Columbus Behavioral HealthAn Association of Independent Practitioners
614.360.2600Westerville | Dublin | New Albany
If YES, STOP! You and your partner/spouse need to complete the NEW PATIENT FORMS FOR COUPLES, not these.
We are committed to making all patients feel welcome, safe and respected. We ask the following questions for the purpose of helping our staff use the most respectful language when addressing you, understanding our population better and fulfilling billing requirements. Your responses will be kept private.
Columbus Behavioral Health, LLC
6631 Commerce Parkway, Ste. R, Dublin, OH 430175071 Forest Drive, Ste. B, New Albany, OH 43054 635 Park Meadow Road, Ste. 101, Westerville 43081
PH: 614.360.2600/ Fax: 844.320.2600
Client Information and Acknowledgment of Informed Consent to Treatment
Columbus Behavioral Health, LLC (hereinafter “CBH”) provides counseling through Ohio licensed mental health therapists and allied health professionals (all of which will be referred to as “therapist”) which are independently contracted with the practice. This Agreement applies to the therapist you will be seeing, and it will also describe the business practices of the therapists at CBH.
Mental Health ServicesThe purpose of mental health services is to help you better understand your situation, change your behavior or move toward resolving your difficulties. Using your therapist’s knowledge of human development and behavior, he or she will make observations about situations and help you to develop new ways to approach them. It will be important for you to examine your own feelings, thoughts and behavior, and to try new approaches in order for change to occur.
The services offered can have risks as well as benefits. Treatment often involves discussing unpleasant issues, and you might experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. On the other hand, mental health care may often lead to better relationships, solutions to specific problems, and significant reductions in feelings of distress. But there are no guarantees of what you will experience.
We do NOT complete FMLA paperwork, disabililty paperwork, leave of absence paperwork and do not write Emotional Support Animal letters.
AppointmentsAppointments are made online or by calling the main line. Please call to cancel or reschedule at least 48 business hours in advance, or the following charges will apply - no charge for the 1st cancellation, $95.00 for the 2nd, and $190 for the 3rd cancellation for the missed appointment unless your therapist determines an emergency was involved. Third party payers will not cover or reimburse for missed appointments. Appointments are typically 45 or 60 minutes in length, but session length may vary for clinical reasons. The number of appointments depends on many factors and your therapist will discuss this as part of your treatment planning. Since there is no way a therapist can see another client when they have a late arrival, no reductions are provided when a client arrives late for an appointment. Some insurance companies will only pay for the actual time during which services are rendered. In that case you, the client, will be billed for the portion of the appointment time when no services could be rendered. Some governmental insurance or employee assistance programs do not allow billing for missed or partially missed appointments and if that is the case you will be billed in accordance with those programs’ rules.
RelationshipYour therapist’s relationship with clients is a professional and therapeutic relationship. In order to preserve this relationship, it is imperative that your therapist not have any other type of relationship with you. Personal and/or business relationships undermine the effectiveness of the therapeutic relationship. Please do not attempt to “friend” your therapist or anyone else in the practice on Facebook or on any other social media site. You always have the right to terminate services with your therapist at any time and for any reason.
Goals, Purposes and TechniquesThere may be alternative ways to effectively treat the problems you are experiencing. It is important for you to discuss any questions you may have regarding the treatment your therapist recommends and to have input into setting the goals of your therapy. As therapy progresses these goals may change. You and your therapist will jointly determine how to effect the changes you are seeking to make for yourself. You always have the opportunity to seek either another opinion or a different therapist. Your therapist will let you know if he or she feels that you are not a good fit or if you might obtain better help with someone else. Your therapist will always retain the right to terminate therapy with you. Some examples of when this may happen is in the event that he or she feels you would be better served with another therapist, for rude or abusive behavior, for a pattern of missed or cancelled appointments, if he or she feels you are not complying with treatment requests, or if payments due remain unpaid. In the event that your therapist terminates services with you he or she will offer you referrals.
