Consent For Services
© 2017 by Anderson Counseling and Consulting Group . Proudly created with Wix.com
We/I give consent for Anderson Counseling and Consulting Group, PLLC (ACCG) to provide services to myself/ my child/ my ward.
We/I will participate in Outpatient Therapy Services and follow all treatment recommendations which address identified goals on my person-centered plan that I will work towards in time frames and methods to achieve the goals.
ACCG services have been described and we/I understand that my ACCG workers will visit in my home, work, school or community to provide services that will help me reach my goals, if necessary and agreed upon by all parties involved.
We/I have been explained about the benefits, risks and alternatives to planned services and the ways that ACCG can support the achievements of the desired outcomes.
Any fees or costs have been explained to us/me.
As a consumer of this program, you have certain rights, which are set out in the Rules and Regulations to assure the rights of consumers in North Carolina. A summary of your rights is set out below.
RIGHT TO NOTIFICATION
You must be informed of your rights every year (12 months) while in the program, and you have the right to see and get a copy of the NC Regulations and the Policy upon request. Also, you must be told what the program’s rules of conduct are, and you have a right to have a copy.
RIGHT TO DIGNITY
You have the right to be treated with respect and dignity at all times. You have the right to be called by your preferred or legal name, to be protected from abuse, and to request help in applying for services or benefits for which you are eligible.
RIGHT TO SERVICE
You have the right to receive services within ANDERSON COUNSELING AND CONSULTING GROUP, PLLC mission, capacity and applicable laws and regulations. ANDERSON COUNSELING AND CONSULTING GROUP, PLLC cannot deny services to you solely on the basis of your race, national origin, sex, age, religion, sexual preference, human immunodeficiency virus status, handicap, or ability to pay. If you think ANDERSON COUNSELING AND CONSULTING GROUP, PLLC has discriminated against you, you can contact any program employee, the owner of ANDERSON COUNSELING AND CONSULTING GROUP, PLLC, or the County’s Consumer Representative.
RIGHT TO QUALITY SERVICE
You have the right to receive services in a manner that is non-coercive, protects your right to self-determination, and allows you to participate in decisions regarding the services provided, unless those rights have been limited by law or court order. You have the right to receive services that are in accordance with all statutory and regulatory requirements. You have the right to participate in the formulation of your individualized treatment or service plan and in the periodic review of this plan.
HOURS IN WHICH THE SERVICES ARE AVAILABLE
Normal hours of operation for ANDERSON COUNSELING AND CONSULTING GROUP, PLLC in Mecklenburg County are 8:00am AM to 8:00 PM, Monday through Friday. Weekend hours are available by appointment. Crisis services are available. You will be given the emergency after-hours crisis clinician phone number.
RIGHT TO CONFIDENTIALITY
You have the right for your confidentiality to be upheld within the limits of the law and to provide informed consent when information is released to another organization or individual outside of ANDERSON COUNSELING AND CONSULTING GROUP, PLLC. Your records will be released only with your consent or the consent of your authorized representative except by court order, in emergencies or as otherwise required or permitted by law. You have the right to inspect and to have copies of your records at your own expense, except where it would be harmful to you. In that situation, a lawyer, doctor or psychologist you choose can see the records on your behalf. If you feel there are mistakes in your record, you can ask to have them corrected, and if the company doesn’t change what you think is an error, you can place your statement about the error in your record.
RIGHT TO REFUSE SERVICES
No consumer shall be subject to treatment without consent of the consumer or parent or legal guardian. You have the right to refuse services, unless those rights have been limited by law or court order, and to be informed of the consequences of such refusal. Consent may be withdrawn at any time by the person who gave consent. If treatment is refused, the qualified professional shall determine whether treatment in some other modality is possible. If all appropriate treatment modalities are refused, the voluntarily admitted consumer may be discharged.
It is your responsibility to actively participate in the services. This includes but is not limited to being honest with the ANDERSON COUNSELING AND CONSULTING GROUP, PLLC staff, following through on recommendations, and keeping scheduled appointments. ANDERSON COUNSELING AND CONSULTING GROUP, PLLC reserves the right to discontinue services if it is determined that you do not participate in services to the best of your ability, consistently miss appointments, or if in the professional opinion of ANDERSON COUNSELING AND CONSULTING GROUP, PLLC this agency is unable to provide the help you need.
RIGHT TO CONSENT
A treatment or service which presents a “significant risk” – that is, one that might cause some injury or have a serious side effect - may not be administered unless you or your authorized representative first give informed consent to it.
