Minor Abbreviated Intake

Professional Disclosure

Four Points Counseling Center (FPCC) employs mental health professionals licensed under the Colorado Department of Regulatory Agencies (DORA) and includes Licensed Clinical Social Workers, Licensed Marriage and Family Therapists, Licensed Professional Counselors, and Licensed Psychologists. Doctoral level clinicians receive a doctorate in psychology and must complete at least 1500 hours of post-graduate clinical work and 75 hours of clinical supervision. Master's level clinicians receive a master's degree in their chosen field and complete the following requirements:

Licensed Clinical Social Workers: 3360 hours over a minimum of 24 months and a minimum of 96 supervision hours

Licensed Marriage and Family Therapists: 2000 hours over a minimum of 24 months and 100 hours of supervision

Licensed Professional Counselors: 2000 hours over a minimum of 24 months while under supervision

FPCC also employs provisionally licensed clinicians including Psychologist Candidates, Licensed Social Workers, Marriage and Family Therapist Candidates, and Licensed Professional Counselor Candidates. These clinicians have received the degrees required by their fields and are in the process of accumulating the supervisory and clinical hours necessary to receive full licensure. They work under the supervision of fully licensed therapists employed by FPCC.

Client Rights 

• You have the right to receive information about your therapy in a way that is easy to understand including your therapist's methods, techniques, and interventions, the anticipated duration of your treatment, and the applicable fee structure. If you would like to receive this information, please ask your therapist at any time.
• You have the right to collaborate with your therapist to develop goals and objectives for your treatment and participate in an individualized treatment planning process.
• You have the right to seek a second opinion from another therapist, to refuse services, or terminate therapy at any time.

Cancellation Policy

FPCC requests cancellations occur with at least 24 hours notice. Cancellations with less than 24 hours notice are referred to as late cancellations and will incur a fee of $75.00. Missed appointments will also incur a $75.00 fee. For the purposes of this policy, Saturdays and Sundays, as well as federal holidays are not considered business days and notice given on these days will be considered received on the following business day. Please note that some insurers and third party payers including Medicaid do not permit the charging of fees and clients holding these policies will not be charged. Please see the Financial Disclosure for more information.

Electronic Communication

Text and email communication will be used by your therapist and FPCC administrative staff for limited reasons. FPCC takes your privacy seriously and cautions you that sending information using unencrypted methods creates risk for your information security. Additionally, the potential for others to access your devices or accounts could compromise your privacy, the security of your identity, and possibly disclose that you receive mental health services.

FPCC also understands that you receive enough communications via text and email and will never send you marketing emails or messages. The following are the reasons you may receive electronic communications from FPCC staff.

• Appointment reminders/confirmations
• Scheduling communications
• Office alerts, for example parking lot closure
• Response to electronic communications sent by you, the client
• Information related to insurance benefits and/or payment responsibility
• Billing and other administrative needs

If you have concerns about communications you receive from FPCC, please contact 970-682-1337 and ask to speak to management. Checking "Yes" below indicates your understanding of the information above and your consent to receive electronic communication. If you would like to opt out of electronic communication, please check "No" and indicate the phone number your therapist and staff may use to call you.

Ethics of the Professional Relationship

Licensed mental health professionals are bound by the ethics codes of their respective regulatory boards. Among other ethical requirements, therapists must hold the boundary of the professional relationship between client and therapist. It is a direct violation for a therapist to develop a friendship, sexual or romantic relationship with a client or to socialize or otherwise spend time with clients outside of therapy. It is never appropriate for a therapist and client to engage in physical intimacy.

Termination of Treatment

Most often termination of treatment is the result of careful collaborative planning between client and therapist over a period of time. There are a few exceptions including but not limited to those highlighted below.

