Consent For Treatment

Welcome to You In Mind Behavioral Health, LLC ("You In Mind"). This document contains important information about our professional services and business policies. It also addresses summary information about the Health Insurance Portability and Accountabiltiy Act (HIPAA), a federal law that provides privacy protections and patient rights about the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. Although these documents are long and sometimes complex, it is important that you understand them. When you sign this document, it will also represent an agreement between us. We can discuss any questions you have when you sign them or at any time in the future. By signing this document you are acknowledging and agreeing to the following:

1. I understand that emergency services are not provided at You In Mind. I will call 911 or go to the nearest emergency room in case of an emergency or if I need help when the clinic is closed, during a holiday, a weekend and/or evening hours.
2. I freely acknowledge my willingness to undergo evaluation and the management of my care by the providers at You In Mind. I understand that treatment is a joint effort between my providers and me, the results of which cannot be guaranteed. Progress depends on many factors, including motivation, effort, and other life circumstances. I understand that when this document says You In Mind that it includes all providers and employees that work with or for You In Mind. 
3. I am free to discontinue treatment at any time. If I decide to discontinue treatment, I will notify the provider so that effective planning or continued care can be implemented. 
4. Conversations with my provider will remain confidential. Any notes taken by the provider, audio recordings, video recordings during therapy shall be kept confidential and secure by the provider at all times and shall not disclose it to anyone without my prior written consent. My prior consent may be contained in this document. I understand the following are exceptions to this confidentiality:
   1. Abuse to a child, disabled, elderly, other people;
   2. Criminal acts;
   3. Sexual abuse;
   4. Acts which may involve the transmisssion of HIV/AIDS;
   5. Any other instance where the provider has a duty or he/she has a firm belief that there is a necessity to disclose, including situation in which the provider is legally obligated to take action to protect others from harm.*In case you have any questions regarding confidentiality, please discuss this with your provider. 
5. I am financially responsible for treatment and services provided by You In Mind. I must pay any balance that is not reimbursed or covered by my health insurance. I also agree to enter a professional arrangement according to all business practices outlined in this agreement or as required by You In Mind. I accept total financial responsibility for payment of all fees and services as described, regardless of insurance coverage or any other "third-party" payers.
6. I understand that You In Mind, through its billing agent, Midwest Medical Billing, will submit charges for services to my primary health insurance plan for payment. You In Mind can change its billing agent at any time. 
7. I will be fully responsible for any services my health plan determines is a non-covered service, and I am fully responsible for any co-payments, co-insurance, or deductible. I will be informed of my co-payment amounts, co-insurance due, and/or deductible that is due prior to my appointment. I will be expected to pay any amount due for my co-payment, co-insurance due, and/or deductible that is due when I arrive for my appointment prior to seeing my provider. If I am a cash paying patient, I will be expected to pay the full amount for services provided on the day of my appointment prior to being seen by my provider. I understand that You In Mind accepts cash, check, credit card/debit card with chip reader as forms of payment. 
8. I will also be releasing You In Mind and Midwest Medical Billing, or any other billing agent that You In Mind might utilize, of any liability that directly or indirectly results from disclosure or exchange of any information covered in this agreement and understand that You In Mind is authorized under law to release certain information for payment purposes. At my request, a copy of this and any other document in my record that bears my signature will be provided. 
9. I further understand that my health plan may not cover all services and/or my provider may not be a participating provider in my health plan. Representatives from Midwest Medical Billing and/or You In Mind will attempt to verify my mental health benefits with my health plan prior to my scheduled appointment. (This statement does not apply to cash paying patients).
10. I authorize, in accordance with federal law, the release and disclosure of any or all part of my medical record, as is neccessary, to any person or entity which may be responsible to pay a portion of the charges incurred, including but not limited to, any private insurance company, government program, employer, or other family member. No person or entity shall be liable for disclosing any or all part of my medical record in good faith belief that disclosure is authorized by this release. This release may not be revoked as to any records relating to the services provided to me by You In Mind  during the course of diagnosis and treatment for the service, and the payment for such services I receive. I understand that, by using my insurance, I authorize You In Mind to release such information to my insurance company, and You In Mind will try to keep that information limited to the minimum neccessary.
11. I understand and agree that in order to collect any amounts I may owe, representatives from You In Mind, Midwest Medical Billing, or collection agencies may contact me by any telephone number associated with my account, including cellular numbers. I expressly authorize and consent to receiving text messages or emails using telephone numbers or email addresses that I have willingly provided. I expressly consent to the use of pre-recorded/artificial voice messages and/or the use of an automatic dialing device, as applicable, to any telephone number that I have provided, including my cell phone.
12. I further understand that, upon request, I will be provided with a written description of The Client's Bill of Rights and I have been appraised regarding the Notice of Privacy Practices of my medical records in accordance with the Health Insurance Portability and Accountability Act (HIPAA).

My signature below verifies that I have read (or have had it read to me) and understand the information contained on this Consent for Treatment, and agree to abide by its terms, and that I have asked questions about anything I do not understand or need further explanation on up to this point.