RIGHT TO LEAST RESTRICTIVE ALTERNATIVE
Your personal and physical freedom can be limited when necessary for your safety or the safety of other consumers, or for treatment. You will be involved in decisions, which may limit your freedom, and you will be told what needs to happen for the limits to be removed. Corporal punishment may not be inflicted on any consumer.
RIGHT TO HEARINGS AND APPEALS
If you are dissatisfied with the services being provided by ANDERSON COUNSELING AND CONSULTING GROUP, PLLC or you believe you received unfair treatment, you can file a complaint with a ANDERSON COUNSELING AND CONSULTING GROUP, PLLC staff person, or file a grievance with the LME Consumer Representative’s office. If you believe any of your rights under the Federal and/or North Carolina laws and statutes have been violated you may file a complaint or grievance and you may appeal the decision. In answering your complaints, ANDERSON COUNSELING AND CONSULTING GROUP, PLLC staff must inform you of your appeal rights, which include the right to appeal a decision to the LME Consumer Representative.
RIGHT TO ASSISTANCE BY LME CONSUMER REPRESENTATIVE
The state has appointed a Consumer Representative to help consumers and to make programs recognize consumer rights. The Representative will help you in making, resolving or appealing complaints about rights violations. You can contact the Consumer Representative yourself and ask for help or at ANDERSON COUNSELING AND CONSULTING GROUP, PLLC staff will help you to make the contact.
RIGHT TO SUPPORT AND ADVICE
The North Carolina’s regional advocate is "The Disability Rights of North Carolina.” The Disability Rights of North Carolina is a statewide agency established to protect and advocate for the rights of persons with disabilities. You can call them at 919-856-2195.
LIABILITY AND IMMUNITY
ANDERSON COUNSELING AND CONSULTING GROUP, PLLC personnel who violate or abuse any right or privilege of a consumer are liable for damages as determined by law. All persons acting in good faith, reasonably, and without negligence in connection with the treatment of a persons shall be free from all liability, civil or criminal, by reason of such acts.
Right To Confidentiality
You have the right for your confidentiality to be upheld within the limits of the law and to provide informed consent when information is released to another organization or individual outside ACCG.
Your records will be released only with your consent or the consent of your authorized representative except by court order, in emergencies or as otherwise required or permitted by law.
You have the right to inspect and to have copies of your records at your own expense, except where it would be harmful to you. In that situation, a lawyer, doctor or psychologist you choose can see the records on your behalf. If you feel there are mistakes in your record, you can ask to have them corrected, and if the company doesn’t change what you think is an error, you can place your statement about the error in your record.
Confidential information may not be disclosed without written consent when Federal Statutes prohibit that release. 42 CFR Part 2 Subpart D Disclosures Without Patient Consent General Statute 122C-52(d) No provision of G.S. 122C-205 and G.S. 122C-53 through G.S. 122C-56 permitting disclosure of confidential information may apply to the records of a client when federal statutes or regulations applicable to that client prohibit the disclosure of this information.
Notice Of Privacy Practices Of ACCG, PLLC
Anderson Counseling and Consulting Group, PLLC must collect timely and accurate health information about you and make that information available to members of your health care team in this agency, so that they can accurately diagnose your condition and provide the care you need. There may also be times when your health information will be sent to service providers outside this agency for services that this agency cannot provide. It is the legal duty of Anderson Counseling and Consulting Group, PLLC to protect your health information from unauthorized use or disclosure while providing health care, obtaining payment for that health care, and for other services relating to your health care.
The purpose of this Notice of Privacy Practices is to inform you about how your health information may be used within Anderson Counseling and Consulting Group, PLLC, as well as reasons why your health information could be sent to other service providers outside of this agency.
This Notice describes your rights in regard to the protection of your health information and how you may exercise those rights. This Notice also gives you the names of contacts should you have questions or comments about the policies and procedures Anderson Counseling and Consulting Group, PLLC uses to protect the privacy of your health information.
Please review this document carefully and ask for clarification if you do not understand any portion of it.
I have read and understand the Anderson Counseling and Consulting Group, PLLC’s Notice of Privacy Practices, which describes this agency’s methods for protecting the privacy of my health information that is used in providing health care services to me.
After Hours Crisis Response Services
After business hours, during weekends and on holidays, Anderson Counseling and Consulting Group, PLLC provide telephone crisis response, assessment, safety planning, and referrals for their clients. This service is accessed by phoning the Anderson Counseling and Consulting Group, PLLC after hours on call Crisis Clinician at (980) 236-0596. All Anderson Counseling and Consulting Group, PLLC clients may utilize this service to obtain immediate, telephone-based consultation and support regarding a variety of crisis issues.