• Misalignment between therapist and client, whether due to lack of mutual schedule availability, client needs lying outside the therapist's scope of practice, or other circumstances
• Clinical need for a higher level of care
• Non-payment of services
• Threatening, harassing or abusive behavior or communication toward the therapist or FPCC staff from the client or client's associates

Confidentiality

Information discussed during therapy sessions is considered privileged and is protected as legally confidential under Colorado law. The therapist cannot be forced to disclose confidential information without obtaining the client's consent with certain exceptions. Several of these exceptions, which do not require the client's consent, as stated in the Colorado Revised Statutes (C.R.S. 12-43-218) are described below

• Incidents of imminent threat of bodily harm to one's self, another identifiable person, or national security
• Incidents of grave disability as a result of a mental disorder
• Suspected abuse or neglect of a child, senior, or disabled individual
• An official complaint or lawsuit against your therapist
• A court order requiring your therapist to submit records or testify
• In the event of court-mandated treatment
• Criminal or delinquency proceedings except as provided in section 13-90-107 C.R.S. 
• Additional exceptions under Colorado law as outlined in Colorado Revised Statute 12-43-218

Important Notes About Your Health Information

• Confidentiality will be maintained in compliance with the requirements of the Division of Alcohol and Drug Abuse and federal regulations governing drug and alcohol problems, 42 C.F.R. Part 2.
• Disclosing information or providing records to other clinicians may be necessary at times as part of your treatment or if you choose to seek care from another provider. In these instances, information disclosed is limited to your name, contact information, dates of treatment, treatment progress and diagnosis.
• FPCC administrative staff may have access to limited confidential information. This information is protected from further disclosure and used solely for administrative purposes. All staff members sign confidentiality agreements and complete HIPAA training prior to accessing confidential data.
• Your therapist may seek consultation from another mental health professional. Your identity will not be revealed without your consent and your privacy will be protected by that professional.
• Under Colorado law, the parents of children under age 15 years have the right to access mental health care information concerning minor children unless the court restricts access to a child's information.
• If you request treatment information, you may be provided with a treatment summary in compliance with HIPAA and Colorado law.

Please see the Notice of Privacy Practices for more information about your rights and the use of your information.

Mental Health Records

All records held by FPCC are the sole property of FPCC and are for the therapist's sole use. Records are stored by FPCC for a period of ten years after your treatment has ended or seven years after a minor client reaches the age of 18. Records may be released to you upon written request. Please see the Notice of Privacy Practices for more information about requesting records.

Legal Proceedings

Therapist testimony and involvement in the legal matters of clients has been shown to be detrimental to the therapeutic relationship. Your signature on this disclosure indicates your agreement to refrain from calling your therapist as a witness in court or to respond in any other way to legal proceedings. If a subpoena is issued, no opinions or statements of clinical judgment will be given and the therapist's time will be billed at a rate of $250 per hour including but not limited to preparation and travel time. This includes subpoenas for records or letters.

Grievances

If you have a concern or complaint at any time, you may discuss this with your therapist or with FPCC management by calling 970-682-1337 and requesting to speak to one of the directors. We hope to address and resolve concerns by working with you directly. You may also file a grievance using the following information:

State Grievance Board	Office of Behavioral Health
1560 Broadway, Suite 1340	Colorado Department of Human Services
Denver, CO 80202	3824 W. Princeton Circle
(303) 894-7766	Denver, CO 80236-3111
	(303) 866-7400

 

Advance Directives

Federal law requires that FPCC share information with you about advance directives and the rights you have in the State of Colorado about making healthcare decisions. An advance directive is a legal document that tells your health care team about your wishes and what you do or don't want for your health care when you are unable to make these decisions for yourself. Whether or not you have an advance directive does not impact your ability to receive mental health services. For more information about advance directives, you may visit: https://cdphe.colorado.gov/colorado-crisis-standards-of-care/advance-care-planning-for-patients-and-families. 

Crisis Services

FPCC is unable to provide emergency services. Your therapist may be available to you after hours within reason by contacting their direct number. If you (or someone else) are in a life-threatening situation and need emergency help, you should call 911 or go to an emergency room or community crisis center. These are some resources you may consider. Some resources may incur a cost to you and your insurance may or may not contribute to that cost.

