I, the undersigned, certify that I (or my dependent) have insurance coverage with Insurance Company * and assign directly to my provider all insurance benefits otherwise payable to me for services rendered. I understand that I am ultimately responsible for all charges accumulated. I hereby authorize Jordan West Family Counseling to release all information necessary to secure the payment of benefits, and authorize the use of this signature on all insurance submissions. I give permission for treatment of myself/my dependent to my assigned provider.
Your insurance will be billed standard rates based upon the CPT (current procedural terminology) code. You will be responsible for co-pays, co-insurance, late cancelation, missed appointment fees or deductibles as directed by your insurance company at the time of service.
An appointment is a reservation for time with a counselor. Out of courtesy and respect for your counselor please contact Jordan West Family Counseling if you need to cancel an appointment. If an appointment is missed, without notifying Jordan West Family Counseling, a fee of $50.00 will be assessed. If an appointment is cancelled less than 24 hour prior to the appointment a fee of $50.00 will be assessed.
Due to insurance carriers’ tardiness in regards to service claims submitted by providers, please read the following information:
Patient’s or authorized person’s signature: I authorize the release of any medical, behavioral health or other information necessary to process my insurance claim.
Insured’s or authorized person’s signature: I authorize payment of medical, behavioral health benefits to the provider for services. I fully understand that, regardless of insurance coverage, I am legally responsible for all fees due. I further understand Jordan West Family Counseling’s missed appointment and late cancellation policy
Patient’s authorized person’s signature: I acknowledge if an appointment is cancelled less than 24 hours prior to the appointment or the appointment is missed a fee $50.00 will be assessed.
Returned checks will be assessed a $30.00 fee. Please note that unless your appointment is cancelled with a 24hour notice, latecancellation fees will apply. Delinquent accounts are subject to referral to collection agencies.If your account is referred to a collection agency the balance will be charged 35%collection fee. Interest will be assessed at a rate of 1% per annumwill apply for balances over 60 days old Any questions regarding financial issues may be directed to the Office Manager.
I have reviewed a treatment plan course of action with my therapist and I approve.
Disclosure of Mental Health Information: Your mental health information and communication of that information is essential to your treatment. We prefer to speak directly with each patient but we understand that other individuals of family members may have knowledge of and be assisting in your treatment and progress. Please, list the individual(s) who we are authorized to discuss your treatment/progress with. (NOTE: We cannot discuss your treatment/progress with others, including parents, spouse, other family members, caseworkers, attorney general, Guardian Ad Litem, Judge, or court clerks unless they are listed below.)
Confidential Communication: Communication between Jordan West Family Counseling and you, the client is critical to your well-being. Please list the phone number(s) where we can reach you, your parent(s) or guardian.
Permissions: Children over the age of 12 will be given consent for a counselor / Jordan West Family Counseling to communicate with parent(s) regarding their progress. In cases of an "in custody" client, permission will be given to communicate with foster parent(s), caseworker(s), Guardian Ad Litem, Attorney General or Judge. In addition, clients who are court referred into treatment will give consent to communicate with probation officers, Judge(s) and court clerks in order to send updates, treatment progress, treatment summaries, and treatment termination.
Note: This restriction applies only to mental health treatment provided by Jordan West Family Counseling. Other providers involved in your treatment may require you to complete a separate request for restriction. Either you, or Jordan West Family Counseling to may terminate this restriction by completing the following.
Jordan West Family Counseling utilizes an auto reminder tool to improve the service we offer to you, the customer. This service allows Jordan West Family Counseling to communicate electronically with mobile devices (cellular phones), landline phones and e-mail accounts.
Despite this being a service offered to you we still put you in ‘the driver’s seat’, by enabling you to start and stop any further messages anytime you want. This service requires no purchase or fee to participate in the service, standard messaging and data fees may apply. Check your mobile plan for more details.
I agree to participate in this messaging service to have voice calls, text message or e-mail reminders sent, which relieves Jordan West Family Counseling of confidentially liability due to HIPPA compliance issues as you, the patient, are choosing the source of contact.
It is our belief that only you will be the person reading your email address. I understand that other members of my family may access messages left on my e-mail address. By signing this form, I agree to relieve Jordan West Family Counseling of any liability for this contact.
Your reminder call will come around 6:00 pm and no later than 8:00 pm the day prior to your appointment. If you need to cancel your appointment, please, contact Jordan West Family Counseling office 24 hours in advance to avoid a late cancellation or no show fee of $50.00.
