What is Case Management?

Case Management provides resource-based assistance to Medicaid clients; let us assist with your food, housing, transportation, legal, employment, education, and various other needs. Many people are afraid to ask for help and we understand. We specialize in helping people find the supports they need to get their lives where they want it to be. 

What happens next if I want this free service?

Eligible clients who sign up for this service will be contacted by a case manager. Establishing therapy is a requirement for this service, so we will contact you once you have started there. You will complete a short intake meeting and then meet at least twice per month. Your case manager can assist with scheduling therapy or medication, and work via telehealth like your therapist or nurse practitioner. In-home or community-based case managers may be an option as well.

TELEHEALTH CONSENT 

Kentucky Counseling Center, LLC DBA Counseling Now
I agree to participate in a telemedicine evaluation and/or ongoing treatment performed by an independently contracted provider who assumes sole responsibility and liability for treatment. By signing this agreement, I authorize the electronic transmission of my medical information and/or videoconference session so that it can be viewed by a doctor and other persons involved in my medical or mental health care. [Note: The likelihood of this transmission being intercepted by persons other than those at the consulting site is extremely small]. I understand that I can withdraw my permission at any time and that I do not have to answer any questions that I consider to be inappropriate or am unwilling to have heard by other persons. I understand that if I do not choose to participate in a telemedicine session, no action will be taken against me that will cause a delay in my care and that I may still pursue face-to-face consultation. I understand that as with any technology, telemedicine does have its limitations. There is no guarantee, therefore, that this telemedicine session will eliminate the need for me to see a specialist in person. I understand that medical records of telemedicine services will be kept at Kentucky Counseling Center, LLC DBA Counseling Now. I understand that some or all of my medical information may be used for teaching or educational purposes. I agree to have my telemedicine medical records reviewed for the purposes of evaluation (data collection, analysis, and presentation in verbal or written format at scientific meetings). I understand that any presentation will not identify me by name or other identifiable markers.

Informed Consent

By signing this form, you agree to receive mental health services provided by Kentucky Counseling Center, LLC DBA Counseling Now and its independent contractors. We know that starting counseling is a big decision and you may have many questions. We will do our best to answer any questions or concerns. This form explains information about KCC policy, State and Federal Laws, and your rights about counseling. All KCC employees and contractors have met the highest level of education, certication, and licensing requirements set forth by state law related to their license. Counseling practices, philosophy and plan limitations and risks will be discussed with you today.

TREATMENT PROCESS AND DOCUMENTATION
It is the mental health professional’s responsibility to keep accurate records including Evaluations, Treatment Plans, and Progress Notes. By signing this document, you are consenting to the Treatment Plan that your provider creates and agree to any goals, objectives, and therapy techniques that may be used in your therapy process.

INSURANCE BILLING
If you plan to use insurance to pay for services, claims will be sent to the insurance company based on information used at the time of service. Sometimes, insurance information may change or may not be up to date. If for any reason, inaccurate information related to deductibles, co-pays, or number of available sessions, etc. is retrieved at the time of service, KCC will bill the client for any additional costs associated with mental health services rendered. Additional services may not be provided until
the client’s balance is current. If balances remain unpaid for 60 days, client information will be sent to a collection agency.

No-Show Policy
Clients will be allowed two (2) no-show appointments per provider for up to two (2) providers. Once the client has no-showed two (2) providers, they will no longer be allowed the opportunity to reschedule with the company for one (1) year.
The company defines a no-show as a client not showing up for their appointment without 48 hours notice. 
In the event the client does no-show their appointment, they will be subject to a fee. Please see that information below. This is subject to change at any time. 

MISSED APPOINTMENT FEES
Appointments will be cancelled and $75.00 fee will be assessed if client "no-call, no-shows" or is 15 minutes late without notice for a therapy appointment or 5 minutes for a psychiatric appointment. If client cancels appointment without a notice greater than 48 hours, KCC will charge the client $75.00. This does not apply to Medicaid-eligible recipients. This is subject to change at any time. 

