informed consent for in-person services during covid … · • you will try not to touch your face...

INFORMED CONSENT FOR IN-PERSON SERVICES DURING COVID-19 PUBLIC HEALTH CRISIS This document contains important information about our decision (yours and mine) to resume in-person services considering the COVID-19 public health crisis. Please read this carefully and let me know if you have any questions. When you sign this document, it will be an official agreement between us. Decision to Meet Face-to-Face We have agreed to meet in person for some or all future sessions. If there is a resurgence of the pandemic or if other health concerns arise, however, I may require that we meet via telehealth. If you have concerns about meeting through telehealth, we will talk about it first and try to address any issues. You understand that, if I believe it is necessary, I may determine that we return to telehealth for everyone’s well-being. If you decide at any time that you would feel safer staying with, or returning to, telehealth services, I will respect that decision, if it is feasible and clinically appropriate. Reimbursement for telehealth services, however, is also determined by the insurance companies and applicable law, so that is an issue we may also need to discuss. Risks of Opting for In-Person Services You understand that by coming to the office, you are assuming the risk of exposure to the coronavirus (or other public health risk). This risk may increase if you travel by public transportation, cab, or ridesharing service. Your Responsibility to Minimize Your Exposure To obtain services in person, you agree to take certain precautions which will help keep everyone (you, me, and our families, [my other staff] and other patients) safer from exposure, sickness and possible death. If you do not adhere to these safeguards, it may result in our starting / returning to a telehealth arrangement. Initial each to indicate that you understand and agree to these actions:

• You will only keep your in-person appointment if you are symptom free. ___ • You will take your temperature before coming to each appointment. If it is elevated (100

Fahrenheit or more), or if you have other symptoms of the coronavirus, you agree to cancel the appointment or proceed using telehealth. If you wish to cancel for this reason, our clinic policy will be waived regarding your services being suspended due to a late cancelation. __

• You will wait in your car or outside [or in a designated safer waiting area] until no earlier than 5 minutes before our appointment time. ___

• You will wash your hands or use alcohol-based hand sanitizer when you enter the building. ___ • You will adhere to the safe distancing precautions we have set up in the waiting room and

testing/therapy room. For example, you will not move chairs or sit where we have signs asking you not to sit. ___

• You will wear a mask in all areas of the office (I [and my staff] will too). ___ • You will keep a distance of 6 feet and there will be no physical contact (e.g. no shaking hands)

with me [or staff]. ___ • You will try not to touch your face or eyes with your hands. If you do, you will immediately wash

or sanitize your hands. ___

• If you are bringing your child, you will make sure that your child follows all of these sanitation and distancing protocols. ___

• You will take steps between appointments to minimize your exposure to COVID. ___ • If you have a job that exposes you to other people who are infected, you will immediately let

me [and my staff] know. ___ • If your commute or other responsibilities or activities put you in close contact with others

(beyond your family), you will let me [and my staff] know. ___ • If a resident of your home tests positive for the infection, you will immediately let me [and my

staff] know and we will then [begin] resume treatment via telehealth. ___

I may change the above precautions if additional local, state or federal orders or guidelines are published. If that happens, we will talk about any necessary changes. My Commitment to Minimize Exposure My practice has taken steps to reduce the risk of spreading the coronavirus within the office and we have posted our efforts on our website and in the office. Please let me know if you have questions about these efforts. If You or I Are Sick You understand that I am committed to keeping you, me, [my staff] and all of our families safe from the spread of this virus. If you show up for an appointment and I [or my office staff] believe that you have a fever or other symptoms, or believe you have been exposed, I will have to require you to leave the office immediately. We can follow up with services by telehealth as appropriate. If I [or my staff] test positive for the coronavirus, I will notify you so that you can take appropriate precautions. Your Confidentiality in the Case of Infection If you have tested positive for the coronavirus, I may be required to notify local health authorities that you have been in the office. If I must report this, I will only provide the minimum information necessary for their data collection and will not go into any details about the reason(s) for our visits. By signing this form, you are agreeing that I may do so without an additional signed release. Informed Consent This agreement supplements the general informed consent/business agreement that we agreed to at the start of our work together. Your signature below shows that you agree to these terms and conditions.

Patient’s Name (please print): __________________________________________ _____________________________________ _________________________ Patient/Client Date _____________________________________ _________________________ Psychologist Date

James Carpenter, Privacy Officer 208-955-7333 2463 E. Gala St, Ste #100 Meridian, ID 83642

YourInformation.YourRights.OurResponsibilities.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.