Hotlines: National Suicide Hotline: (800) 273-8255

Youth Crisis Helpline: (800) 999-9999

Colorado Crisis Services: 844-493-8255 or text "TALK" to 38255

Fort Collins Crisis Services
Poudre Valley ER	Banner N Colorado ER	SummitStone Walk-In Clinic
1024 S Lemay Ave	4700 Lady Moon Dr	1217 Riverside Ave
Fort Collins, CO 80524	Fort Collins, CO 80528	Fort Collins, CO 80524
970-495-7000	970-821-4000	970-494-4200
Loveland Crisis Services
McKee Med Center- Banner	UCHealth MCR Emergency
2000 N Boise Ave	2500 Rocky Mountain Ave
Loveland, CO 80538	Loveland, CO 80538
970-820-4640	970-624-1600
Greeley Crisis Services
Colorado Crisis Services	North CO Med Center ER	UCHealth Greeley ER
928 12th Street	1801 16th St	6906 W 10th St
Greeley, CO 80631	Greeley, CO 80631	Greeley, CO 80634
844-493-8255	970-810-4121	970-392-4320
Text "TALK" to 38255
coloradocrisisservices.org

   

 

I give Four Points Counseling Center (FPCC) and the therapists employed by FPCC permission to administer therapy services in an outpatient setting. I understand that there are benefits and risks of therapy. Risks include but are not limited to experiencing discomfort and vulnerability. Therapy involves the sharing of personal information which may itself feel distressing, and the processing of events, memories, and difficulties may evoke emotions including anger, fear, sadness, and guilt, among other emotions. The benefits of therapy include but are not limited to improving coping skills, decreasing symptoms, gaining insights about yourself and others, achieving progress toward important goals, repairing relationships and beginning a healing process from traumatic events. FPCC is unable to guarantee outcomes of any kind and will at times provide referrals to other healthcare providers in the interest of meeting your needs.

Minors

In the State of Colorado, individuals age 12 and older may independently consent to treatment. If the client is under age 12, please review the Direction for Treatment of Minors before the intake appointment.

COVID-19

FPCC follows COVID-related health orders as set forth by the State of Colorado and the Larimer County Department of Health, as well as voluntarily implements various best practices as recommended by the Centers for Disease Control and Prevention (CDC). There is, however, the possibility of exposure to COVID-19.

I understand that by receiving services in person, I assume the risk of exposure to COVID-19. I further understand that it may be possible for me to receive services via telehealth rather than attending servicesin person and that I may inquire about this as an alternative if I wish.

 

Recordings

Please initial below to indicate your understanding and agreement to the recording policy. 

Session recordings of any kind, including in person, telehealth and/or hybrid sessions, in which one or more parties attend remotely and one or more parties attend face-to-face, are prohibited. Sessions shall not be recorded by any party at any time unless express permission is granted in writing.

Acknowledgment

My signature below indicates my consent to treatment as well as my understanding and agreement to the information contained in this disclosure. I understand I may ask questions about any of the information outlined in this document at any time.

*Or signature of parent, guardian, or client representative. Future pages will state this only as representative.

For questions about this form or other forms requested for completion prior to receiving services, please contact us at (970) 682-1337 or info@fourpointscc.com in advance of the intake appointment.

Effective November 1, 2021

This notice describes how medical and mental health information about you may be used and disclosed and how you may obtain access to this information. Please review it carefully.

This document may be changed at any time. The current version of this notice will be the version in effect for all health information collected and maintained by Four Points Counseling Center (FPCC You may obtain a copy of the newest version of this document by contacting FPCC at info@fourpointscc.com or calling 970-682-1337.

