Thank you for taking the time to complete this form. The information you have given will be very helpful in planning the most appropriate treatment for you and/or your family.
Agency Representative Signature: ______________________ Date: ______________
Agency Representative Signature: ______________________ Date: ______________
AUTHORIZATION TO BILL INSURANCE AND HAVE DIAGNOSIS SENT TO INSURANCE
I consent to have the psychiatric diagnosis and information necessary for billing purposes shared with my insurance company. This consent is in effect for the duration of services and until payment for services is complete. I reserve the right to inspect and receive a copy of the material to be disclosed, as well as receive a copy of this consent form upon my request.
Our usual and customary fee for master’s level professional services is $140.00 per hour. The fee for an Initial Evaluation is $150.00. If you are seeing a Clinical Psychologist, the hourly fee is $155.00 per hour and the fee for an Initial Evaluation is $185.00. If you are seeing a psychiatrist or advanced practice nurse prescriber, the hourly fee is $250 and the fee for the initial evaluation is $300.
If appointments are not cancelled 24 hours in advance, I understand I may be charged $25.00 for the time reserved. I also understand these charges cannot be billed to my insurance company and they are my responsibility to pay.
I understand that fee payments and insurance co-payments are due at the time services are rendered. If expected payment from insurance is not received within 90 days, I understand I am responsible for the full amount. I also understand that Jewish Family Services is empowered to use a collection agent if default occurs and that I am responsible for all related expenses incurred.
I have read and understand the information on this page and agree to the above.
I am voluntarily seeking services at Jewish Family Services, Inc. for myself, my minor child or legal ward. Services may include, but are not limited to, an initial assessment, supportive services, individual, group, conjoint or family treatment, case management services, psychological testing or psychiatric evaluation and/or a medication prescription (adults only).
I UNDERSTAND THAT:Consent to Evaluate/Treat: I voluntarily consent that I will participate in a mental health (e.g. psychological or psychiatric) evaluation and/or the treatment by staff from Jewish Family Services. I understand that following the evaluation and/or treatment, complete and accurate information will be provided concerning each of the following areas:• The benefits of the proposed treatment• Alternative treatment modes and services• The manner in which treatment will be administered• Expected side effects from treatment and/or the risks of side effects from medications (when applicable).• Probable consequences of not receiving treatmentThe evaluation or treatment will be conducted by a psychotherapist, a psychologist, a physician, licensed therapist or an individual supervised by any of the professionals listed. Treatment will be conducted within the boundaries of Wisconsin Law for Psychological, Psychiatric, Social Work, Professional Counseling, or Marriage and Family Therapy.Benefits to Evaluation/Treatment: Evaluation and treatment may be administered with psychological interviews, psychological assessment or testing, psychotherapy, medication management, as well as expectations regarding the length and frequency of treatment. It may be beneficial to me, as well as the referring professional, to understand the nature and cause of any difficulties affecting my daily functioning so that appropriate recommendations and treatments may be offered. Uses of this evaluation include diagnosis, evaluation of recovery or treatment, estimating prognosis, and education and rehabilitation planning. Possible benefits to treatment include improved cognitive or academic/job performance, health status, quality of life, and awareness of strengths and limitations.
Charges: Fees are based on the length or type of the evaluation or treatment, which are determined by the nature of the service. I will be responsible for any charges not covered by insurance, including co-payments and deductibles. A fee subsidy is available to me upon request.
Confidentiality, Harm, and Inquiry: Information from my evaluation and/or treatment is contained in a confidential record at Jewish Family Services, and I consent to disclosure for use by Jewish Family Services staff for the purpose of continuity of my care. Per Wisconsin mental health law, information provided will be kept confidential with the following exceptions: 1) if I am deemed to present a danger to myself or others; 2) if concerns about possible abuse or neglect arise; or 3) if a court order is issued to obtain records.
I understand that Jewish Family Services uses a secure electronic health record for billing and documentation. This system complies with all HIPAA regulations and all security measures will be taken to maintain the confidentiality of my records.
Client Discharge Policy: There are circumstances under which I may be discharged. Clients discharged from the clinic will receive written or phone notification of the decision.Reasons for unplanned discharge include:• The client has become inactive in the clinic for a minimum of 30 days with no plan for continued treatment.• The new client has two (2) consecutive no-shows or late cancellations (within 24 hours of appointment).• The returning client has two (2) no shows or late cancellations within a rolling six (6) month period.• The client’s behavior is such that it prevents the clinic or the mental health provider from providing adequate care.• The client has threatened the safety and well-being of clinic staff or other clients.• The client demonstrates a lack of compliance with necessary treatment interventions orrecommendations.
Transfer of Care: There are circumstances under which a therapist may depart the clinic. I will be informed when possible by the therapist. In the instance that the therapist’s departure is immediate, a clinic representative will notify me. A letter will follow within two (2) weeks from Jewish Family Services confirming the therapist’sdeparture and pertinent information for continuity of care. An offer will be extended that will include:• Two (2) to six (6) weeks for closure with the current therapist, when possible• Internal referral to other providers if appropriate.• External referral to other agencies, with their initial contact information. A post discharge follow up will be made within two (2) months if appropriate.
Right to Withdraw Consent: I have the right to withdraw my consent for evaluation and/or treatment at any time by providing a written request to the treating clinician.
Expiration of Consent: This consent to treat will expire not more than twelve (12) months from the date of signature, unless otherwise specified.
I have read and understand the above, have had an opportunity to ask questions about this information, and I consent to the evaluation and treatment. I also attest that I have the right to consent for treatment. I understand that I have the right to ask questions of my service provider about the above information at any time.
