I agree to participate in a telemedicine evaluation and/or ongoing treatment performed by an independently contracted provider who assumes sole responsibility and liability for treatment. By signing this agreement, I authorize the electronic transmission of my medical information and/or videoconference session so that it can be viewed by a doctor and other persons involved in my medical or mental health care. [Note: The likelihood of this transmission being intercepted by persons other than those at the consulting site is extremely small]. I understand that I can withdraw my permission at any time and that I do not have to answer any questions that I consider to be inappropriate or am unwilling to have heard by other persons. I understand that if I do not choose to participate in a telemedicine session, no action will be taken against me that will cause a delay in my care and that I may still pursue face-to-face consultation. I understand that as with any technology, telemedicine does have its limitations. There is no guarantee, therefore, that this telemedicine session will eliminate the need for me to see a specialist in person. I understand that medical records of telemedicine services will be kept at Kentucky Counseling Center. I understand that some or all of my medical information may be used for teaching or educational purposes. I agree to have my telemedicine medical records reviewed for the purposes of evaluation (data collection, analysis and presentation in verbal or written format at scientific meetings). I understand that any presentation will not identify me by name or other identifiable markers. *
Please complete this section if you have Medicaid
Please complete this section if you have other insurance
By signing this form, you agree to receive mental health services provided by Kentucky Counseling Center, LLC, and its independent contractors. We know that starting counseling is a big decision and you may have many questions. We will do our best to answer any questions or concerns. This form explains information about KCC policy, State and Federal Laws, and your rights about counseling. All KCC employees and contractors have met the highest level of education, certification, and licensing requirements set forth by Kentucky state law. Counseling practices, philosophy and plan limitations and risks will be discussed with you today.
TREATMENT PROCESS AND DOCUMENTATION
It is the mental health professional’s responsibility to keep accurate records including Evaluations, Treatment Plans, and Progress Notes. By signing this document, you are consenting to the Treatment Plan that your provider creates and agree to any goals, objectives, and therapy techniques that may be used in your therapy process.
If you plan to use insurance to pay for services, claims will be sent to the insurance company based on information used at the time of service. Sometimes, insurance information may change or may not be up to date. If for any reason, inaccurate information related to deductibles, co-pays, or number of available sessions, etc. is retrieved at the time of service, KCC will bill the client for any additional costs associated with mental health services rendered. Additional services may not be provided until the client’s balance is current. If balances remain unpaid for 60 days, client information will be sent to a collection agency.
MISSED APPOINTMENT FEES Appointments will be cancelled and $25.00 fee will be assessed if client is 15 minutes late without notice. If client cancels appointment without a notice greater than 24 hours, KCC will charge the client $25.00.
RETURNED CHECK FEE If your check is returned, your account will be assessed a $35.00 fee.
CREDIT CARD PAYMENTS You may choose to have KCC store your credit card information for future bills you may incur. Should you do so, KCC will automatically process all outstanding balances one time per month and will not provide any additional warning other than what is written in this section of the Informed Consent form.
CONFIDENTIALITY AND EMERGENCY SITUATIONS: Confidential information discussed in session is not discussed with anyone without your written permission except for:
1. Diagnosis and dates of service shared with your insurance company to process your claims
2. Information you tell KCC about physical, sexual or elder abuse; then, by Kentucky State Law, I have to report this to the Kentucky Department of Children and Family Services
3. Where you sign a release of information to have specific information shared
4. If you tell KCC you are in danger of harming yourself or others
5. Information shared with therapist’s clinical supervisor if applicable
6. When required by law.
If you need to contact us between counseling sessions please call 855-591-002. E-mail, text messages and social networking sites are not confidential and we may not be able to respond. In the event of an emergency please call 911.
I consent for Kentucky Counseling Center, LLC and those representing this group to share my private health care information with the following individuals and/or entities. KCC is permitted to send and receive information to and from the entities below if needed:
I understand that I have the right to revoke this authorization, in writing, at any time by sending notice to Kentucky Counseling Center, LLC. I understand that a revocation is not valid to the extent that Kentucky Counseling Center, LLC has acted in reliance on such authorization. This authorization does not expire until I submit a written request. A copy of this release shall have the same force and effect as the original.
NOTICE TO RECEIVING INDIVIDUAL, PROVIDER, OR ENTITY: You may not re-disclose any of this information unless the person who consented to this disclosure specifically consents to such re-disclosure.
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.
Kentucky Counseling Center, LLC is committed to maintaining client confidentiality in accordance with federal and state laws and ethics of the counseling profession. This notice describes our policies related to the use and disclose of your healthcare information.
TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS
Your health information may be used for the purposes of providing treatment services, collecting payment, and conducting healthcare operations as necessary to support our operations and to promote quality care. We will use and disclosure your information for these purposes as state and federal laws allow. Examples include:
Treatment We may need to use or disclose health information about you to provide, manage, or coordinate your care or related services, including with third parties such as consultants and potential referral sources.
Payment We may use and disclose your information needed to verify insurance coverage and/or benefits with your insurance carrier, to process your claims, as well as for billing and collection purposes. We may bill the person in your family who pays for your insurance.
Healthcare Operations We may need to use information about you to review our treatment procedures and business activity. For example, information may be used for certification, compliance, and licensing activities. We may also contact you with information about treatment alternatives or other services that may be of interest to you. We may send you appointment reminders by text or by phone and/or leave a voicemail.
