Thank you for choosing Integrative Counseling Solutions, Inc. for your health care needs.

Please be sure to have essential information such as insurance info, medications, etc. on hand in order to complete these forms successfully.

If you need help at any time call us Mon-Fri., 9am-5pm at (515) 267-1340.

 

Any form filled out after Friday at 5:00 PM will not be recieved until the following Monday.

If this is in reference to Alcohol or Substance abuse please call 515-348-8257.

I hereby give consent for myself to receive therapy and/or skill development services by Integrative Counseling Solutions, Inc. I understand that my insurance will be notified of my consent to receive services and that information will be shared with my insurance company for the purpose of payment.

Health care services are available by two-way interactive video communications and by the electronic transmission of information. Referred to as “telemedicine”, this means that I may be evaluated and treated by a health care provider from a different location. Since this is different than the type of consultation with which I am familiar, if I choose to participate in this type of service, I understand and agree to the following:

1. The health care provider will be at a different location from me.

2. I will be informed if any additional personnel are to be present other than myself and any individuals accompanying me. I will give my verbal permission prior to additional personnel being present.

3. Video recordings may be taken of the telemedicine consultation after I have given my written permission prior to recording. Video recording and other data including images and photos may be kept, viewed, and used for purposes including teaching, training, technically, scientific, research, or administrative purposes.

Noting all the above, I understand that my participation in the process described (called “telemedicine”) is voluntary and constitutes a waiver of the usual right to patient privacy and may possibly increase the risk of disclosure of my medical or mental health data.

I further understand that I have the right to:

1.Refuse the telemedicine consultation or stop participation in the telemedicine consultation at any time.

2.Request that the health care provider refrains from transmitting my information if I make the request before the information is transmitted.

3.Request that nonmedical personnel leave the room at any time.

I acknowledge that the health care provider involved explained the consultation in a satisfactory manner and that all questions that I have asked about the consultation have been answered in a manner satisfactory to me or my representative.

Understanding the above, I consent to the telemedicine process described above.

This agreement will remain in effect for one year. Please sign below to agree.

Please only report contact information where we may identify ourselves as Integrative Counseling Solutions, Inc. on the voice mail, email, and/or text message.

OCCUPATIONAL INFORMATION (please check all that apply):

It may be necessary to sign a release of information for previous providers in order to request any information they have gathered about you.

PROHIBITION ON REDISCLOSURE

This form does not authorize re-disclosure of medical information beyond the limits of this consent. Where information has been disclosed from records protected by federal law for alcohol/drug abuse records or by state law for mental health records, federal requirements (42 C.F.R. Part 2) and state requirements (Iowa Code Ch. 22) prohibits further disclosure without the specific written consent of the client or as otherwise permitted by such law and/or regulations. A general authorization for the release of medical or other information is not sufficient for these purposes. Civil and/or criminal penalties may attach for unauthorized disclosure of alcohol/drug abuse or mental health information. 

* Only persons 18 years of age or his/her legal representative may authorize release of mental health information. 

** Only the subject may authorize release of substance abuse information unless the subject is under legal age or incompetent as defined by statute. Sharing information: It is the responsibility of all agencies listed to provide requested information. The recipient of the information is responsible for maintaining confidentiality of the information. 

THE FOLLOWING 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!

Integrative Counseling Solutions, Inc., maintains full compliance with all local, state and federal laws and regulations pertaining to protected health information.

Generally, no protected health information will be disclosed to any third party or agency without your specific, written authorization. There are circumstances, however, where Integrative Counseling Solutions, Inc., may disclose some protected health information about a client without an express, written authorization.

These include disclosures made to secure payment for services rendered, as where your health insurer requests information from our files to process a payment for services, pursuant to their agreement with you.

If, however, you, or any one you authorize, pays the full fee for services of Integrative Counseling Solutions, Inc., without submitting a claim to an insurer or agency for payment, no such disclosure will be made.

Another example is a limited release for purposes of treatment. Integrative Counseling Solutions, Inc., may share certain protected health information with other staff persons, including professional staff, at Integrative Counseling Solutions, Inc., to enable that person to treat a client.