CREDIT CARD PAYMENTS
You may be required by KCC to store your credit card information in your chart for future bills you may incur not covered by insurance. KCC will automatically process all outstanding balances one time per month (typically the second week of each month) and will not provide any additional warning other than what is written in this section of the Informed Consent form.Please be aware that if your balance is not paid in full after 2 statement cycles your account will be sent to collections with GLA. Please note that once your debt is filed with GLA you will then be liable for an additional charge of 30% of your total balance. We will not permit you to be seen until you have satisfied your outstanding balance in full with GLA.

CONFIDENTIALITY AND EMERGENCY SITUATIONS:
Confidential information discussed in session is not discussed with anyone without your written permission except for:
1. Diagnosis and dates of service shared with your insurance company to process your claims
2. Information you tell KCC about physical, sexual or elder abuse; then, by Kentucky State Law, I have to report this to the Kentucky Department of Children and Family Services
3. Where you sign a release of information to have specific information shared
4. If you tell KCC you are in danger of harming yourself or others
5. Information shared with therapist’s clinical supervisor if applicable
6. When required by law.

If you need to contact us between counseling sessions we're available at kentuckycounselingcenter.com via live chat. Text messages and social networking sites are not confidential and we may not be able to respond. In the event of an emergency please call 911.

MARKETING

By submitting this form, you are opting in to the KCC newsletter and we may send you an email from time to time. You can unsubscribe at anytime by clicking unsubscribe at the bottom of the email.

Liability Waiver and Informed Consent for Services

I understand and acknowledge that I am voluntarily seeking services from Kentucky Counseling Center, doing business as Counseling Now (hereinafter referred to as "the Company"). I understand that the Company offers the following services:

Counseling sessions provided by licensed counselors employed or contracted by the Company
Targeted Case Management services provided by certified individuals employed by the Company
Medication Management services provided by certified individuals employed or contracted by the Company

I understand that all services rendered by Kentucky Counseling Center DBA Counseling Now employees and contractors involve discussing sensitive and personal information and that there may be risks involved in participating in services, including but not limited to:

1. Emotional distress or discomfort that may arise when discussing sensitive or challenging topics

2. Potential for recalling or revisiting past experiences that may be distressing

3. The possibility of discussing thoughts or feelings that may be difficult to process

4. Unforeseen emotional or mental reactions during or after sessions and/or services

I hereby waive any claims or causes of action against the Company, its employees, affiliates, agents, contractors, or any other persons or entities associated with the Company arising out of or relating to my participation in services.

I understand that the Company takes reasonable measures to protect the confidentiality of my personal and medical information in accordance with applicable laws and regulations. I also acknowledge that confidentiality in services rendered may be subject to limitations as required by law.

I agree to hold harmless and indemnify the Company and its employees and contractors from any and all claims, liabilities, damages, or expenses (including attorney fees) that may arise from my participation in services rendered with Kentucky Counseling Center, DBA Counseling Now.

I acknowledge that I have read and understand this liability waiver and informed consent, and I voluntarily agree to its terms. I also understand that I have the right to seek clarification on any aspect of this waiver before signing.

Dispute Resolution Clause for Kentucky Counseling Center DBA Counseling Now

1. Informal Resolution: In the event of any dispute, claim, or controversy arising out of or relating to services provided by Kentucky Counseling Center, doing business as Counseling Now (hereinafter referred to as "the Company"), the parties agree to first attempt to resolve the matter through informal discussions and negotiations. Each party shall designate a representative with decision-making authority to participate in these discussions.

2. Mediation: If the dispute cannot be resolved through informal discussions within a reasonable period, the parties agree to submit the dispute to mediation. The mediation shall be conducted by a neutral mediator selected jointly by the parties or through a mediation service provider in accordance with the laws of Kentucky. The parties shall share the costs of mediation equally, unless otherwise agreed.

