maximum insurance benefits have been reached, you will be responsible for any fees for services subsequently rendered.
Missed appointments are not reimbursed by any insurance company. We reserve the right to bill you for any appointment that is missed without your giving 24 hours notice. These may be billed to you at the usual fee.
If unpaid balances are over $200 and/or over 90 days old and if arrangements for payment have not been agreed upon, we have the option of using legal means to secure payment, including going through small claims court or involving a collection agency. These will require us to disclose otherwise confidential information. However, we will release only as little information as necessary. Any costs of legal action will be included in the claim. We shall not be obligated to send any report concerning you or your dependent to anyone until the balance on your account is paid in full.
Your signature below acknowledges that you are voluntarily authorizing diagnostic and treatment services at Relationship Center of Michigan for yourself or your dependent. You recognize that you may refuse any aspect of treatment. You also recognize that such a refusal may, in some instances, result in termination of services.
Your signature below indicates you have read this document and agree to its terms and also serves as an acknowledgement that you have received the HIPAA Notice of Privacy Practices described above.
____________________________________________________________________________________________
Signature of Client or
Parent/Guardian
Date
_____________________________________________________________________________
Witness
Date