All consumers of outpatient mental health services are guaranteed the following rights under Wisconsin State law:
A complete list of client rights is available upon request.
Communication and Privacy Rights:As a client of Jewish Family Services (JFS) you have the right to confidentiality. Your records will be released only if authorized by you. Exceptions to confidentiality include: if you pose a danger to yourself or to others and by lawful order of the court. In instances where a client’s competency is in question and/or there is suspected physical abuse, verbal abuse, financial abuse, neglect or self-neglect, the agency’s responsibility to the client’s safety and well-being takes precedence over the client’s right toconfidentiality.Your Right to Complaint:As a client of Jewish Family Services, you have the right to file a grievance if you feel your rights have been violated. Our agency has a grievance process through which you may file your complaint. Grievances must be filed in writing within 45 days of the incident or issue. JFS staff will supply you with a copy of the Grievance Procedure upon request. You retain the right to take legal action at any time.I have read and understand the above and have had an opportunity to ask questions about the information contained above. I understand that I have the right to ask questions of my service provider about the above information at any time.
Effective Date: September 23, 2013
This notice gives you basic information about how your protected health information (PHI) may be used and disclosed by Jewish Family Services.
PLEASE REVIEW THIS DOCUMENT CAREFULLY
Jewish Family Services is required by law to: make sure that protected health and service information that identifies you is kept private; offer you this notice of our legal duties and privacy practices with respect to that information about you; and follow the practices of our Notice of Privacy Practices that is currently in effect.
When Jewish Family Services is Required to Obtain an Authorization toUse or Disclose Your Health Information
Except as described in this Notice of Privacy Practices, Jewish Family Services will not use or disclose your health information without written authorization from you. For example, uses and disclosures made for the purpose of psychotherapy, marketing and the sale of your protected health information require your authorization. If Jewish Family Services should contact you for fundraising purposes, you have the right to opt out of receiving such communications. If you do authorize us to use or disclose your health information for another purpose, you may revoke your authorization in writing at any time. If you revoke your authorization, Jewish Family Services will no longer be able to use or disclose health information about you for the reasons covered by your written authorization, though we will be unable to take back any disclosures we have already made with your permission.
When Jewish Family Services May Use or Disclose Your Protected Health Information Without Your Written Authorization
Where permitted or required by law, Jewish Family Services may disclose your health information without your authorization. Some examples in which this might occur follow:
Your Rights Regarding Your Protected Health and Service Information
For each of the above, your request must be in writing. Jewish Family Services is not required to agree to your request. If Jewish Family Services agrees to honor your request, we will do so unless the information is needed to provide you with emergency treatment or required or permitted by law to be disclosed.
If you have any questions or concerns regarding your privacy rights or the information in this notice, please contact:Shane Beecraft, Privacy OfficerJewish Family Services1300 North Jackson StreetMilwaukee, WI 53202Changes to Jewish Family Services’ Notice of Privacy Practices
Jewish Family Services reserves the right to amend this Notice of Privacy Practices at any time in the future and to make the new Notice provisions effective for all health information that it maintains. We will post a copy of the current notice in all of Jewish Family Services’ service locations. The notice will contain, on the first page, in the topright-hand corner, the effective date. In addition, each time you register at or are admitted to Jewish Family Services for services, you may request a copy of the current notice in effect. By signing this form, you acknowledge that Jewish Family Services has given you a copy of its Notice of Privacy Practices Regarding Health Information, which explains how your health information will be handled in various situations. All clients receiving services on or after April 14, 2003 will be asked to sign this form.
By my signature below, I acknowledge I have received a copy of the Jewish Family Services Notice of Privacy Practices Regarding Protected Health Information and have been given an opportunity to discuss my concerns and questions.
During this national emergency related to the COVID-19 pandemic, the Outpatient Mental Health Clinic of Jewish Family Services is offering telehealth services in order to minimize face to face contact with consumers and ensure safety of all parties. Telehealth involves the use of electronic communications to enable clinicians toprovide mental health services to clients who are not in the same physical location using live interactive video and audio communications.The benefit of utilizing telehealth during the COVID emergency is to provide access to mental health services while being able to appropriately engage in social distancing for your own health, and the health of others (loved ones, providers, etc.) Utilizing telehealth to conduct services will include a continual focus and commitment towards your treatment goals during these trying times.I understand that I have the following rights with respect to telehealth:1. The laws that protect the confidentiality of my personal information also apply to telehealth.2. I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course ofmy care at any time, without affecting my right to future care or treatment.3. I understand that there are risks and consequences from telehealth, including, but not limited to:a. Due to the nature of phone contact, privacy cannot be guaranteed as someone may overhear your side of the conversation;b. The possibility, despite reasonable efforts on the part of the care coordinator, that the transmission of my personal information could be disrupted or distorted by technical failures;c. If using your cell phone this may affect your minutes or data usage; applicable charges from your mobile provider may apply.I have read and understand the information provided above regarding telehealth, have discussed it with JFS staff, as needed, and all of my questions have been answered to my satisfaction. I understand the risks and benefits related to the use of telehealth services. I give my informed consent to participate in the use of telehealth servicesfor treatment under the terms described herein.
The purpose of the disclosure authorized herein is to provide information to parties personally interested in my whereabouts. This consent may be revoked in writing at any time except to the extent that action has been taken in reliance thereon. This consent (unless expressly revoked in writing earlier) expires upon my formal discharge from Jewish Family Services.