Four Points Counseling Center releases information only in accordance with state and federal laws and the ethics of the boards governing the professions of the practitioners therein. This notice describes the policies of FPCC related to the use and disclosure of client protected health information (PHI). Protected health information refers to information about you, including demographic information, that may identify you or be used to identify you, and that relates to your past, present or future physical or mental health or condition, the provision of health care services, or the past, present or future payment for the provision of health care.

FPCC is permitted to disclose your PHI for the health care functions of providing treatment, collecting payment for health care services, and conducting health care operations. These activities are necessary for the provision of quality care and state and federal laws allow us to use and disclose your health information for these purposes.

Treatment: FPCC may use and disclose your health information to:

• Provide, manage and coordinate care with other entities currently involved in your health care
• Communicate with your referral source

Payment: FPCC may use and disclose your health information to: 

• Verify insurance benefits and coverage Process claims and collect fees

Health Care Operations: FPCC may use and disclose your health information to: 

• Conduct internal audits of treatment procedures to improve your care 
• Conduct routine business and administrative functions surrounding your care 
• Adhere to compliance, audit, investigation and licensing requirements

Other Uses and Disclosures Without Your Consent:

• Mandated reporting, emergencies and criminal activities 
• Coroners, medical examiners and related professionals 
• Appointment scheduling 
• Research (rarely used and requires a rigorous approval process) 
• Any and all other uses and disclosures as required by law

 

Client Rights 

Right to Confidential Communication 

You have the right to request where you are contacted and for communication to occur in a specific, limited or confidential manner. The Consent to Electronic Communication section of the Professional Disclosure and Consent to Treatment is one method you may use to state your preferences. FPCC will accommodate all reasonable requests.

Right to Obtain and Release Records

You may submit a written request to view or receive an electronic or paper copy of your health record and other health information, or to have your records sent to a third party. Contact FPCC at 970-682-1337 for information about making this request. We may provide a copy or summary of your record usually within thirty days of your request, and in compliance with all applicable laws. We may charge a reasonable, cost-based fee. You have the right to revoke in writing releases of information. Revocation is not valid to the extent that you have acted in reliance on such previous authorization.

Right to Request Amendment to Your Records

You may request to correct health information about you that you think is incorrect or incomplete. Contact FPCC at 970-682-1337 for information about making this request. Requests may not result in formal modifications to the health record. The request for the correction, however, will be added to the health record as an addendum.

Right to Accounting of Disclosures

You may obtain a list of the disclosures of your health information for six years prior to the date of your request including the recipient of the information and the reason for disclosure. We will include all disclosures except those about treatment, payment, and health care operations, and certain other disclosures, such as those requested by you with a signed release or those made to law enforcement. FPCC will provide one accounting per year without charge. FPCC will charge a reasonable, cost-based fee if another is requested within the same twelve month period.

Right to Request Restrictions on Uses and Disclosures of PHI

You may request that we not use or share certain health information for treatment, payment, or operations. FPCC is not required to agree to the request, and may decline if it would affect your care. If you are not utilizing insurance or a third party payer for services, you may request that information not be shared with a payer. This can be accommodated unless FPCC is legally bound to disclose information.

Right to File a Complaint

If you feel your rights have been violated and wish to file a complaint, you may contact us directly at info@fourpointscc.com or 970-682-1337. You may also contact the United States Department of Health and Human Services. Please know we will not retaliate against you in any way for filing a complaint.

By placing your signature below, you attest that you have read and understand your rights and responsibilities under federal law regarding your protected health information. If you have questions about this notice or the privacy practices of Four Points Counseling Center, please contact Compliance Officer Ashley Shaw at 970-682-1337 or ashley@fourpointscc.com.

*Biological, adoptive or foster parent with legal rights

Divorce, Court Orders and Other Legal Matters

Have court orders or other legal actions impacted the authority to make decisions for the minor client? These may include but are not limited to legal separation and divorce, determination of custody and/or guardianship, limitation or termination of parental rights, actions related to client paternity, and proceedings regarding participation in mental health services.