ConfidentialityLaws protect the privacy of all communications between a client and a therapist. In most situations your therapist can only release information about your treatment to others if you sign a written authorization. There are some situations where they are permitted or required to disclose information either with or without your consent or authorization. For example:
There are some situations in which your therapist is legally obligated to take actions that he or she believes is necessary to attempt to protect others from harm, and in such cases they might have to reveal some information about your treatment. If such a situation arises, your therapist will make every effort to fully discuss it with you before taking any action, if they deem that to be appropriate under the circumstances, and will limit disclosure to what is necessary. For instance:
You agree that the practice may release information about your claim(s) to the Ohio Department of Insurance in connection with any insurance company’s failure to properly pay a claim in a timely manner as well as to the Ohio Department of Commerce, which requires certain reporting of unclaimed funds. In those instances, only the minimal, required, information will be supplied.
You agree that from time to time your therapist may have the need to consult with his or her practice attorney regarding legal issues involving your care (this is an infrequent occurrence, but does happen from time to time). The practice attorney is bound by confidentiality rules also. In addition, your therapist will reveal only the information that he or she needs to reveal to receive appropriate legal advice in connection with those contacts.
You should be aware that your therapist practices with other mental health professionals and that the practice may employ administrative staff. In most cases, protected information may need to be shared with these individuals, as well as outside medical professionals for both clinical and administrative purposes, such as typing, scheduling, billing, and quality assurance, or to coordinate care in the event that another therapist in the practice is seeing one of your family members. If your therapist or the practice does that only the information necessary in order for them to provide help to you, the client, will be released. All of the health care professionals are bound by the same rules of confidentiality. All staff members have been given training about protecting your privacy and have agreed not to release any information outside of the practice without the permission of a professional staff member.
Also, the practice may have a contract with a collection agency. If that is the case, the practice will have a formal contract with this business, in which the business promises to maintain the confidentiality of the data except where release of certain information is allowed in the contract or is required by law. Only limited information, just enough to collect the amount you owe, will be disclosed by the practice in this situation.
This summary is designed to provide an overview of confidentiality and its limits. It is important that you read the Notice of Privacy Practices form that has been provided to you for more detailed explanations, and that you discuss with your therapist any questions or concerns that you have.
Legal SituationsIf you or the client (if the client is a minor or a ward of a guardian) become involved in legal proceedings that require your therapist’s participation you will be expected to pay for all of their professional time, even if they are called to testify by another party. Your therapist will ask that a retainer be paid of half of the expected fees at least one week prior to providing these services, and the second half of expected fees and any additional fees that may have been accrued be paid within one week after services are delivered. Any unused amounts will be refunded. Your therapist’s professional time for legal proceedings may include preparation (document review or letter preparation), phone consultation with other professionals or you, record copying fees, and travel time to and from proceedings, testifying, and time that they wait in court prior to or after they may be called to testify. Due to the time-consuming and often difficult nature of legal involvement, your therapist charges $375.00 per hour for these services. You will also be responsible for any legal fees that they may incur in connection with the legal proceeding, which may include responding to subpoenas.
Please be advised that as a treating therapist, your therapist cannot ethically provide any recommendations on guardianship, custody, visitation, parenting capacity or abilities or what is in the best interest of the child(ren) if you or your child(ren) are involved in custody/divorce/guardianship proceedings.
Professional RecordsThe laws and standards of your therapist’s profession require that your therapist keep Protected Health Information about you in your Clinical Record. Your Clinical Record may include information about your reasons for seeking therapy, a description of the ways in which your problems affect your life, your diagnosis, the goals for treatment, your progress toward those goals, your medical and social history, your treatment history, results of clinical tests (including raw test data), any past treatment records that your therapist receives from other providers, reports of any professional consultations, any payment records, and copies of any reports that have been sent to anyone. You may examine and/or receive a copy of your Clinical Record if you request it in writing, unless your therapist determines for clearly stated treatment reasons that disclosure of the records to you is likely to have an adverse effect on you, and in that event under Ohio law they may exercise the option of turning the records over to another mental health therapist designated by you, unless otherwise required by federal law. Because these are professional records they can be misinterpreted and/or upsetting to untrained readers, it is therefore recommended that you initially review them with your therapist, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, your therapist is allowed to charge fees set under Ohio and federal laws for copying and sending records. These fees may change every year, so he or she will let you know what the charge is at the time that a records request is made. If you desire to have the information sent to you electronically, and if we store the information in an electronic format, your therapist will provide the information to you in an electronic format if you agree to accept the potential risks involved in sending the records that way.