A third situation where a release of protected health information can occur is when necessary for health care operations. An example of this is when certain protected health care information is shared with support staff of Integrative Counseling Solutions, Inc.

All health care providers, including Integrative Counseling Solutions, Inc., are required, under state law, to report to the appropriate government agency, instances where it has a reasonable basis to believe a child or dependent adult has been or is likely to be abused or neglected.

Similarly, if a client threatens self-harm, we may be required to notify law enforcement or family members who can help provide protection.

In addition, if a client communicates a threat or intent to cause significant physical harm to an identifiable person or persons, Integrative Counseling Services, Inc., may be required to disclose protected health information concerning the threat to the affected person or to law enforcement personnel.

This is known as our “duty to warn.” In addition, Integrative Counseling Solutions, Inc., may be required to release certain information by court order or pursuant to a subpoena.

No protected health information will be disclosed for purposes of marketing or fundraising without your prior, written, approval.

Integrative Counseling Solutions, Inc., may contact a client or the guardian or custodial parent of a client to provide appointment reminders or to provide information about treatment alternatives.

You have the right to request certain restrictions on certain uses and disclosures of protected health information, but Integrative Counseling Solutions, Inc., is not required to agree to such restrictions.

The client or, in the case of an unemancipated minor, the guardian or custodial parent of a client, has the right to inspect and copy protected health information about the client, and to amend such information and to receive certain confidential communication from Integrative Counseling Solutions, Inc.

Integrative Counseling Solutions, Inc., is required by law to maintain the privacy of protected health information. It also has the right to change its privacy practices.

Any change in privacy practices will necessitate the client or, in the case of an unemancipated minor, the guardian or custodial parent of a client, to be given a revised Notice of Privacy Policies.

In the event a client, or in the case of an unemancipated minor, the guardian or custodial parent of a client, wishes to make a complaint about a violation of these privacy policies, a complaint may be made to Integrative Counseling Services, Inc., as set out in the Client Handbook, or to the Secretary of the Department of Health and Human Services by going to the website: HHs.gov/ocr/privacy and following the instructions for filing a complaint.

In the event of a breach of the confidentiality requirements set out in local, state or federal laws or regulations, Integrative Counseling Solutions, Inc., may have an obligation to notify the client or, in the case of an unemancipated minor, the guardian or custodial parent of a client of such breach.

It is your responsibility to keep Integrative Counseling Solutions, Inc., advised as to how you wish such a notification to be communicated to you. We ask that you keep your contact information current.

If you wish notification to be made by electronic needs, you should be aware that e-mail, cell phone, text messaging and fax transmissions may not be secure.

Please fill out insurance information completely it will facilitate processing of the intake!

I HEREBY AUTHORIZE ICSI to furnish the insured’s third party payor with billing information which said third party payor may request concerning my present circumstances. This also applies to clients involved with their county’s Mental Health Plan and their CPC. This includes, but is not limited to, diagnosis, dates of treatment, progress notes, treatment plans, etc. I hereby assign to ICSI all money to which I am entitled for expenses relating to the services performed from time to time, but not to exceed my indebtedness. This will be refunded to me when my bill is paid in full. I understand that I am personally responsible to ICSI for charges not covered by my insurance company. I further authorize photocopies to be made of this authorization and assignment for attachment to any insurance form and authorize the insurance company to accept the copy. This authorization shall continue and be in force until revoked by me in writing.

Integrative Counseling Solutions, Inc. has been selected to provide services to you and your family. No information identifying you or your family will be released or disclosed without written consent by a parent or other legally designated representative. The effective provision of services may require your consent to the exchange of information between Integrative Counseling Solutions, Inc. and the insurance company you are using as a payment agent. You may be asked to sign a specific release of information to any other individual or agencies which staff deems important to communicate with in the best interest of your family.

Integrative Counseling Solutions, Inc. will not knowingly utilize any treatment or procedure, which is experimental, controversial or carries intrinsic risk.

We/I, the undersigned, agree to accept services from Integrative Counseling Solutions, Inc. We agree to cooperate with the requirements for the services our child/family will be participating in during the next twelve months.

We/I, the undersigned, understand that with the proper release, when information needs to be shared quickly, it may be done via fax or computer e-mail. We/I also understand that individual client records may be kept on computer. We/I understand that there is no guarantee that information we disclose in a group or family setting will be held confidential by other members of the group or the family.