Medical Decision Making Documentation

Examples of documentation referenced below may include: Separation agreements, divorce decrees, medical/mental health care powers of attorney, emergency guardianship orders, other court orders

If the individual signing this document is the minor client (age 12+), or is the biological/adoptive parent and there have been no legal actions that have impacted decision-making authority for the minor client, no supporting documentation is required.

If the individual signing this document is not the biological or adoptive parent of the minor client, or if legal actions have impacted decision-making authority regarding the minor client, documentation should be provided verifying the individual's legal authority to make medical decisions for the minor client.

By signing below, I attest that the information I have entered is accurate and that I have not knowingly omitted information from this form.

For questions about this form or other forms requested for completion prior to receiving services, please contact us at (970) 682-1337 or info@fourpointscc.com in advance of the intake appointment.

You may meet with your therapist exclusively via telehealth, occasionally as requested by you or your therapist, or not at all. We ask that all clients review this policy primarily so that every client has the flexibility of engaging in telehealth should the need arise and you wish to use this modality.

Potential Benefits of Telehealth

• High level of convenience
• Increased access to services and clinicians
• Ability to keep appointments that would otherwise be canceled, for example due to bad weather
• Efficacy and outcomes comparable to face-to-face services

Potential Risks of Telehealth and Risk Management

Technology issues may occur and disrupt your session or delay its start. Internet stability and speeds may change suddenly and result in the loss of your connection and may be unpredictable from one session to another.

Your therapist will discuss with you how a disrupted connection and technology issues will be managed and what you can expect should you become disconnected during your session.

Clients and therapists alike must be able to successfully launch and navigate the telehealth platform to engage in telehealth sessions.

FPCC uses Zoom which is accessed through our user-friendly portal. We've worked to make this as intuitive as possible.

Confidentiality may be compromised. The nature of telecommunication technology is such that FPCC cannot guarantee that communications will remain confidential, secure, or that unauthorized individuals may not gain access to information.

FPCC uses an encrypted online service and information is transmitted over a secure network. We recommend that clients only use secure networks for telehealth sessions and that devices are password protected.

Conversations may be overheard by unintended individuals.

FPCC therapists use private spaces for telehealth sessions. They may inquire about the space you use for sessions and make recommendations to increase your privacy if possible.

Telehealth is not recommended for all clients, for example individuals in crisis or those who would benefit from a high level of support and intervention.

Your therapist will utilize an intake appointment to ascertain your needs and goals and work with you to develop a plan if telehealth is not currently an option.

Alternatives to Telehealth

Face-to-face services, also referred to as "in-person" services, in which the therapist is physically present in the same room as the client, is an alternative to receiving services via telehealth. At times, access to in-person services may be limited.

Fees for Telehealth Services

Self-pay rates for those paying for sessions entirely out of pocket are the same whether the session is in person or via telehealth. For those utilizing insurance or a third party payer to cover some or all of the session fees, the rates for telehealth and in-person sessions are often the same, but not always. Your insurance company or other payer establishes service rates. FPCC will attempt to assist you in estimating your responsibility for payment, but it is ultimately your responsibility to understand your benefits and coverage.

Insurance companies and third party payers may not cover telehealth sessions. If a third party payer does not cover telehealth, you will be responsible for the full fee for services. FPCC will attempt to assist you in determining your coverage, but it is ultimately your responsibility to determine whether telehealth is covered. It is strongly encouraged that you contact your insurance company prior to engaging in telehealth services to determine whether it is covered.

Informed Consent

The terms of this agreement are presented in addition to those described in the Informed Consent to Treatment located within the Professional Disclosure and Consent to Treatment. It does not amend any of the terms contained therein. These terms are presented separately for the sake of clarity.