Your therapist may also keep a set of psychotherapy notes which are for their own use and which are designed to assist them in providing you with the best treatment. These notes are kept separate from your Clinical Record. They are not routinely released to others with your Clinical Record, except in rare legal circumstances. Their release requires a separate authorization in addition to one for the Clinical Record. Your therapist will discuss with you whether or not they are maintaining psychotherapy notes on you.
Fees, Payments, and BillingPayment for services is an important part of any professional relationship. This is even more true in therapy; one treatment goal is to make relationships and the duties and obligations they involve clear. You are responsible for seeing that your therapist’s services are paid for. Meeting this responsibility shows your commitment and maturity.
Our current billable rates are $160-$230 per session, depending on service and duration. Fees are billed to your insurance, if applicable, and you are responsible for copay, coinsurance and/or deductible amounts. If you are not using insurance, please ask about cash rates. Payment for each session is due at its start or at its end. The practice has found that this arrangement helps you and your therapist to stay focused on our goals, and so it works best. It also allows your therapist to keep their fees as low as possible because it cuts down on bookkeeping costs. The practice suggests you make out your check, or pay by credit card, before each session begins, so that your time will be used best. The practice accepts Visa, Mastercard, American Express, and Discover credit cards and offers a way for the practice to store your credit card information for incurred charges. Other payment or fee arrangements must be worked out before the end of the first session.
Telephone consultations: Your therapist believes that telephone consultations may be suitable or even needed at times in therapy. If so, he or she will charge you their regular fee, prorated for the time needed. If your therapist needs to have long telephone conferences with other professionals as part of your treatment, you will be billed for these at the same rate as for regular therapy services. If you are concerned about this, please be sure to discuss it with your therapist in advance so you and they can set a policy that is comfortable for both of you. Of course, there is no charge for calls about appointments or similar business issues. Insurance companies will typically not provide reimbursement for telephone consultations.
Extended sessions: Occasionally it may be better to go on with a session, rather than stop or postpone work on a particular issue. When this extension is more than 10 minutes your therapist will tell you, because sessions that are extended beyond 10 minutes will be charged on a prorated basis. Insurance may not pay for the extended portion of a session.
Reports: Your therapist will not charge you for his or her time spent making routine reports to your insurance company.
A late payment fee of $25.00 will be charged each month that a balance remains unpaid, since your therapist will incur costs to rebill and other accounting costs. A returned check fee of $35.00 will be charged if your check bounces.
If you think you may have trouble paying your bills on time, please discuss this with your therapist. Your therapist will also raise the matter with you so you can arrive at a solution. If your unpaid balance reaches $400.00 your therapist will notify you. If it then remains unpaid, he or she may stop therapy with you if you and he or she cannot agree on a payment plan. Fees that continue unpaid after this may be turned over to small-claims court or a collection service and you agree to allow the practice to do that. If the practice chooses to do that, they will report only enough information to collect fees due to your therapist.
Because your therapist is a licensed mental health therapist, many health insurance plans will help you pay for therapy and other services he or she offers. Because health insurance is written by many different companies, your therapist cannot tell you what your plan covers. Please read your plan’s booklet under coverage for “Outpatient Psychotherapy” or under “Treatment of Mental and Nervous Conditions.” Or call your employer’s benefits office to find out what you need to know.
If your health insurance will pay part of your therapist’s fee, the practice will help you with your insurance claim forms. However, please keep some things in mind: Your therapist had no role in deciding what your insurance covers. Your employer or you (if you have individual coverage) decided which, if any, services will be covered and how much you have to pay. You are responsible for checking your insurance coverage, deductibles, payment rates, copayments, and so forth. Your insurance contract is between you and your insurance company; it is not between your therapist and the insurance company unless he or she or the practice has signed a separate agreement with that particular company. You are responsible for paying the fees that are agreed upon. If you ask the practice to bill a separated spouse, a relative, or an insurance company and payment is not received on time, then you agree to pay this amount. In addition, the plan may have rules, limits, and procedures that should be discussed, and your therapist may not be on one of their panels. Please bring your health insurance plan’s description of services to one of the early meetings with your therapist, so that you can talk about it and decide what to do. The practice does not participate in all insurance or governmental plans, so it’s important to check whether or not you have coverage available before you begin therapy.