Policy: Anderson Counseling and Consulting Group, PLLC shall maintain an after-business hours, during weekends and on holidays crisis response for all clients. One Anderson Counseling and Consulting Group, PLLC staff will be on-call at a time rotating weekly. Crisis response shall be designed for prevention, intervention and resolution at the least restrictive level possible to ensure the consumer’s safety.
If you have any questions about the After-Hours Crisis Response Services, please speak with any of the administrative staff or your therapist.
I have read and understand the After-Hours Crisis Response Services Policy.
Court Appearances, Subpoenas And Expert Witness Testimony
-Preparation: $100.00 per hour; billed in 15-minute increments
-Travel: $500/day flat rate for out-of-town travel not including lodging expenses
-Time in court: $200.00/hour
-Supervised Therapeutic Visitation: $200.00/hour (includes court summary)
I have read the above, understand and agree with the provisions and associated fees of this policy.
Fees And Insurance
Anderson Counseling and Consulting Group, PLLC (ACCG, PLLC) appreciates you considering us as your mental/behavioral health provider. As a part of the delivery of mental health services, we have prepared important information about fees, insurance, client responsibilities and related polices. PLEASE READ THIS CAREFULLY and if you have any questions, please discuss them with us.
As a courtesy, we file your insurance for you, but must have your full insurance information, including secondary insurances in order to do so. Payment for co-payments, co-insurance and deductibles are expected when services are rendered. If insurance payment is not received within ninety (90) days after a claim is filed, the client is then responsible for payment of the total amount due regardless of any outstanding secondary insurance payments. It is your responsibility to follow-up with your insurance company for delayed payments or other concerns.
While we try to avoid situations in which insurance coverage is expected but later denied, we cannot guarantee the service provided will be reimbursed. It is up to you to know your and/or your child’s insurance coverage, including knowledge of payment amounts and yearly deductibles.
The client (or referring parent in the case of minors) is considered responsible for payment of professional fees. It is the client’s responsibility to know if services are covered and the amount of their deductible and/or co-payment. When we are asked to bill a third-party such as an insurance company, and that third-party fails to make timely payments, payment is expected from the client or referring parent that signed the consent for services. The client will be responsible for fees for claims that are denied (e.g., due to exceeding the number of available sessions, if new coverage has not begun or if insurance has changed, filing past the insurance carrier’s time limit, etc.)
While payment at the time of service is expected, we bill monthly for outstanding balances and to keep you up to date regarding the status of your account.
We reconcile accounts on a monthly basis to ensure that claims pay according to the insurance plan verified at the beginning of services. Please keep in mind that the verification of insurance is the interpretation of the benefits representative. If it is found that you have a credit due to you after reconciliation, the credit will be applied to your account for copays, coinsurance and fees during active status. If you discontinue services or you are discharged any refunds due to you will be mailed at the end of the year.
PAST DUE ACCOUNTS
We send out several letters to clients with past due accounts in an effort to provide an opportunity to pay in full or make payment arrangements. If a client has not made good faith efforts to pay their bill, the overdue account may be assigned to a collections agency and all collection costs associated with the debt will be the client’s responsibility. We also reserve the right to assign the account to small claims court, depending on the total balance due.
I have read, understand and agree with the provisions of this policy.
Cancellation, No Show And Late Arrival Policy
Anderson Counseling and Consulting Group, PLLC would like to make sure that you access high-quality treatment services when you need it. To ensure we provide everyone with quality services, please be aware of the following appointment policy:
Scheduled Appointments: If you cannot make your scheduled appointment, you must call us at least 24 hours in advance to let us know. This allows us enough time to offer your appointment to another client. Failure to provide at least 24 hours’ notice counts as a missed appointment. If 24 hour notice is not received, the full session rate will be charged to your account (excludes Medicaid and Health Choice Insurances). This fee is not covered by insurance and is therefore the sole responsibility of the Client.
Missed Appointments: Missed appointments will be documented in your record with us. If you miss more than four scheduled appointments you will be informed that Anderson Counseling and Consulting Group, PLLC will be unable to provide additional services and you will be discharged from the practice.
Late Arrivals: If you arrive more than 15 minutes late for your scheduled appointment you will be given one of the following options:
· You may reschedule the appointment or
· Wait for an available same-day opening in the schedule
Appointment Reminders: Please note that appointment reminders are provided as a courtesy of ACCG. In the event that you do not receive a reminder, making your scheduled appointments remains your responsibility. We encourage you not to rely on ACCG reminders as your only means of remembering your appointments.