We/I understand that in the course of treatment, many subjects will be discussed. Some of these subjects may be, but are not limited to: age, educational achievement, family background, prior treatment efforts, family relationships, marital issues, sexuality, violence, leisure activities, drug/alcohol usage, medical involvement, housekeeping, shopping habits and hygiene.

We/I hereby authorize Integrative Counseling Solutions, Inc. and the identified insurance/funding agent to exchange (both receive and release) information concerning myself or my ward (child or dependent) for the purpose of providing effective treatment services.

We/I understand that it is my responsibility to keep insurance information updated with Integrative

Counseling Solutions, Inc. We/I further understand that we need to provide a copy of our insurance card to Integrative Counseling Solutions, Inc. at the beginning/first appointment of each month.

We/I further agree to pay Integrative Counseling Solutions, Inc., the full balance of any account. I understand that I am responsible for any insurance co-pay, and will pay co-payment at each visit. I further understand that after my insurance company has finalized my claims and made payments to Integrative Counseling Solutions, Inc., I am responsible for any outstanding balances. I also understand that payment is due within 30 days of my receiving a billing statement from Integrative Counseling Solutions, Inc., and/or KASA Practice Solutions on behalf of Integrative Counseling Solutions, Inc. I understand that a 48 hours’ notice is required for change or cancellation of appointment. I understand that if I fail to give 48 hours notice, I will be charged for the cost of the session. If I am unable to pay the full balance, I will contact the billing department at (515) 267-1340 or will talk with my therapist to make acceptable payment arrangements. If this bill is not paid as agreed in full the balance of the bill for care rendered will be processed

For security purposes please call the office at 515-267-1340 to provide your credit card information.

Description of services: My signature below verifies that I have received and read the ICSI handbook. Included in the handbook is a description of the ICSI’s services, specific procedures to be followed, client’s right and responsibilities, appeals process, confidentiality and explanation of the cost for services.

Clients Rights and Responsibilities: I have received information outlining my rights and responsibilities as a client of ICSI. I understand that it is my right to ask questions if I need clarifications or have concerns.

Appeals Process: I have received the information about appeals and grievances. I understand I may ask for help in this process if needed.

HIPAA: The Privacy Rule, which was put into place under the Health Insurance Portability and Accountability Act of 1996 (HIPAA Privacy Rule), establishes a floor of national standards protecting individuals’ identifiable health information. I understand that what I share in the course of treatment at ICSI with my therapist and/or worker is private and confidential and my records are protected under state and federal regulations governing confidentiality. My records cannot be disclosed without written consent, unless otherwise provided for in the regulations, or signed release. I understand that information regarding my care may be shared internally with other professional staff members to assure effective treatment. Information regarding my care will also be provided to our support staff to maintain my records.

Acknowledgement of Child and Dependent Adult Abuse/Neglect Reporting Requirements: I understand that all health and human service providers are required by state law to report suspected abuse or neglect to the appropriate authorities. (If you have any questions about this, please feel free to ask for a better understanding before you signMy signature below acknowledges my understanding.

Consent for Services: I authorize Integrative Counseling Solution’s, Inc. to perform diagnostic and/or treatment services for myself.

If you need to cancel an appointment, we require at least 24 hours’ notice. If you do not give us 48 hours’ notice, you may be charged for that appointment.

Service Outcome: The intended outcome of services at ICSI is to reduce the symptoms that are associated with my DSM-V diagnosis. I understand the person who provides my clinical services is not responsible for the outcome of those services.

Authorizing Signature: I understand that I have the right to revoke the consent, in writing, at any time except to the extent that my provider has taken action in reliance upon the consent.

By signing below I agree to have read and understood the Integrative Counseling Solutions, Inc. handbook. And so give consent of services to the above checked.

Please feel free to call the office if you have any questions concerning the intake or if you would like to know the status of your intake or to make and appointment after a therapist has contacted you.

● 1200 Valley West Drive #508 West Des Moines, Iowa 50266 ●

● Phone: (515) 267-1340 ● Fax: (515) 267-1355 ● www.integrativecs.net ●