The practice will provide information about you to your insurance company with your consent, and by signing below you agree that it may do that. If the practice or your therapist has a contract with your insurance company then billing will be sent in accordance with the contract with that company. If your therapist or the practice is not contracted with that insurance company then you will be supplied with an invoice for your therapist’s services with the standard diagnostic and procedure codes for billing purposes, the times you met, the charges, and your payments. You can use this to apply for reimbursement. By signing this form, you agree to assign any reimbursement you receive from your insurance company to the practice.
If you choose to not have your therapist send information to your insurance company, you must select this option before each session and then pay for the session in full. With this option no report of any information will be made to your insurance company about that session. Although insurance companies say that they maintain confidentiality, oftentimes they report information to a national data bank that may later affect your ability to obtain other types of insurance.
MinorsIf you are under 18 years of age, please be aware that the law generally provides your parents the right to examine your treatment records, unless blocked by court order or if your therapist feels that the release of your records to your parents might have an adverse effect on you, in which case under Ohio law they can name another mental health therapist that your therapist will have to turn them over to, unless otherwise required by federal law. Before giving your parents any information your therapist will discuss the matter with you, if possible, and do their best to handle any objections you may have. Except in unusual circumstances, your therapist likes to make both parents aware of and involved in the treatment. In addition, if one parent brings in a child and the therapy only involves the child, under Ohio law since generally both parents have access to the child’s records unless that access is blocked by a court order, and therefore anything that either parent says in the sessions is available to both parents. Legal documents need to be provided in cases where custody, visitation, shared parenting, guardianship or other matters which are covered by court documents are involved before your therapist sees a minor for treatment. Minors 14 years of age and older should be aware that they have an option to see a therapist on a limited basis without their parents’ knowledge, except where there is a compelling need for disclosure based on a substantial probability of harm to the minor or to other persons, and if the minor is notified of your therapist’s intent to inform the minor’s parent, or guardian. Only the minor is responsible for paying for services under this option.
Emergencies and After-Hours CareIf you have an emergency, you should go directly to a hospital emergency department or call 911 or Netcare Access at 614-276-2273. The National Suicide Prevention Lifeline number is 1-800-273-8255. Emergencies are urgent situations and require your immediate action.
Incapacity or Death of TherapistIn the event that your therapist is incapacitated or dies, it will be necessary for another therapist to take possession of your file and records. By signing this form you consent to allow another licensed mental health professional whom your therapist or the practice designates to take possession of your file and records, provide you with copies upon request, or to deliver them to a therapist of your choice.
Release of Liability: If you fail to show for an appointment, we will try to contact you during that appt. time at the number you have provided. If we do not hear from you within one week of the missed appointment, you have released us of all liability for your psychological counseling/care. If you cancel an appointment without rescheduling, you release us from liability for your psychological care/counseling. You are welcome to reschedule at any time, provided any past balances, including no show fees, are paid. If you have not been seen for 90 days, the relationship is considered terminated, your chart will be made inactive, and you release us from liability for your psychological care/counseling. Of course there are extenuating circumstances, such as an extended vacation, family emergency, unforeseen business trip, etc. In such cases, please contact us as soon as possible to keep us informed.
Disclosing Information to Family Members, Relatives, or Close Friends.
By initialing below you agree to allow your therapist, if you are incapacitated, in an emergency situation, or are not available, to contact a family member, a relative, a close friend or any other person you identify, to disclose your personal health information that directly relates to that person’s involvement in your healthcare. This information will be disclosed as necessary only if he or she determines that it is your best interest based on his or her professional judgment.
Email, Texting, and Electronic CommunicationsThe therapists and this practice do not like to use e-mail, texting, or electronic communications unless we both agree that is appropriate. If you decide you want to utilize any form of electronic communication, you acknowledge that there are confidentiality risks inherent in such communications if they are unencrypted and you agree to accept those risks. If you wish to use unencrypted electronic communications, please place your initials in the space below
If you do not want your therapist or the office to contact you at a certain address or phone number, please let your therapist know at your first meeting with him or her.