3. Arbitration: If mediation does not result in a resolution within a specified time, any remaining dispute, claim, or controversy shall be settled by binding arbitration in accordance with the rules of the American Arbitration Association (AAA), and judgment upon the award rendered by the arbitrator(s) may be entered in any court having jurisdiction thereof. The arbitration shall be conducted in [City, State], or another mutually agreed-upon location, and shall be presided over by a single arbitrator, unless the parties agree to a panel of arbitrators.

4. Governing Law: The arbitration shall be governed by the laws of the State of Kentucky, without regard to its conflict of laws principles.

5. No Class Actions: The parties agree that any arbitration or legal proceeding shall be conducted solely on an individual basis and not as a class, representative, or consolidated action. There shall be no right or authority for any dispute to be arbitrated or litigated on a class-action basis.

6. Equitable Relief: Notwithstanding anything to the contrary in this dispute resolution clause, either party may seek preliminary or permanent injunctive relief or any other equitable remedy from any court of competent jurisdiction.

7. Attorney's Fees: In any arbitration or legal proceeding arising under or relating to this dispute resolution clause or the parties' agreement, the Company shall be entitled to recover its reasonable attorney's fees and costs incurred in connection with such arbitration or legal proceeding. The client is responsible for 100% of their attorney’s fees, no matter the outcome of the proceeding.

8. Waiver of Jury Trial: Each party knowingly and voluntarily waives any right to a trial by jury in any action or proceeding to enforce or defend any rights under this dispute resolution clause or the parties' agreement.

By signing below, the parties acknowledge their understanding and agreement to the terms of this dispute resolution clause.

Indemnification Clause for Kentucky Counseling Center, DBA Counseling Now

1. Indemnification Obligation: To the fullest extent permitted by law, the Client agrees to indemnify, defend, and hold harmless Kentucky Counseling Center doing business as Counseling Now (hereinafter referred to as "the Company"), its employees, officers, directors, affiliates, and agents (the "Indemnified Parties") from and against any and all claims, liabilities, damages, losses, costs, and expenses, including reasonable attorney's fees, arising out of or in connection with the Client's use of the Company's counseling services.

2. Scope of Indemnity: The Client's indemnification obligation under this clause shall apply to any claims or causes of action, including but not limited to those arising from:

   a. Negligence, willful misconduct, or breach of the Client's obligations under the terms of the counseling services.

   b. Any misrepresentation, misinformation, or omissions made by the Client regarding their personal or medical information.

   c. Violation of any applicable laws, regulations, or rights of third parties by the Client.

3. Procedure for Indemnification: In the event that any claim, lawsuit, or demand is brought against any Indemnified Party, the Company shall promptly notify the Client in writing of such claim. The Client shall have the right to assume the defense of any such claim at its expense and with counsel reasonably satisfactory to the Indemnified Parties. The failure of the Client to promptly assume the defense shall not relieve the Client of its indemnification obligations under this clause unless such failure prejudices the Company's ability to defend the claim.

4. Settlement: The Client shall not settle any claim that results in liability or other obligations for any Indemnified Party without the prior written consent of the Company, which shall not be unreasonably withheld. However, the Company shall have the right to settle any claim on its own behalf without the Client's consent.

5. Limitation of Liability: The Company shall not be liable to the Client for any indirect, special, incidental, consequential, or punitive damages arising out of or related to the counseling services, even if the Company has been advised of the possibility of such damages.

By signing below, the Client acknowledges their understanding and agreement to the terms of this indemnification clause.

I consent for Kentucky Counseling Center, LLC DBA Counseling Now and those representing this group to share my private health care information with the following individuals and/or entities. KCC is permitted to send and receive information to and from the entities below if needed:

I understand that I have the right to revoke this authorization, in writing, at any time by sending notice to KCC. I understand that a revocation is not valid to the extent that the company has acted in reliance on such authorization. This authorization does not expire until I submit a written request. A copy of this release shall have the same force and effect as the original.