YourRightsYou have the right to:

• Get a copy of your paper or electronic medical record • Correct your paper or electronic medical record • Request confidential communication • Ask us to limit the information we share • Get a list of those with whom we’ve shared your information • Get a copy of this privacy notice • Choose someone to act for you • File a complaint if you believe your privacy rights have been violated

YourChoicesYou have some choices in the way that we use and share information as we:

• Tell family and friends about your condition • Provide disaster relief • Include you in a hospital directory • Provide mental health care • Market our services and sell your information • Raise funds

OurUsesandDisclosuresWe may use and share your information as we:

• Treat you • Run our organization • Bill for your services • Help with public health and safety issues • Do research • Comply with the law • Respond to organ and tissue donation requests • Work with a medical examiner or funeral director • Address workers’ compensation, law enforcement, and other government requests • Respond to lawsuits and legal actions

YourRightsWhen it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Get an electronic or paper copy of your medical record

• You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.

• We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

Ask us to correct your medical record

• You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.

• We may say “no” to your request, but we’ll tell you why in writing within 60 days.

Request confidential communications

• You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.

• We will say “yes” to all reasonable requests.

Ask us to limit what we use or share

• You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.

• If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.

Get a list of those with whom we’ve shared information

• You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.

• We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this privacy notice

You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

Choose someone to act for you

• If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.

• We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated

• You can complain if you feel we have violated your rights by contacting us using the information on page 1.

• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.

• We will not retaliate against you for filing a complaint.

YourChoicesFor certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:

• Share information with your family, close friends, or others involved in your care • Share information in a disaster relief situation • Include your information in a hospital directory

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases we never share your information unless you give us written permission:

• Marketing purposes • Sale of your information • Most sharing of psychotherapy notes

In the case of fundraising:

• We may contact you for fundraising efforts, but you can tell us not to contact you again.

OurUsesandDisclosures

Howdowetypicallyuseorshareyourhealthinformation?We typically use or share your health information in the following ways.

Treat you

We can use your health information and share it with other professionals who are treating you.

Example: A doctor treating you for an injury asks another doctor about your overall health condition.

Run our organization

We can use and share your health information to run our practice, improve your care, and contact you when necessary.

Example: We use health information about you to manage your treatment and services.

Bill for your services

We can use and share your health information to bill and get payment from health plans or other entities. Example: We give information about you to your health insurance plan so it will pay for your services.

Howelsecanweuseorshareyourhealthinformation?We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

Help with public health and safety issues

We can share health information about you for certain situations such as:

• Preventing disease • Helping with product recalls • Reporting adverse reactions to medications • Reporting suspected abuse, neglect, or domestic violence • Preventing or reducing a serious threat to anyone’s health or safety

Do research

We can use or share your information for health research.

Comply with the law

We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.

Respond to organ and tissue donation requests

We can share health information about you with organ procurement organizations.

Work with a medical examiner or funeral director

We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Address workers’ compensation, law enforcement, and other government requests

We can use or share health information about you:

• For workers’ compensation claims • For law enforcement purposes or with a law enforcement official • With health oversight agencies for activities authorized by law • For special government functions such as military, national security, and presidential

protective services

Respond to lawsuits and legal actions

We can share health information about you in response to a court or administrative order, or in response to a subpoena.

OurResponsibilities• We are required by law to maintain the privacy and security of your protected health

information. • We will let you know promptly if a breach occurs that may have compromised the privacy or

security of your information. • We must follow the duties and privacy practices described in this notice and give you a copy

of it. • We will not use or share your information other than as described here unless you tell us we can

in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

• For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

ChangestotheTermsofthisNoticeWe can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.

Effective Date: July 10, 2020

Your signature below indicates that you have read this information and agree to abide by its terms.

Client Signature Date

Parent/Guardian Signature Relationship Date

Therapist’s Signature Date

2463 E. Gala Street #100, Meridian ID 83642 *Phone 208-955-7333 *Fax 208-955-7330 *nnhidaho.com

TeleMental Health Informed Consent

I _______________________________ (parent/guardian of child, or self) hereby consent to engage in TeleMental Health as an adjunct to in person therapy for and on behalf of ______________________________ (self/minor client) for counseling, psychological or neuropsychological testing, speech therapy, occupational therapy and/or medication management. I understand that TeleMental Health includes the practice of health care delivery, including mental health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, and/or data communications. I understand that TeleMental Health also involves the communication of my medical/mental health information, both orally and visually, to other health care practitioners.

I understand that I have the following rights with respect to TeleMental Health:

(1) I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment nor risking the loss or withdrawal of any program benefits to which I would otherwise be entitled.