Acknowledgment of Informed Consent to Treatment
I voluntarily agree to receive mental health assessment, care, treatment, or services and authorize the therapist I will be seeing at the practice to provide such care, treatment or services as are considered necessary and advisable. I further authorize the submission of information to an insurance company or third party payer to obtain reimbursement, unless I direct otherwise.I understand and agree that I will participate in the planning of my care, treatment, or services and that I may stop such care, treatment or services that I receive through a therapist at the practice at any time. I also understand that there are no guarantees that treatment will be successful.
By signing this Acknowledgment of Informed Consent to Treatment, I, the undersigned client, acknowledge that I have both read and understand all the terms and information contained herein and I agree to be bound by the provisions in this agreement. Ample opportunity has been offered to me to ask questions and seek clarification of anything unclear to me. If a minor or a ward with a court approved guardian is the client I am signing on behalf of the minor or the ward as the authorized parent/guardian. (Information on minor rights will be shared with the minor, as appropriate.)
I also acknowledge that I have received a copy of the Notice of Privacy Practices for the practice listed at the top of this form.
A copy of the Notice of Privacy Practices is available on our website at ColumbusBehavioralHealth.com under Paperwork/Forms.
I have read and/or have received a copy of the HIPAA Privacy Practices. Available on our website at ColumbusBehavioralHealth.com under Paperwork/Forms.
I understand that my mental health provider, as an independent contractor, is solely legally responsible for my treatment and care.
COLUMBUS BEHAVIORAL HEALTHin DUBLIN/WESTERVILLE/NEW ALBANY
ELECTRONIC SERVICE DELIVERY INFORMED CONSENT
Electronic Service Delivery is defined as mental health therapy in any form offered or rendered primarily by electronic or technology assisted approaches when the mental health therapist and the client are not located in the same place during delivery of services. While working with your therapist you will always have the opportunity to ask any questions that you have about the therapy, electronic communications in general, and other issues involving your therapy. Your therapist will also assess your ability to handle computers and the internet, so that you and he or she may work in this way.As a client receiving mental health services through electronic service deliverymethods, you should understand:
1) This service is provided by technology and there are benefits and limitations to this type of service, which may also include emails and texting. You will need access to, and familiarity with, the appropriate technology to participate in the service provided. Exchange of information may not be direct, and any paperwork exchanged will likely be exchanged through electronic means or through postal delivery. Your therapist will assess whether or not therapy through means of electronic service delivery is appropriate for addressing your issues and whether or not you have the knowledge and skills to use the technology involved.
2) As a therapist licensed in Ohio, your therapist may only deliver services to residents or people located in Ohio. If you plan on leaving Ohio for any length of time in the future, please let your therapist know as soon as possible so that you and he or she can make proper arrangements for future work or referrals, as appropriate. If you are going to be out of state during therapy, then your therapist will have to comply with the licensing laws of the state where you will be located.
3) If a need for direct, face to face services arises, it is your responsibility to contact providers in your area, or to contact this office for a face to face appointment. You understand that an opening may not be immediately available. 4) You may decline any electronic service delivery service at any time without jeopardizing your access to future care, services, and benefits.