NOTICE TO RECEIVING INDIVIDUAL, PROVIDER, OR ENTITY: You may not re-disclose any of this information unless the person who consented to this disclosure specifically consents to such re-disclosure.

Credit/Debit Card Policy Terms and Conditions

The company requires all clients who are not Medicaid recipients to maintain an active credit/debit card on file at all times. We will ask for this information over the phone at the time of scheduling, and your information will be kept confidential and secure within our electronic medical record system. 

By signing below, you authorize KCC to store and charge your credit/debit account for all balances due for services rendered, including late/cancellation fees, and patient responsibilities not covered by insurance that you may incur during treatment. KCC will process all credit cards 1 time per month without further notice if there is an outstanding balance on your account. This typically takes place during the second week of each month.
This authorization will remain in effect until you cancel this authorization in writing or verbally, and you may do so at any time. If you request to cancel this authorization, you are providing KCC permission to use the card on file at the time of your request to pay all outstanding balances before the card is removed. If your payment is declined at the time your card is processed, your services may be subject to termination. My signature indicates that I have read and accept these disclosures.

HIPAA NOTICE OF PRIVACY POLICIES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Kentucky Counseling Center, LLC DBA Counseling Now is committed to maintaining client confidentiality in accordance with federal and state laws and ethics of the counseling profession. This notice describes our policies related to the use and disclose of your healthcare information.

TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS
Your health information may be used for the purposes of providing treatment services, collecting payment, and conducting healthcare operations as necessary to support our operations and to promote quality care. We will use and disclosure your information for these purposes as state and federal laws allow. Examples include:
Treatment We may need to use or disclose health information about you to provide, manage, or coordinate your care or related services, including with third parties such as consultants and potential referral sources.
Payment We may use and disclose your information needed to verify insurance coverage and/or benefits with your insurance carrier, to process your claims, as well as for billing and collection purposes. We may bill the person in your family who pays for your insurance.
Healthcare Operations We may need to use information about you to review our treatment procedures and business activity. For example, information may be used for certification, compliance, and licensing activities. We may also contact you with information about treatment alternatives or other services that may be of interest to you. We may send you appointment reminders by text or by phone and/or leave a voicemail.

OTHER USES AND DISCLOSURES
Opportunity to Object to Certain Uses and Disclosures
You have the right to tell us whether you want us to use or disclose your information for the following purposes:
To Individuals Involved in Your Care or Payment for Your Care. We may share medical information about you with your family members, friends, or any others involved in your medical care or who helps pay for it. We may also share you information as necessary to identify, locate, and notify family members, guardians, or others involved in your care about your location, and general condition.
For Disaster Relief. In some cases, we may share limited information about you to a disaster relief agency assisting in disaster relief efforts.
If you are not present or unable to tell us your preference, we may go ahead and share your information if your health care provider thinks that it may be best for you.
Other Permitted Uses and Disclosures
We may share your information when needed to lessen a serious and imminent threat to health or safety. When permitted by law, we may also share information in certain situations to help with public health and safety issues. For example, in preventing disease, reporting adverse medication reactions, or helping with product recalls. We may share information with a medical examiner or coroner when an individual dies. We may share information with health oversight agencies for activities authorized by law, and for certain specialized government functions such a national security and presidential protective services.

Required Uses and Disclosures
There are some instances where we may be required by law to use and disclose information. For example, when you and/or your child or children report information about physical or sexual abuse, when required by the Secretary of the Department of Health and Human Services to audit or evaluate our compliance with the requirements of federal privacy law, or if you provide information that informs us that you are in danger of harming yourself or others. We may share information with law enforcement consistent with applicable laws, such as if a crime is committed on our premises or against our staff, or if required in response to a valid court order.

Use and Disclosure Requiring Your Authorization
Certain uses and sharing of your health information are only permitted with your written authorization. These include most uses and disclosures of psychotherapy notes, uses and disclosures of your health information for marketing communications, and disclosures that constitute a sale of your health information.