OTHER USES AND DISCLOSURES
Opportunity to Object to Certain Uses and Disclosures
You have the right to tell us whether you want us to use or disclose your information for the following purposes:
To Individuals Involved in Your Care or Payment for Your Care. We may share medical information about you with your family members, friends, or any others involved in your medical care or who helps pay for it. We may also share you information as necessary to identify, locate, and notify family members, guardians, or others involved in your care about your location, and general condition.
For Disaster Relief. In some cases, we may share limited information about you to a disaster relief agency assisting in disaster relief efforts.
If you are not present or unable to tell us your preference, we may go ahead and share your information if your health care provider thinks that it may be best for you.
Other Permitted Uses and Disclosures
We may share your information when needed to lessen a serious and imminent threat to health or safety. When permitted by law, we may also share information in certain situations to help with public health and safety issues. For example, in preventing disease, reporting adverse medication reactions, or helping with product recalls. We may share information with a medical examiner or coroner when an individual dies. We may share information with health oversight agencies for activities authorized by law, and for certain specialized government functions such a national security and presidential protective services.
Required Uses and Disclosures
There are some instances where we may be required by law to use and disclose information. For example, when you and/or your child or children report information about physical or sexual abuse, when required by the Secretary of the Department of Health and Human Services to audit or evaluate our compliance with the requirements of federal privacy law, or if you provide information that informs us that you are in danger of harming yourself or others. We may share information with law enforcement consistent with applicable laws, such as if a crime is committed on our premises or against our staff, or if required in response to a valid court order.
Use and Disclosure Requiring Your Authorization
Certain uses and sharing of your health information are only permitted with your written authorization. These include most uses and disclosures of psychotherapy notes, uses and disclosures of your health information for marketing communications, and disclosures that constitute a sale of your health information.
Uses and disclosures of your health information other than those described in this notice will be made only with your written authorization.
You may revoke an authorization, at any time, in writing, except to the extent that your provider or we have taken an action in reliance on the use or disclosure indicated in the authorization. To revoke an authorization, you must write to Kentucky Counseling Center at the address listed below.
The following is a statement of your rights with respect to your protected health information. If you have questions about how to exercise these rights, contact our Privacy Officer using the information below.
Right to request how we contact you
It is our normal practice to communicate with you at your home address and daytime phone number you gave us when you scheduled your appointment, about health matters, such as appointment reminders. Sometimes we may send a text appointment reminder or leave messages on your voicemail. You have the right to request that our office communicate with you by alternative means or at an alternative location. You must submit your request in writing to us at the address below. We will agree to reasonable requests.
Right to release your medical records
You may consent in writing to release your records to others. You have the right to revoke your consent, in writing, at any time. However, a revocation is not valid to the extent that we acted in reliance on such consent.
Right to inspect and copy your medical and billing records.
You have the right to inspect and obtain a copy of your information contained in our medical records. To request access to your billing or health information, contact the Privacy Officer. Under limited circumstance we may deny your request to inspect and copy. When permitted by law, may charge a reasonable fee for the costs of copying, mailing, and supplies to provide a copy of your information.
Right to add information or amend your medical records.
If you feel that information contained in your medical record is incorrect or incomplete, you may ask us to amend the record. We will make a decision on your request with 60 days, or some cases within 90 days. Under certain circumstance, we may deny your request to add or amend information. If we deny your request, you have a right to file a statement that you disagree. Your statement and our response will be added to your record. To request an amendment, you must contact the Privacy Officer. We will require you to submit your request in writing and to provide an explanation concerning the reason for your request.
Right to an accounting of disclosures.
You may request an accounting of any disclosures, if any, we have made related to your medical information, except for information we used for treatment, payment, or health care operations purposes or that we shared with you or your family, or information that you gave us specific consent to release. To receive information regarding disclosure made for a specific time period no longer than six years and after April 14, 2003, please submit your request in writing to the Privacy Officer. We will notify you of any cost involved in preparing this list.
Right to request restrictions on uses and disclosures of your health information.
You have the right to ask for restrictions on certain uses and disclosures of your health information. This request must be in writing and submitted to our Privacy Officer. You must tell us the type of restriction you want and to whom it applies. We are generally not required to agree to such a request, with one exception. You have a right to restrict any disclosure of personal health information for payment purposes or for our health care operations if you have paid for services out-of-pocket and in full.
You have a right to receive notification of a breach of your unsecured personal health information.
Right to complain.
If you believe your privacy rights have been violated, please contact us personally, and discuss your concerns. You may also file a written complaint with the U.S. Department of Health and Human Services. We will not retaliate against you for filing such a complaint.
OTHER INFORMATION ABOUT THIS NOTICE
Compliance with Laws
We are required by law to provide you with this notice of our legal duties and privacy practices with respect to your protected health information, and to notify you in writing if the privacy or security of your health information is breached. We are required to abide by the terms of our Notice of Privacy Practices currently in effect.
Right to Request a Paper Copy
You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice electronically.
Revisions to This Notice
We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for your health information we already have, as well as any we get in the future. Any changes in this notice will be posted on our website at kentuckycounselingcenter.com. The revised notice also will be available upon request at our offices.
Our Notice of Privacy Practices was originally effective in August, 2014.
This revised version is effective as of February 11, 2019.
Questions and Contact
If you have any questions about this notice or about how your health information is used or shared by us, please contact us at: Kentucky Counseling Center, LLC Attn: Privacy Officer 4835 Poplar Level Road Suite 110 Louisville, KY 40213
Please provide copies of your insurance and id if possible.