5) These services rely on technology, which allows for greater convenience in service delivery. There are risks in transmitting information over the internet or through other electronic services that include, but are not limited to, breaches of confidentiality, theft of personal information, and disruption of service due to technical difficulties. Your therapist and you will regularly reassess the appropriateness of continuing to deliver services through the use of technology. When using these services you agree to accept the risks involved with the unencrypted exchange of information, if it is provided in that way.6) Your therapist will need to verify your identity in a face to face meeting, which may be via video/audio electronically and then at subsequent sessions. At the initial session you and your therapist will address imposter concerns. You should be aware that misunderstandings are possible with telephone, text-based modalities (e.g., email), and real-time internet chat, since non-verbal cues are relatively lacking. Even with video chat software, since bandwidth may be limited and images may lack detail, misunderstandings may occur. Your therapist is an observer of human behavior. He or she will gather information from body language, vocal inflection, eye contact, and other non-verbal cues. Cultural differences and how they affect non-verbal cues may also be involved and your therapist will assess whether or not this type of therapy is appropriate for your cultural experiences, your environment and your therapeutic needs. If work is being done with families or groups with different levels of technology competence, power dynamics will be acknowledged. Please let your therapist know if you have any type of audio/visual or cognitive impairment prior to beginning therapy. If you have never engaged in online counseling, you need to have patience with the process and request clarification if you believe that you are not being understood by your therapist or you do not understand something that your therapist says. He or she will regularly review whether or not electronic service delivery is meeting the goals of therapy. Your therapist will also discuss with you how to handle disruptions in services and all methods of delivering services that are compliant with commonly accepted standards of technology safety and security at the time at which services are rendered.7) In emergencies, in the event of disruption of service, or for routine oradministrative reasons, it may be necessary to communicate by other means:
a) In emergency situations: If it is an imminent situation that requires face-to-face contact call 911 or go to the nearest emergency room. If it can be managed over the phone, you can call your therapist but if your therapist does not respond immediately or within a short period of time, you should contact local emergency services (for example, call 911 or go to your local hospital’s emergency room, or call the National Suicide Prevention Hotline number -1-800-273-8255 or Netcare at 1- 614-276-CARE.) Also, other local hotline crisis phone numbers may be available to call, and you can check on the internet to find those.
b) Should service be disrupted: Try to regain contact using the same medium. If that does not work, attempt to make contact using text or e-mail. Your therapist will also make every effort to regain contact. If service is disrupted during a therapy session before the pre-agreed time frame has ended, you will have the opportunity to use the remaining time as soon as contact is made. If contact is not re-established within one hour, you will have the choice to end the session and be charged a pro- rated amount or allowed to schedule an additional session to use the remaining time.
c) For other communications: Your therapist and you may agree to communicate via a phone call, videoconferencing, e-mail, text, fax, or mailed letters.(8) The potential benefits of online counseling include flexibility in scheduling and allowing you to engage in counseling outside of the office, which eliminates issues like transportation and other psycho-social barriers that might make it difficult for you to handle in a traditional office setting. The provision of online counseling may include risks related to the technology used, the distance between you and your therapist, and issues related to timeliness. For example, the potential risk of confidentiality may pertain to your accessing the internet from public locations. You should consider the visibility of your screen and being overheard when in public settings. It is recommended that you be in a private setting when engaging in online counseling. You should also always use strong passwords to protect any information shared with your therapist. Never use a work computer for therapy as your employer may have access to the information shared in electronic communications. Be cautious when using a shared network with others.
(9) Although the internet provides the appearance of anonymity and privacy in counseling, privacy is more of an issue online than it is in person. You are responsible for confidentiality in your own environment, including securing your hardware, internet access points, chat software, email, and passwords. Please develop passwords that are appropriate and strong and not use auto-fill for user names or passwords. Although your therapist will take steps to protect your information, he or she will have policies in effect to notify you of a breach of any of your confidential information which is required to be reported to you.
(10) Your therapist may utilize alternative means of communication in the followingcircumstances: if you do not respond to text, your therapist may call. If you do not respond to a call, your therapist may follow up with text or e-mail. If you do not respond to a call, text, or e-mail, your therapist may follow up with a mailed letter. In case of emergency (or concerns over your welfare), your therapist may contact your emergency contact if you have provided one.
(11) Your therapist will attempt to respond to communications and routine messages within 48 hours if he or she is available.
(12) Most insurance companies in Ohio only currently reimburse for face to face in person therapy sessions, so there may not be insurance coverage for therapy sessions delivered through technology. You should check with your insurance company to determine if they will reimburse you for electronic service delivery sessions. If insurance does not cover reimbursement, then you agree to pay the fee for the service.
(13) You need to take the following precautions to ensure that your communications are directed only to your therapist or other individuals: Ensure that you use the correct e-mail address, telephone number, skype or online name, fax number, and physical address to contact the appropriate individuals. Only leave voice messages after ensuring that the correct phone number was dialed and the voicemail introduction identifies the correct individual.