(2) The laws that protect the confidentiality of my medical information also apply to TeleMental Health. As such, I understand that the information disclosed by me during my therapy is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality including, but not limited to: reporting child, elder, and dependent adult abuse; expressed threats of violence towards an ascertainable victim; and where I make my mental or emotional state an issue in a legal proceeding. (See also Office Policies and HIPAA Notice of Privacy Practices forms, provided to me, for more details of confidentiality and other issues.)

I also understand that the dissemination of any personally identifiable images or information from the TeleMental Health interaction to researchers or other entities shall not occur.

(3) I understand that there are risks and consequences from TeleMental Health. These may include, but are not limited to, the possibility, despite reasonable efforts on the part of the clinician, that: the transmission of my medical information could be disrupted or distorted by technical failures; the transmission of my medical information could be interrupted by unauthorized persons; the electronic storage of my medical information could be accessed by


unauthorized persons and/or misunderstandings can more easily occur, especially when care is delivered in an asynchronous manner.

In addition, I understand that TeleMental Health based services and care may not yield the same results nor be as complete as face-to-face service. I also understand that if my clinician believes I would be better served by another form of service (e.g. face-to-face service), I will engage in face to face services only (TeleMental Health will not be an option for services with my current clinician if they are deemed in their professional judgment to be contraindicated) or be referred to a clinician in my area who can provide such service. Finally, I understand that there are potential risks and benefits associated with the service being provided, and that despite my efforts and the efforts of my clinician, my condition may not improve and in some cases may even get worse.

(4) I understand that I may benefit from TeleMental Health, but results cannot be guaranteed or assured. The benefits of TeleMental Health may include but are not limited to: finding a greater ability to express thoughts and emotions; transportation and travel difficulties are avoided; time constraints are minimized; and there may be a greater opportunity to prepare in advance for my sessions.

(5) As part of risks associated with TeleMental Health my clinician cannot assure personal safety and safety to others as much as when in their office at Northwest Neurobehavioral Health. Therefore, as part of safety planning, I will designate at a minimum one emergency contact who will be able to respond to me in a timely manner during TeleMental Health sessions and help in emergency situations (e.g. client is feeling suicidal, client is getting dysregulated and needs assistance calming down, client is a physical threat to themselves or others). I further understand that my clinician may call and talk with emergency contact(s) prior to them needing to utilize them in responding to emergencies as this is a preventative planning measure necessary for engaging in TeleMental Health services.

In addition to my clinician using emergency contacts they may use traditional emergency response measures in the community (calling 911 for medical/mental health emergencies). I understand that I’m giving consent to my clinician to contact the emergency contacts listed below as well as community emergency responders should they deem it necessary during TeleMental Health sessions for both emergency planning purposes as well as for emergency situations. I give consent for my clinician to communicate with emergency contacts through phone, email, mail and other communication methods. My clinician will make efforts to ensure HIPAA compliance in these communications with emergency contacts.


My primary emergency contact is: ______________________________ (name of primary emergency contact.)

Primary emergency contact phone number is: ________________________

Primary emergency contact’s email is: ___________________________________________

Primary emergency contact’s address is: ______________________________________________

My secondary emergency contact is: ______________________________ (name of primary emergency contact.)

Secondary emergency contact phone number is: ________________________

Secondary emergency contact’s email is: ___________________________________________

Secondary emergency contact’s address is: ______________________________________________

I have read and understand the information provided above, which has also been explained to me verbally. I have discussed it with my clinician and all my questions have been answered to my satisfaction.

Client’s Signature (self or minor client): _______________________________ Date: _________

Signature of minor client (If 14+ years of age - required):

________________________________________________________ Date: ________________

Clinician’s Signature: _______________________________________ Date:________________

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Financial Policy and Agreement

Thank you for choosing Northwest Neurobehavioral Health, LLC (NNH) as your provider. Involvement in evaluation and treatment is a partnership between you and our organization. Upon your agreement to pay for care we agree to provide you that care. The information below is intended to explain our billing and payment policies.

BILLING FOR OUR SERVICES

• NNH is not responsible for contacting your insurance carrier to inquire about referrals, benefits, and/or co-pays. It is your responsibility to check with your insurance whether our services are covered, need to be prior authorized, and any limits to benefits. Please bring your insurance card for us to make a copy and for claims submission.

• Payment of co-payments, deductibles, and non-covered services are required at the time service is rendered.

• Clients without insurance must meet with administration to determine financial arrangements before services will be rendered.

• Northwest Neurobehavioral Health, LLC does not deny access to services based on inability to pay. We offer sliding fee services for those who qualify.

• You will receive monthly billing statements indicating the status of your account and your current balance due.

• If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, we have the option of using legal means to secure payment. This may involve hiring a collection agency or going through small claims court. If such legal action is necessary, its costs will be included in the claim.