Uses and disclosures of your health information other than those described in this notice will be made only with your written authorization.

You may revoke an authorization, at any time, in writing, except to the extent that your provider or we have taken an action in reliance on the use or disclosure indicated in the authorization. To revoke an authorization, you must write to Kentucky Counseling Center at the address listed below.

CLIENT RIGHTS

The following is a statement of your rights with respect to your protected health information. If you have questions about how to exercise these rights, contact our Privacy Officer using the information below.

Right to request how we contact you
It is our normal practice to communicate with you at your home address and daytime phone number you gave us when you scheduled your appointment, about health matters, such as appointment reminders. Sometimes we may send a text appointment reminder or leave messages on your voicemail. You have the right to request that our office communicate with you by alternative means or at an alternative location. You must submit your request in writing to us at the address below. We will agree to reasonable requests.

Right to release your medical records
You may consent in writing to release your records to others. You have the right to revoke your consent, in writing, at any time. However, a revocation is not valid to the extent that we acted in reliance on such consent.

Right to inspect and copy your medical and billing records
You have the right to inspect and obtain a copy of your information contained in our medical records. To request access to your billing or health information, contact the Privacy Officer. Under limited circumstance we may deny your request to inspect and copy. When permitted by law, may charge a reasonable fee for the costs of copying, mailing, and supplies to provide a copy of your information.

Right to add information or amend your medical records
If you feel that information contained in your medical record is incorrect or incomplete, you may ask us to amend the record. We will make a decision on your request with 60 days, or some cases within 90 days. Under certain circumstance, we may deny your request to add or amend information. If we deny your request, you have a right to file a statement that you disagree. Your statement and our response will be added to your record. To request an amendment, you must contact the Privacy Officer. We will require you to submit your request in writing and to provide an explanation concerning the reason for your request.

Right to an accounting of disclosures
You may request an accounting of any disclosures, if any, we have made related to your medical information, except for information we used for treatment, payment, or health care operations purposes or that we shared with you or your family, or information that you gave us specific consent to release. To receive information regarding disclosure made for a specific time period no longer than six years and after April 14, 2003, please submit your request in writing to the Privacy Officer. We will notify you of any cost involved in preparing this list.

Right to request restrictions on uses and disclosures of your health information.
You have the right to ask for restrictions on certain uses and disclosures of your health information. This request must be in writing and submitted to our Privacy Officer. You must tell us the type of restriction you want and to whom it applies. We are generally not required to agree to such a request, with one exception. You have a right to restrict any disclosure of personal health information for payment purposes or for our health care operations if you have paid for services out-of-pocket and in full.

Breach Notification
You have a right to receive notification of a breach of your unsecured personal health information.

Right to complain.
If you believe your privacy rights have been violated, please contact us personally, and discuss your concerns. You may also file a written complaint with the U.S. Department of Health and Human Services. We will not retaliate against you for filing such a complaint.

OTHER INFORMATION ABOUT THIS NOTICE

Compliance with Laws
We are required by law to provide you with this notice of our legal duties and privacy practices with respect to your protected health information, and to notify you in writing if the privacy or security of your health information is breached. We are required to abide by the terms of our Notice of Privacy Practices currently in effect.

Right to Request a Paper Copy
You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice electronically.

Revisions to This Notice
We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for your health information we already have, as well as any we get in the future. Any changes in this notice will be posted on our website at kentuckycounselingcenter.com. The revised notice also will be available upon request at our offices. My signature indicates that I have read and accept these disclosures.

Our Notice of Privacy Practices was originally effective in August, 2014.
This revised version is effective as of February 11, 2019.

Questions and Contact
If you have any questions about this notice or about how your health information is used or shared by us, please contact us at:
Kentucky Counseling Center, LLC DBA Counseling Now
Attn: Privacy Officer
PO Box 701059 , PMB 50499, Louisville, KY, 40270
www.kentuckycounselingcenter.com, www.counselingnow.com