(14) Your communications exchanged with your therapist, if capable of being put into written form, will be stored in the following manner: e-mails, texts, and other electronic communication relevant to treatment will be printed and kept in your file. Mailed letters and documents will also be kept in your file. Notes outlining electronic service delivery treatment sessions will be written and kept in your file. Your file will be kept in a locked file cabinet or stored electronically and will be accessible only by those who require or are allowed access and will be available to you or someone named by you for the length of time required under Ohio law. Your therapist will not record sessions without first discussing it with you and obtaining your permission to do that. Please see your therapists regular Informed Consent form for information on access to your records, including who will have access to them. (15) The laws, ethics and professional standards that apply to in-person therapeutic services also apply to services delivered by electronic means. This document does not replace other agreements, contracts, or documentation of informed consent covering other issues. If you want licensing information on your therapist, you can find it at one of the licensing board websites. Psychology Board statutes, rules and other helpful information may be found at www.psychology.ohio.gov, and the Counselor, Social Worker & Marriage and Family Therapist Board’s website may be found at www.cswmft.ohio.gov. Acknowledgment of Informed Consent to Treatment via Electronic Service Delivery Means
You voluntarily agree to receive mental health assessment, care, treatment, or services and authorize your therapist to provide such care, treatment or services as are considered necessary and advisable via electronic service delivery means.
By signing this Electronic Service Delivery Informed Consent, you, the undersigned client, acknowledge that you have both read and understood all the terms and information contained herein and you agree to be bound by the provisions in this agreement. Ample opportunity has been offered to you to ask questions and seek clarification of anything unclear to you. If a minor is the client, you are signing on behalf of the minor as the authorized parent/guardian. (Information on Minor rights will be shared with the minor)
You also acknowledge that you have received a copy of the regular Informed Consent and Notice of Privacy Practices for the practice listed at the top of this form.
OHIO NOTICE FORM CONTRACT
I have read and had an opportunity to ask questions about the Notice Form on the Policies and Practices to Protect the Privacy of My Health Information.
My signature below acknowledges my understanding and agreement with this document including that:
1. I give my consent to Columbus Behavioral Health, LLC to use and disclose my protected health information (PHI) for treatment, payment, and health care operations purposes.
2. I may sign an Authorization Form to release my records to others as desired.
3. My PHI may be released without authorization in cases of suspected abuse or threat to safety, by Court order, or Worker’s Compensation claim.
Copies of all documents are available on our website: www.columbusbehavioralhealth.com
PATIENT FINANCIAL RESPONSIBILITY
I understand and agree that I am financially responsible for all charges for any and all services rendered.
I understand that while my insurance may confirm my benefits, confirmation of benefits is not a guarantee of payment and that I am responsible for any copays, coinsurances or unpaid balances.
I understand and agree that it is my responsibility to know if my insurance has any deductible, co- payment, co-insurance, out-of-network, usual and customary limit, prior authorization requirements or any other type of benefit limitation for the services I receive and I agree to make payment in full.
I agree to inform the office of any changes in my insurance coverage. If my insurance has changed or is terminated at the time of service, I agree that I am financially responsible for the balance in full.
I understand that if I have a balance over $300, I may be discharged from CBH.
By signing this form, I consent to the use and disclosure of protected health information about me for treatment, payment and health care operations, and/or as required by law. I authorize CBH to release/exchange treatment information with my family physician and health plan’s utilization reviewers in order to facilitate my treatment at CBH. I have the right to revoke this Consent, in writing, signed by me. However, such revocation shall not affect any disclosures already made in compliance with my prior Consent. CBH provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
By signing below, I understand and agree that (regardless of my insurance status) I am ultimately responsible for the balance on my account for any professional services rendered. If I do not pay this balance within 30 days of being billed, a late fee of $25 may be added to my account each time it is rebilled. If I do not pay this balance or arrange a payment plan, I understand that I may be turned over to a collection agency and I will be billed for any subsequent collection charges, including a minimum charge of $25.00. I understand that returned checks are subject to a $30 return fee.
I certify this information is true and correct to the best of my knowledge, and I will notify you of any changes in my health insurance or the above information as soon as possible.
About Your Childhood
Education & Occupation
Goals and Additional Information