• Please call our billing company, Practice Management, Inc. at (208) 472-8112 with any questions regarding your bill.

INSURANCE

• Your insurance policy is a contract between you and your insurance company. • Regardless of your insurance coverage, clients are ultimately responsible for payment of their bills.

Co-payments and deductible amounts are set by your insurance company and are not subject to negotiation with Northwest Neurobehavioral Health, LLC.

• You are responsible for informing the clinic about changes to your insurance coverage. Insurance companies do not allow us to retroactively bill for services. You will be responsible for full payment of fees if we are not informed about changes in your insurance before services are rendered.

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• Although we will bill on your behalf and make all reasonable efforts to obtain payment from your insurance, if they reject the claim, or delay payment, we will look to you for payment in full.

• Submission of claims does not guarantee payment by the insurance company. • Health insurance does not relieve the client of the financial responsibility for services rendered. • NNH is a Medicaid and Medicare provider. All Medicaid patients must provide us a copy of the

Medicaid card, Healthy Connection Referral, if applicable, and a copy of the latest History and Physical from the primary care physician.

LATE CANCEL/NO-SHOW FEE

• We require at least 24 hour notice for a cancelation. If the appointment is cancelled with less than 24 hour notice, this will be considered a late cancellation. After receiving 2 late cancellations or no-show your child's therapy will be suspended.

SELF PAY AGREEMENT

• I understand fees will be established based on my family income and size. Documentation of income will be required to determine sliding fee eligibility.

• I agree to inform NNH of any change in income, employment, address, telephone number, or if I obtain insurance.

• I agree to pay determined fee at the time of service. • I understand I will need to resubmit documentation for eligibility of sliding fee services every 120

days.

INSURANCE AGREEMENT

• I understand if I have an insurance deductible to meet, I will pay the full fee at the time of service until my deductible is met. Thereafter, any insurance co-payments amount is due at the time of service.

• I understand I am responsible for providing all necessary requested insurance information to NNH and my insurance company. If I fail to supply this information or if I choose to not have these services submitted to my insurance company, I will be responsible for all applicable fees at the time of service.

• I assign and authorize direct payment of all benefits due for client services to Northwest Neurobehavioral Health, LLC. A copy of this assignment may be used in lieu of the original. NNH may release such information as may be necessary and pertinent to the insurance companies named in those documents to secure payment for services.

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FINANCIAL RESPONSIBILITY I accept financial responsibility for the charges incurred by myself and/or family members receiving services at Northwest Neurobehavioral Health, LLC. I agree to the financial terms as outlined above.

Please initial below: I understand that I am financially responsible for all evaluation and treatment costs incurred, even if my insurance does not authorize or pay for some or all of services rendered.

I understand that payment is required at the time of service and upon receipt of any bill I receive.

I understand if I do not make payment for services rendered the clinician I or my child sees will not receive any payment for services they have provided.

I understand if an appointment is cancelled with less than 24 hour notice this will be considered a late cancellation. After receiving 2 late cancellations or no-show my child's therapy will be suspended.

I understand I will be charged $35 for insufficient funds. I have requested and received a copy of this Financial Policy and Agreement.

Client’s Signature Date Printed Name of Client

Parent/Legal Guardian Signature Date

NNH Representative Date

Information for Clients/Consent to Treatment Welcome to our practice. We appreciate your giving us the opportunity to be of help to you. This form will help answers some questions clients often ask about any therapy practice. It is important to us that you know how we will work together. Please read this carefully and write down any questions you might have so that we can discuss them at our next meeting. Testing This assessment will involve evaluation of intellectual, academic, personality and/or emotional functioning. It will not involve any psychotherapy, medical procedures or medical treatment. Providing information about your background, family and/or child will be included in a clinical interview. Please speak with the testing therapist regarding specific instruments that will be used and tasks that will be required. The information generated from the clinical interview and the testing results will be used to formulate a written report. When the report has been completed, a feedback session will be scheduled in order to share the results with the guardian, and child, if appropriate. At the feedback session, information about test performance, areas of strengths and weaknesses, diagnoses, possible modes of treatment and recommendations may be provided. Our current fees range from $1450 to $2250 for a full battery; a full battery varies depending on the nature of the presenting problem and requested information. If you have questions, please speak with the testing therapist regarding your specific battery. Relatively brief testing evaluation will be billed per hour, with hourly rates ranging from $145 to $225. The fees include the time spent with the client, feedback session as well as time needed to score and write the evaluation. Our services may be partly reimbursable under your health plan. In most cases, we will bill directly for services rendered. The insurance company will send the payment directly to us, but you will be responsible for any co-insurance payment, deductible and any services deemed uncovered by the insurance company. Therefore, if for any reason, your insurance company fails to pay the full amount expected, the responsible party will be required to pay the balance. Payment is expected at the time of your first appointment. Please speak with an office staff member regarding the types of insurance we accept. We require at least 24 hours’ notice for a cancellation. If the appointment is cancelled with less than 24 hours, this will be considered a late cancellation. After receiving 2 late cancellations or no-show your child’s therapy will be suspended. Occupational Therapy Occupational Therapy Services are provided within the scope of practice of licensed occupational therapists. These services are necessary for the evaluation and treatment of impairments, functional disabilities, or changes in physical function and health status; and the goal to improve the individual’s ability to perform those tasks required for independent functioning. Occupational Therapy may involve removal of some clothing articles, palpation (manual examination) of body part(s) and close observation of body part(s). I consent to the use of photographs for postural comparison and educational purposes during evaluation and reevaluation. The treatment will be discussed prior to its application and that at any time you have the right to refuse treatment. No assurance or guarantee has been provided to me as to the results of the treatment. With any treatment there can be risks. At NNH our Occupational Therapist must be fully aware of your child’s existing medical conditions. You must have completed the medical history form and have disclosed all of the medical conditions affecting you.

