CLIENT CONSENT FORMS & CLIENT RIGHTS

  ACKNOWLEDGEMENT OF RECEIPT of NOTICE OF PRIVACY PRACTICES & PATIENT RIGHTS

In accordance with the Health Insurance Portability & Accountability Act (HIPAA).  I acknowledge that I received a copy of the Notice of Privacy Practices & Patient Rights for Holistic Elevation LLC. I acknowledge that I am signing this consent in the absence of coercion, duress or deceit.

ACKNOWLEDGEMENT OF RECEIPT of  CONFIDENTIALITY

 I acknowledge that I received a copy of the Confidentiality Procedures for Holistic Elevation LLC. All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your (client’s) written permission, except where disclosure is required by law.

By signing this contract, you are consenting to a release of information about your case to your health plan for claims, certification and case management for the purposes of treatment and payment.  H.E. has no control or knowledge over what insurance companies do with the information that is submitted or who has access to this information.  You must be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk to confidentiality, privacy or to future capacity to obtain health or life insurance.  I have reviewed and understand H.E. 's HIPAA policies- Notice of Privacy Practices and have been made aware of how my records may be used and disclosed.

ACKNOWLEDGEMENT OF RECEIPT of  TELEPHONE & EMERGENCY PROCEDURES

 I acknowledge that I received a copy of the Telephone and Emergency Procedures for Holistic Elevation LLC. By initialing below, I agree that I understand the disclosures listed above regarding communicating with H.E. using email. I also agree that if I send an email to an H.E. counselor and request a response via email, that I am willing to accept the above-stated risks. I also agree that I will not use email for emergencies. I understand I give permission for H.E. to initiate emails to me. 

ACKNOWLEDGEMENT OF RECEIPT of PAYMENT & INSURANCE REIMBURSEMENT

 I acknowledge that I received a copy of the payment and insurance reimbursement for Holistic Elevation LLC. I acknowledge that I am signing this consent regarding treatment should the client become ineligible for insurance coverage, checks returned for insufficient funds, Additional fees, Co-pays,  cash clients payments, payment responsibility, Collection Policy.  

ACKNOWLEDGEMENT OF RECEIPT of COUNSELOR FEES FOR RECORDS REQUESTS, COURT APPEARANCES, LETTERS, TREATMENT SUMMARIES

 I acknowledge that I received a copy of the Counselor Fees For Records Requests, Court Appearances, Letters, Treatment Summaries for Holistic Elevation LLC. I acknowledge that I am signing this consent regarding Counselor Fees, Records Requests, Writing a Treatment Summary, Writing Letter, Attendance in Court and other medical request documentation

 ACKNOWLEDGEMENT OF RECEIPT of PATIENT CONSENT FORM FOR SCRIBE SERVICES 

I understand my physician uses a professional medical scribe service that assists in documentation. The scribe service may be remote. 

• I understand that this allows a more focused patient-physician engagement. 

• I understand that I do not have to pay for this service. 

• I understand that the medical scribes follow a professional code of ethics that ensures that all medical information discussed with my physician, or the staff will be kept confidential. 

• I agree to the use of a professional medical scribe when I discuss my healthcare issues with my provider.

 ACKNOWLEDGEMENT OF RECEIPT of APPEALS AND GRIEVANCES

 I acknowledge that I received a copy of the Appeals And Grievances Procedures for Holistic Elevation LLC. I acknowledge my right to request reconsideration (an Appeal) in the case that client care is not certified by Managed Care Company.  I understand that I would request an Appeal directly through my Managed Care Organization. I also understand that I may submit a grievance to my practitioner at any time to register a complaint about my care or I may send the complaint directly to my insurance company.  My practitioner has access to information to facilitate this.

ACKNOWLEDGEMENT OF RECEIPT OF CONSENT TO DIGITALLY RECORD SESSION

 I acknowledge that I received a copy of the Consent To Digitally Record Session Appeals And Grievances Procedures for Holistic Elevation LLC. I understand that  Holistic Elevation continuously participates in professional development in order to provide quality therapeutic services to our clients. I understand that as a requirement of professional development my therapist will be digitally recording some of the sessions to be reviewed by a supervising consultant. I also understand that I will be able to decide if there are any parts of a session that I do not want to have recorded. 

This is for staff and/or students in training professional development. Clients will be asked prior to ever training

I consent to video recording

I have been informed of the intent and the parameters of surveillance

 ACKNOWLEDGEMENT OF RECEIPT of THE PROCESS OF THERAPY/ EVALUATION

I acknowledge that I received a copy of The Process Of Therapy/ Evaluation Procedures for Holistic Elevation LLC.

I consent and give permission to be contacted during and after my counseling with the understanding my response will be held confidential. 

I have read the above Agreement and Office Policies and General Information carefully; I understand them and agree to comply with them.

ACKNOWLEDGEMENT OF RECEIPT of CLIENT CRISIS BEHAVIORAL SUPPORT INTERVENTIONS

 I acknowledge that I received a copy of the Client Crisis Behavioral Support Interventions Procedures for Holistic Elevation LLC My signature below indicates that this policy/procedure has been reviewed with me and that I have received a copy for my records.

ACKNOWLEDGEMENT OF RECEIPT of INFORMED CONSENT FOR TELEMENTAL HEALTH SERVICES 

I acknowledge that I received a copy of the Informed Consent For Telemental Health Services Procedures for Holistic Elevation LLC. I agree to take full responsibility for the security of any communications or treatment on my own computer or electronic device and in my own physical location. I understand I  am solely responsible for maintaining the strict confidentiality of my user ID, password, and/or connectivity link. I shall not allow another person to use my user ID or connectivity link to access the services. I also understand that I am responsible for using  this technology in a secure and private location so that others cannot hear my  conversation.

ACKNOWLEDGEMENT OF RECEIPT of   INFORMED CONSENT FOR MENTAL & BEHAVIORAL TREATMENT

I acknowledge that I received a copy of the Informed Consent For Mental & Behavioral Treatment Procedures for Holistic Elevation LLC. I consent for treatment to be rendered by a therapist of Holistic Elevation.  I grant the therapist to perform those procedures and treatments, which may include professional consultation or emergency telephone responses, necessary for my condition that are generally used in this and similar settings.  I understand that information or opinions will be given to others only with my written consent.

I acknowledge that I received a copy of the clients Rights & Procedure Handbook for Holistic Elevation LLC. Signing this document is acknowledgement of my understanding as a client. This consent is valid until client discharge.

I consent to video recording

I have been informed of the intent and the parameters of surveillance