The message that may be delivered is as follows: “John/Mary this important reminder is to let you know it is time for your appointment with (name of therapist)”.
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.
This office is required to maintain the privacy of your health information and to provide you with notice of its legal duties and privacy practices. This office will not use or disclose your health information except as described in this Notice. If you consent, the office is permitted by federal privacy laws to make uses and disclosures of your health information for purposes of treatment, payment, and health care operations. Protected health information is the information we create and obtain in providing our services to you. Such information may include documenting your symptoms, medical history, examination and test results, diagnoses, treatment, and applying for future care or treatment. It also includes billing documents for those services.
Examples of uses of your health information for treatment purposes are:
Example of use of your health information for payment purposes:
Example of use of your health information for health care operations:
YOUR HEALTH INFORMATION RIGHTS
The health and billing records we maintain are the physical property of the treating provider. The information in it, however, belongs to you. You have the right to:
You have the right to review this Notice before signing the consent authorizing use and disclosure of your protected health information for treatment, payment, and health care operations purposes.
This office is required to:
TO REQUEST INFORMATION OR FILE A COMPLAINT
If you have questions, would like additional information, or want to report a problem regarding the handling of your information, you may contact Betty Owen at 801-566-0749. Additionally, if you believe your privacy rights have been violated, you may file a written complaint at our office by delivering the written complaint to Betty Owen. You may also file a complaint by mailing it to the Department of Health and Human Services. We cannot, and will not, require you to waive the right to file a complaint with the Department of Health and Human Services (HHS) as a condition of receiving treatment from the office. Likewise, we cannot, and will not, retaliate against you for filing a complaint with the Secretary of Health and Human Services.
OTHER DISCLOSURES AND USES
Notification of Family/Friends: Our office does NOT disclose protected health information or any other information to family members.
Appointment Reminders and Treatment Information: We may contact you and/or leave a message on your telephone answering machine to provide you with appointment reminders, lab results, prescription information, or billing information.
Workers Compensation: If you are seeking compensation through Workers Compensation, we may disclose your health information to the extent necessary to comply with laws relating to Workers Compensation.
Abuse, Neglect & Domestic Violence: We may disclose your health information to public authorities as allowed by law to report abuse, neglect, or domestic violence.
Law Enforcement: We may disclose your health information for law enforcement purposes as required by law, such as when required by a court order; for identification of a victim of a crime if certain protective requirements are met; to report a crime in emergencies; and other appropriate situations as permitted by law.
Judicial/Administrative Proceedings: We may disclose your health information in the course of any judicial or administrative proceeding as allowed or required by law or as directed by a proper court order or in response to a subpoena, discovery request or other lawful process if certain specific requirements are met. To avert a serious threat to health or safely, we may disclose your health information consistent with applicable law to prevent or lessen a serious, imminent threat to the health or safety of a person or the public.
Other Uses: Any other uses and disclosures of your health information besides those identified in this Notice will be made only as otherwise authorized by law or with your written authorization and you may revoke the authorization as previously provided.
HIPAA requires that we make the Notice of Privacy Practices available to you. We ask that you sign and date this form. When you sign and date this form you are agreeing that you were given a copy of the Notice of Privacy Practices. You are not agreeing to what the notice says.
Your score is equal to the number of questions you answer YES.A score of five or less points indicates a Normal Score.A score of six or more points indicates a Drug Problem.
This quiz is scored by allocating one point to each “yes” answer, except for questions 1 and four, where one point is allocated for each “no” answer, and totaling the responses. (Please note that we have provided the current revised version of the MAST; the original MAST included 25 questions and used a more complex scoring method) The questions refer to the past 12 months. Carefully read each statement and decide whether your answer is “yes” or “no”
Key:0=Not at All1=Somewhat2 =Moderately3=A lot
Key:0=Not at All1=Somewhat2 =Moderately3=A lot4= Extremely
1. Please use the following code to report your use of any of the following substances in the past 12 months:
1= Every day2 = 5 to 6 days per week3 = 3 to 4 days per week4 = 1 to 2 days per week5 = At least 12 times per year6 = Fewer than 12 times per year7 = Never used
When did you last use any of the following substances? Code use according to the following:
Please use the following code to indicate your use of the following substances in your entire lifetime:
Please answer the following questions about your employment history for the past 10 years:
I have completed this questionnaire and verify that my answers are accurate.