Because the Occupational therapy treatment room is a shared space, I acknowledge that other patients and families may be present in the occupational therapy treatment room during my child’s treatment. We require at least 24 hours’ notice for a cancellation. If the appointment is cancelled with less than 24 hours, this will be considered a late cancellation. After receiving 2 late cancellations or no-show your child’s therapy will be suspended. Speech Therapy Speech Therapy Services are provided within the scope of practice of licensed speech-language pathologists. Speech-language pathology services are necessary for the evaluation and treatment of speech and language disorders which may result in communication disabilities; or necessary for the evaluation and treatment of swallowing disorders (dysphagia), regardless of the presence of communication disability. A plan of treatment, including goals of treatment, is developed by the patient and the speech therapist together after an initial evaluation of the problem is performed. This plan is sent to the referring physician for approval. The patient acknowledges that no guarantee has been given as to the outcome of this speech therapy plan of care. The patient agrees to notify NNH if he/she has previously seen another speech therapist for treatment of this condition or if he/she sees another such therapist during treatment with NNH. We require at least 24 hours’ notice for a cancellation. If the appointment is cancelled with less than 24 hours, this will be considered a late cancellation. After receiving 2 late cancellations or no-show your child’s therapy will be suspended. Physician Services NNH provides medication evaluation and management with our team of Psychiatrists, Physicians, and Board Certified Psychiatric Nurse Practitioners. Prescription refills may be requested with one-week notice. Refills can be requested by having the pharmacy fax your request to NNH. The fax number is (208) 955-7330; or schedule an appointment to see a physician to have the refill authorized. Physician’s fees are hourly ranging from $65 to $400. You will be expected to pay for each session at the time of service. We require at least 24 hours’ notice for a cancellation. If the appointment is cancelled with less than 24 hours, this will be considered a late cancellation. After receiving 2 late cancellations or no-show your child’s therapy will be suspended. Psychotherapy Because you will be putting a good deal of time, money, and energy into therapy, you should choose a therapist carefully. You have the right to ask us about other treatments for your condition and potential risks and benefits. If at any time, you wish another professional’s opinion and wish to consult with another therapist, we will assist you in finding someone qualified and provide him or her with the essential information needed. Psychotherapy is not like visiting a medical doctor in that it requires your very active involvement and efforts to change your thoughts, feelings, and behaviors. It will be important for you to offer your feelings about treatment and progress you are making. Offering your views and responses when they are important to you is one of the ways you are an active partner in this process. You will have work to do both in the therapy office and many other times not spent in the therapeutic situation. There may be “homework”: assignments and will certainly be time spent working on your personal relationships. Change will sometimes be easy and swift, but more often it will be slow, frustrating, and require a need for repetition. As with any powerful treatment, there are both benefits and risks associated with psychotherapy. Risks might include experiencing uncomfortable levels of feeling like sadness, guilt, anxiety, anger, frustration, loneliness, and helplessness. You may begin recalling unpleasant aspect of your history or experience difficulties with close relatives or friends. Some changes may lead to losses, such as deciding to end a relationship or change careers. Despite the above-mentioned risks, you should know that psychotherapy has been repeatedly scientifically

