This notice describes how your health information may be used by Advenium, LLC and its affiliated entities ("Advenium") and how you can get access to this information. Please review it carefully. Treatment: Advenium may use or disclose your health information to professionals who are treating you. Payment: Advenium may use or disclose your health information to bill and obtain payment from health plans or other entities. Health Care Operations: Advenium may use or disclose your health information in connection with health care operations. Health care operations include quality assessment and improvement activities, reviewing the competency or qualifications of health care professionals, evaluating provider performance, conducting training programs, accreditations, certification, licensing, or credentialing activities. Non-Identifiable Information: Advenium may use your information in a non-identifiable, aggregate form for the purposes it deems appropriate in the evaluation of overall effectiveness of its personnel and methods and may share non-identifiable, aggregate information in order to further the development of its practice and in peer review settings. Your Rights as a Patient: a. You have a right to confidential communication regarding your protected information. b. You have a right to inspect and copy your protected health information. c. You have a right to amend your protect health information. d. You have a right to receive an account of disclosures of your protected health information. e. You have a right to request a paper copy of this notice, even if signed electronically. I understand and agree that this authorization will remain valid for the duration of the named patient's treatment with Advenium unless explicitly revoked. I understand that I may revoke this authorization at any time by notifying Advenium in writing, except to the extent that action has already been taken based on this authorization. I understand that signing this is voluntary.

These rules are in place to make sure everyone's experience at Advenium is enjoyable, safe and therapeutic.

 

1. Confidentiality: What is said in the group stays in the group. Anything said between group members is considered confidential. The names of members in the group are kept confidential and anything that occurs in the group or is said in the group is not shared outside of the group. Things that are spoken about in the group can be discussed further in the group.

2. Reporting: When the group leader suspects that someone is in danger, the leader takes action to keep everyone safe, as required by law.

3. Privacy: Group members decide when to answer questions and speak. Group members respect other participants' privacy and space.

4. Dignity: Each group member is treated with respect. No group member is ever humiliated, embarrassed, shamed, put down, or disrespected. Members are polite and listen when others are speaking or sharing. The group facilitator is spoken to respectfully and participants listen to the group facilitator's directions. Only one person talks at a time. Participants respect the property of other members and Advenium. Participants work together as a team.

5. Conduct: Group members are aware of other participants' needs and do not disturb the group in any way. Members share the responsibility to make the group work. Violence, teasing, putting others down, shouting, yelling, or intimidation toward other group members is not tolerated. Excessive talking and questions are disruptive and are limited. Quiet voice is used.

6. Sharp Objects: No sharp or dangerous objects are brought to groups.

7. Attendance and Participation: Groups begin and end on time. Group members arrive on time to avoid group disturbances. Members participate in the group activity and follow the facilitator's prompts. Members stay in the group room and do not roam the hallways or disturb other groups in session.

8. Dress Code: Group members arrive in appropriate apparel and footwear for the group they are attending.

All group members are required to comply with these rules. Failure to comply could result in group members being asked to leave Advenium groups.

Consent for Treatment. I give consent to Advenium LLC and its affiliated entities ("Advenium") to provide mental health services as deemed necessary and beneficial for the health and wellbeing of my child without my supervision.

Authorization of Payment of Insurance Benefits. I authorize payment to the Advenium of all monies and/or benefits to which I may be entitled from government agencies, insurance carriers or others who are financially liable for the medical care of my child and treatment, to cover the costs of care and treatment. I hereby authorize the release of any/all medical records for the purposes of payment for the service rendered to my child.

Authorization for Release of Information. By signing below, I authorize Advenium to release relevant health information: (1) to any requesting health care provider for further diagnosis, care or treatment or for that provider's payment or health care operation purposes; (2) to any person or entity which may be responsible for billing/collection of claims for medical services or products; (3) to any person or entity which is, or may be liable to Advenium or me for all or part of the Advenium's charges, including but not limited to, insurance companies, HMO or third party payors; (4) to any governments agency or other organization responsible for oversight of Advenium or a third party payer; (5) for Advenium's normal health care operations. I authorize Advenium to communicate with me through phone or email, even if not encrypted, and to allow the individuals listed above to access such information through any medium including over the Internet, even though the emails may not be encrypted, and through Advenium's electronic medical record system.

Acknowledgment of Notice of Privacy Practices. I have received a copy of Advenium's Notice of Privacy Practices, and have had the opportunity to receive assistance in the understanding and exercising these rights.

Signature. I have carefully read and fully understand this informed consent form and have had all my questions answered.