1. I understand that signing this disclosure and consent is not a commitment to engage in telehealth services.
2. Should I choose to engage in telehealth services, I grant my therapist permission to conduct therapy via telehealth.
3. I understand it is my responsibility to ensure the privacy of the space I use for telehealth sessions. I understand that telehealth sessions should occur in a private space where others cannot overhear my therapy session.
4. I understand the differences between telehealth services and face-to-face services, and have received an explanation of alternatives to telehealth.
5. I understand there are potential risks to using telecommunication technology, including session interruptions, unauthorized access and other technical issues.
6. I understand that my therapist or I may discontinue telehealth sessions if the modality does not seem to sufficiently meet my needs.
7. I understand that the extent of confidentiality and the exceptions to confidentiality outlined in the Informed Consent section of the Professional Disclosure and Consent to Treatment apply to telehealth services. I understand I may ask questions about this or any other matter at any time.
8. I understand that my healthcare information may be shared with others for scheduling and billing purposes in addition to other allowances as permitted under HIPAA.

For questions concerning the telehealth policies and practices of Four Points Counseling Center, please call 970-682-1337 or email info@fourpointscc.com and the staff will be happy to answer your questions. Your therapist is also able to answer any questions you may have.

My signature below indicates my understanding and agreement to the information contained in this disclosure.

For questions about this form or other forms requested for completion prior to receiving services, please contact us at (970) 682-1337 or info@fourpointscc.com in advance of the intake appointment.

The following represents the financial policies of Four Points Counseling Center including charging for services with card on file transactions.

Cards on File

It is the policy of Four Points Counseling Center (FPCC) that clients provide a credit or debit card that will be kept on file. Health Savings Account (HSA) cards may also be used for payment. Please note that due to the regulations of Colorado Medicaid and several third party payers, clients with these plans are not required to provide a card and will be informed of such upon scheduling.

FPCC requests cards on file primarily due to the administrative logistics of the practice, making payment collection at each visit faster, simpler and more convenient for both clients and therapists. Cards on file are used for any client payment responsibility which may include copay, coinsurance, deductible, and private pay amounts. Charges may also include amounts for unreimbursed services by insurance companies or fees for missed appointments.

We appreciate your adherence to this policy and are available to answer questions at any time. You may also revoke your authorization verbally or in writing by informing your therapist, calling 970-682-1337 or emailing info@fourpointscc.com. 

Benefits Verification

If you utilize insurance or a third party payer to cover some or all of your session fees, FPCC will attempt to assist you in estimating your responsibility for payment. However, it is ultimately your responsibility to understand your benefits and coverage. FPCC is not responsible for any inaccuracy in relaying benefit information as thisisa courtesy only and you are strongly encouraged to contact your insurance company prior to beginning services. If you consent to electronic communication, as reflected in the Disclosure and Consent to Treatment, we may contact you via the email address on file to communicate with you regarding balances owed, changes to your payment responsibility, or other billing-related matters.

Client Responsibility

You understand and agree that the fees for services are ultimately your responsibility. Any unpaid balances after insurance submissions are your responsibility and will be charged to the card on file. These amounts may include copays, coinsurance amounts, full fee amounts due to unmet deductibles, and fees for missed appointments and late cancellations. Clients not utilizing insurance will be responsible for the full fee for services. FPCC will provide access to the patient portal where you may view your account, request statements, and pay balances.

Routine Charges for Services

The card on file will be charged within one calendar week of the date of service. If you prefer that a different card be used than the one on file, or would like to use another method of payment such as cash or check, please let your therapist know at the time of your session.

Missed Appointments and Late Cancellations Missed appointment and late cancellation fees are automatically charged to the card on file within one calendar week of the date of the scheduled service. Late cancellations are those that are canceled with less than 24 hours notice. The fee for missed appointments and late cancellations is $75.

Collateral Services and Miscellaneous Fees

Occasionally your therapist may provide a service for you, as requested by you, outside of sessions. These services, such as writing a letter, are not therapeutic services and as such are not covered by insurance. Rates for collateral services vary. Additionally, fees are listed for returned checks and court-related activity. Please reference the Professional Disclosure and Consent to Treatment for more information about client legal matters, as well as our request to refrain from asking for therapist involvement.