demonstrated to be of benefit for most people and most situations. Benefits might include the lifting of depression, diminished anxiety or anger, improvements in relationships and skills. We require at least 24 hours’ notice for a cancellation. If the appointment is cancelled with less than 24 hours, this will be considered a late cancellation. After receiving 2 late cancellations or no-show your child’s therapy will be suspended. Psychotherapy with a Minor You as the parent/guardian have a right to know about the treatment process. We agree that therapists may talk with parents/guardians to discuss how your child is doing with general information. The things talked about in meetings with the therapist are private. Therapist will not tell others about the specific things told to him or her. He or she will not repeat these things to parents/guardians, teachers, the police, probation officers, or clinic employees. But there are two exceptions. First, because of the law, the therapist will tell others what has been said if the minor talks about hurting them self or someone else. Therapist will have to tell someone who can help protect the minor or the person the minor talked about hurting. Second, if the minor is being seriously hurt by anyone, this therapist has to inform Child Protection Services and/or local police for the minor’s protection. Parents/guardians have the right to ask about other treatments for the child’s condition and potential risks and benefits. If at any time, you wish to receive another professional’s opinion or wish to consult with another therapist we will assist in finding someone qualified and provide him or her with the essential information needed. When difficult issues arise in therapy, children sometimes feel angry, sad or guilty. If any of these things become evident, please mention them to the therapist. Please encourage the child to directly discuss them with the therapist and ask any questions they may have about treatment. Psychotherapy can have benefits and risks. Therapy often involves discussing unpleasant aspects of your child’s life. Your child may experience uncomfortable feelings like sadness, guilt, anger, loneliness and helplessness. Psychotherapy has been shown to have benefits for those who commit to therapy. Our first sessions will involve an evaluation of your child’s needs and situation. After the evaluation the therapist will be able to offer you his/her clinical impression. You and your child will be involved in the treatment planning process. Therapy involves a large commitment of time, money and effort. If at any time you have doubts about the therapy provided we will assist you the referral sources.

I UNDERSTAND THAT MY THERAPIST, PHYSICIAN, OR NURSE PRACTITIONER WILL NOT BE INVOLVED IN COURT-ORIENTED ACTIVITIES, INCLUDING TESTIFYING IN CUSTODY MATTERS. IT IS THE POLICY OF NORTHWEST NEUROBEHAVIORAL HEALTH TO SUPPORT THE CLIENT THERAPEUTICALLY AND NOT TO ENTER INTO LEGAL PROCEEDINGS. NORTHWEST NEUROBEHAVIORAL HEALTH DOES NOT OFFER ANY CUSTODY EVALUATIONS OR HOME STUDY SERVICES. CLINICIANS, IN THEIR ROLE AS NORTHWEST NEUROBEHAVIORAL HEALTH THERAPISTS OR MEDICAL PROVIDERS, DO NOT GIVE LEGAL OPINIONS OR RECOMMENDATIONS REGARDING CUSTODY OR CUSTODIAL ISSUES. IN THE UNLIKELY EVENT THAT A THERAPIST, PHYSICIAN OR NURSE PRACTITIONER IS SUBPOENAED AS A WITNESS BY A JUDGE, FEES FOR THE REQUESTING PARTY WILL BE BILLED AT $200 PER HOUR FOR A THERAPIST AND $400 PER HOUR FOR A PHYSICIAN OR NURSE PRACTITIONER, WITH A MINIMUM FOUR-HOUR CHARGE. SUCH FEES ARE NOT BILLABLE TO INSURANCE AND ARE DUE A MINIMUM OF ONE WEEK BEFORE THE SCHEDULED COURT APPEARANCE. FEES ARE NOT REFUNDABLE, DESPITE ANY CANCELLATION MADE WITHIN 24 HOURS.

_______ INITIAL

Appointments Psychotherapy appointments are usually scheduled as one 50-minute session one time per week. Once an appointment is scheduled for you or your child you will be expected to pay for that session at the time of the scheduled session. Our hourly fees for psychotherapy range from $90 to $200. You will be expected to pay for each session at the time of service. We require at least 24 hours’ notice for a cancellation. If the appointment is cancelled with less than 24 hours, this will be considered a late cancellation. After receiving 2 late cancellations or no-show your child’s therapy will be suspended. Professional Fees/Billing Payments Insurance carriers will be billed as a courtesy to you. If your policy requires a referral form and/or co-pay you will be solely responsible to have these items the day of your appointment. Additionally, if you have not met the yearly deductible for your insurance you will be required to pay toward that deductible at the time of each appointment until the deductible amount is met. NNH is not responsible for calling your insurance carrier to inquire about referrals, benefits, and/or co-pays. Please bring your insurance card for us to make a copy. This will assist us in submitting your claims. If your insurance company has not paid NNH in a timely manner, you will be responsible for payment of all charges incurred. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, we have the option of using legal means to secure payment. This may involve hiring a collection agency or going through small claims court. If such legal action is necessary, its costs will be included in the claim. NNH is a Medicaid and Medicare provider. All Medicaid patients must provide us a copy of the Medicaid card, Healthy Connection Referral, and a copy of the latest History and Physical. Northwest Neurobehavioral Health, LLC does not deny access to services based on inability to pay. We offer sliding fee services for those who qualify. Professional Records The laws and standards of the mental health profession require the NNH keep treatment records. Clients are entitled to receive a copy of these records or NNH can provide a summary (verbally or written). Clients may be charged a small fee for this service. Confidentiality In general, the law protects the privacy of all communication between a client and a clinician, and NNH can release information about our work to others only with your written consent. There are a few exceptions:

-If a clinician at NNH believes that a client is threatening serious bodily harm to another. -If there is reason to believe client may hurt him/herself or someone else. -If there is reason to believe the client may be abused or neglected. -If there are legal proceedings to settle this account. -If the records are subpoenaed by the court.

The above described are the situations in which NNH records would be released. We will not release any information about you or your treatment, diagnosis, or client identification, without the full knowledge and signed release of information form. Please review and sign the Notice of Privacy Practices for additional information regarding information related to the protection of you or your child’s medical information.

Safety Northwest Neurobehavioral Health, LLC strictly prohibits the presence of the following items on premise: -Firearms -Alcohol and/or illicit drugs If someone has these items they will be asked to leave and Emergency Personnel may be contacted. Please keep your children, including non-clients, within your eyesight at all times. Do not allow your child to leave the premises without you. In the event of a fire or other emergency please proceed to the nearest exit and gather at the location indicated on the Fire map. Please listen to staff for additional direction. If your child is being seen at the time of the emergency their clinician will meet you, with your child, at the location indicated above. Health In an effort to minimize the risk of the spread of infectious diseases between clients and NNH staff we require cancellation of appointments in the case of infectious illness. Staff members will notify supervisor and Director of Operations of exposure to, or known infection with, general communicable diseases (which include, but are not limited to, influenza, meningitis, mumps, whooping cough, measles, diphtheria, lice, chicken pox, and tuberculosis), and to see a medical provider to develop a plan which minimizes the risk to others becoming infected.

Employees and/or clients shall be temporarily restricted from the clinic if infected with communicable respiratory illness or contagious illness. They will be allowed back in the clinic after they have been cleared by a physician or have gone 24 hours without symptoms of any kind (fever, vomiting, rash, etc.). When necessary, the Director of Operations will communicate with the public health officials regarding infectious disease exposure. The Idaho Reportable Disease List will be utilized for further information. You and/or your child are welcome to return to the clinic when you have been asymptomatic for a 24 hour period.

Consent Your signature below signifies that you have been informed and understand the services to be received; expected benefits and potential risks of receiving those services; your right to refuse services; and that you will be provided with alternative forms of services available through referral resources, if requested. Furthermore, your signature indicates that you agree to abide by the terms of this document. ____________________________________________ ____________________________________ Client’s Signature Date ____________________________________ _____________________________ ______________ Parent/Guardian Signature Relationship Date

____________________________________________ ____________________________________ Clinician’s Signature Date

*2463 E Gala Street #100, Meridian ID 83642 *Phone: (208) 955-7333 *Fax: (208) 955-7330

Authorization for Use and Disclosure of Protected Health Information

Please note that this form must be filled out completely to be valid.

Patient: ______________________________________________ Date of birth:________________________________

Parent/Guardian:_______________________________________ Phone number:______________________________

I, and/or my parent/guardian, authorize:

Name/Title/Organization: Northwest Neurobehavioral Health

Address: 2463 E Gala St #100____________________________ Phone:_208-955-7333________________

Meridian, ID 83642______________________ _______ Fax: __208-955-7330________________

To release records to: To obtain records from: (check one or both)

Name/Title/Organization: ________________________________________________________________

Address: _____________________________________________ Phone: ___________________________

______________________________________________ Fax: _____________________________

Information to be released: (check all that apply)

____ Initial Evaluation/CDA

____ Treatment Plan(s)

____ Discharge Summary

____ Medical History & Physical

____ Medication list/Progress notes

____ Evaluation (please list type below)

__________________________________

__________________________________

____ Clinical Studies including: Labs, EKG’s, CT Scan, or MRI results.

____ IEP/504 Plan

____ Presence/Participation in Treatment

____ Other (please specify in below)

___________________________________

___________________________________

___________________________________

Purpose: The purpose of this disclosure of information is to improve assessment and treatment planning, share information relevant to treatment and when appropriate, coordinate treatment services.

Conditions: I understand that Northwest Neurobehavioral Health, LLC will not condition my treatment on whether I give authorization for the requested disclosure. However, it has been explained to me that failure to sign this authorization may have consequences including, but not limited to, impacting the outcome of coordinated care.

Please note: Medical records may contain sensitive information including, but not limited to: Alcohol, Drugs, Mental Health, HIV/AIDS, and Sexually Transmitted Diseases.

Revocation: I understand that I have a right to revoke this authorization, in writing, at any time by sending written notification to Northwest Neurobehavioral Health, LLC. I further understand that a revocation of the authorization is not effective to the extent that action has already been taken in reliance on the authorization.

Form of Disclosure: Unless you have specifically requested in writing that the disclosure be made in a certain format, we reserve the right to disclose information as permitted by this authorization in any manner that we deem to be appropriate and consistent with applicable law, including, but not limited to, verbally, in paper format, or directly.

Redisclosure: I understand that there is the potential that the protected health information that is disclosed pursuant to this authorization may be redisclosed by the recipient and the protected health information will no longer be protected by the HIPPA privacy regulations, unless a State law applies that is more strict than HIPPA and provides additional privacy solutions.

Expiration: Unless sooner revoked, this authorization expires one year from the date signed below, or as otherwise indicated: _________________________________ (cannot exceed one year).

Signature of Patient (If 14+ years of age) Date

Signature of Parent or Guardian Date

www.nnhidaho.com 2463 East Gala St Suite 100, Meridian, ID 83642

Phone: (208) 955-7333 Fax: (208) 955-7330

The information disclosed to you may be from records protected by Federal confidentiality rules (42 CFR Part 2). The Federal rules and state law prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by

the written consent of the person to whom it pertains or as otherwise permitted by 42 CRF Part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of this information to

criminally investigate or prosecute any alcohol or drug abuse individual. Authorization for Release PHI – HMO 1026041.doc

Authorization for Use and Disclosure of Protected Health Information:

Parent/Guardian Please note that this form must be filled out completely to be valid.

Patient: ______________________________________________ Date of birth:________________________________




Address: 2463 E Gala St #100_________________________ Phone:_208-955-7333____________________

Meridian, ID 83742__________________ _______ Fax:_208-955-7330______________________


Parent/Guardian Name(s): __________________________________________________________________

Address: _____________________________________________ Phone: ___________________________

______________________________________________ Fax: _____________________________


____ Speech Evaluation

____ OT Evaluation

____ Physician Note


____ Psychological Evaluation

____ Neuropsychological Evaluation

____ ASD Clinic Evaluation

____ Participation/Presence in Treatment

____ Intake Evaluation/CDA

____ Other (please specify in space below)

___________________________________

___________________________________







Expiration: Unless sooner revoked, this authorization expires one year from the signed date, or as otherwise indicated: _________________________________ (cannot exceed one year).




Phone: (208) 955-7333 Fax: (208) 955-7330

The information disclosed to you may be from records protected by Federal confidentiality rules (42 CFR Part 2). The Federal rules and state law prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CRF Part 2.

A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of this information to criminally investigate or prosecute any alcohol or drug abuse individual.

Authorization for Release PHI – HMO 1026041.doc

Authorization for Use and Disclosure of Protected Health Information: Primary Care Physician

Please note that this form must be filled out completely to be valid. Patient: ______________________________________________ Date of birth:________________________________




Address: 2463 E Gala St #100____________________________ Phone:_208-955-7333________________

Meridian, ID 83642______________________ _______ Fax:_208-955-7330__________________


Primary Care Physician/Organization: _________________________________________________________

Address: _____________________________________________ Phone: ___________________________

______________________________________________ Fax: _____________________________


____ Speech Evaluation

____ OT Evaluation

____ Intake Evaluation/CDA

____ Psychological Evaluation

____ Neuropsychological Evaluation

____ ASD Clinic Evaluation

____ Participation/Presence in Treatment


____ Physician Note

____ Other (please specify in space below)

___________________________________

___________________________________







Expiration: Unless sooner revoked, this authorization expires one year from the date signed below, or as otherwise indicated: _________________________________ (cannot exceed one year).




Phone: (208) 955-7333 Fax: (208) 955-7330

The information disclosed to you may be from records protected by Federal confidentiality rules (42 CFR Part 2). The Federal rules and state law prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CRF Part 2.

A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of this information to criminally investigate or prosecute any alcohol or drug abuse individual.

Authorization for Release PHI – HMO 1026041.doc

informed consent for in-person services during covid … · • you will try not to touch your face...

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