Collateral Services: Varies by therapist and service provided

Court-Related Matters: $250/hour (including but not limited to preparation and travel time)

Returned Checks: $20 per check

Information Storage

Card information is stored via PCI-compliant encryption with International Bancard.

Surprise Billing

Beginning January 1, 2020, Colorado law protects some individuals from "surprise billing," also known as "balance-billing." This law does not apply to all Colorado health plans. It only applies if you have "CO-DOI" indicated on your health insurance ID card. These protections apply when:

• You receive covered emergency services, other than ambulance services, from an out-of-network provider in Colorado, and/or
• You unintentionally receive covered services from an out-of-network provider at an in-network facility in Colorado

What is surprise/balance-billing, and when does it happen?

If you are seen by a health care provider or use services in a facility or agency that is not in your health insurance plan's provider network, sometimes referred to as "out-of-network," you may receive a bill for additional costs associated with that care. Out-of-network health care providers often bill you for the difference between what your insurer decides is the eligible charge and what the out-of-network provider bills as the total charge. This is called "surprise" or "balance" billing.

When You CANNOT Be Balance-Billed: Emergency Services

If you are receiving emergency services, the most you can be billed for is your plan's in-network cost-sharing amounts, which are copayments, deductibles, and/or coinsurance. You cannot be balance-billed for any other amount. This includes both the emergency facility where you receive emergency services and any providers that see you for

When You CANNOT Be Balance-Billed: Non-Emergency Services at In-Network or Out-of-Network Provider

The health care provider must tell you if you are at an out-of-network location or at an in-network location that is using out-of-network providers. They must also tell you what types of services that you will be using may be provided by any out-of-network provider. You have the right to request that in-network providers perform all covered medical services. However, you may have to receive medical services from an out-of-network provider if an in-network provider is not available. In this case, the most you can be billed for covered services is your in-network cost-sharing amount, which are copayments, deductibles, and/or coinsurance. These providers cannot balance-bill you for additional costs.

Additional Protections

• Your insurer will pay out-of-network providers and facilities directly.
• Your insurer must count any amount you pay for emergency services or certain out-of-network services (described above) toward your in-network deductible and out-of-pocket limit.
• Your provider, facility, hospital, or agency must refund any amount you overpay within sixty days of being notified.
• No one, including a provider, hospital, or insurer can ask you to limit or give up these rights.

If you receive services from an out-of-network provider or facility or agency or OTHER situation, you may still be balance-billed, or you may be responsible for the entire bill. If you intentionally receive nonemergency services from an out-of-network provider or facility, you may also be balance-billed.

If you want to file a complaint against your health care provider, you can submit an online complaint by visiting this website: https://www.colorado.gov/pacific/dora/DPO_File_Complaint 

If you think you have received a bill for amounts other than your copayments, deductible, and/or coinsurance, please contact the billing department, or the Colorado Division of Insurance at 303-894-7490 or 1-800-930-3745. Please contact your health insurance plan at the number on your health insurance ID card or the Colorado Division of Insurance with questions.

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My signature below indicates my understanding of the information above and my agreement to the terms contained in this financial policy. I authorize FPCC to keep my credit, debit and/or HSA card on file and to charge my card the amounts for which I am responsible including those related to late cancellations and missed appointments, except where prohibited by law and/or third party payers. I understand I have the right to request my card be removed via written or verbal request at any time.

For questions about this form or other forms requested for completion prior to receiving services, please contact us at (970) 682-1337 or info@fourpointscc.com in advance of the intake appointment.

Mental healthcare providers are required to ask brief questions about your primary and dental care and inquire if you will allow communication about your mental health services with your primary care provider (PCP).

You are not obligated to allow the sharing of information and declining will not impact your ability to receive care from Four Points Counseling Center.

The following individual(s) are designated as emergency contact(s) in the event of a mental health or physical health crisis. It is not required to list an emergency contact, however we encourage listing at least one