Consent for use and disclosure of health information
Purpose of Consent: by signing this form, you will be giving your consent to my use and disclosure of your protected healthcare information. This information will be utilized solely for the rendering of mental health treatment and associated payment activities.
Notice of Privacy Practices: you have the right to read my Notice of Privacy Practices before deciding whether to sign this Consent. My notice provides a description of the uses and disclosures I may make of your protected health information and other other important matters about your protected health information. The copy of my Notice of Privacy Practices as displayed in the office for your convenience. I encourage you to read it carefully before signing this Consent.
As circumstances may dictate, and within the limits of the law, I reserve the right to change my privacy practices. If changes are implemented, they will be posted for your review. That changes may apply to your healthcare information which was previously obtained.
You may obtain a copy of my Notice of Privacy Practices, including any revisions of my notice, at anytime by contacting me.
Right to Revoke: Client or guardian have the right to revoke this Consent at any time by giving a written notice of revocation submitted to the above address or fax number. You understand that the revocation of this Consent will not affect any action I took an reliance of this Consent before I received your revocation.
Client or guardian have had full opportunity to read and consider the contents of this Consent form and this offices Notice of Privacy Practices. I understand that, by signing this consent form, I am giving my Consent to the use and disclosure of my protected health information to carry out treatment, payment activities and healthcare operations.
I, (client or guardian) acknowledge that on today’s date have, on behalf of myself and/or any minor or incapacitated dependents, read and understand this office’s Notice of Privacy Practices.
You are entitled to a copy of this consent after signature/submission.
Notice of Privacy Practices
Confidentiality
The law requires a report to the proper authorities any person who is a danger to self or others for gravely disabled. I must also report all instances of suspected physical and sexual abuse and neglect of children, the elderly, and the disabled. My records can be subpoenaed by a court of law and criminal liability cases in those involving child custody disputes. All other disclosures require a signed Release of Information (ROI).
Payment Policy
Payment/copayment for each session is due at the time of the session. My fee is $200.00 per session. You are responsible for any balance not covered by your insurance provider. It is responsibility of the insured to know if mental health services are covered into his covered to provide services. I am a Licensed Independent Clinical Social Worker in Washington; and a licensed Clinical Social Worker in Alaska, and I am covered by most insurances. Any unpaid balances will be turned over for collections after 90 days unless other arrangements are made. Any and all fees associated with collecting unpaid balances will be added to total amount owed.
Cancellation Policy
Sessions are made by appointment only and your appointment time is reserved only for you. I ask for a 24-hour notice of cancellation. If the appointment is not canceled, I will charge you $100.00 late fee for the missed appointment. I will excuse late cancellations for sudden illnesses, work issues, and child-care issues if the appointment is cancelled before the scheduled appointment time. Your insurance does not cover for missed appointments.
After Hours
Messages can be left 24 hours a day to my voicemail (360-254-3642). I check messages throughout the day and will return phone calls. I'm not able to provide 24 hours a day emergency care. If you have an after hours emergency, you can call 911 or go to your nearest emergency room. If your need is greater than what I can provide for, we will need to discuss alternative plans.
By submitting the below form, I acknowledge that I have read and understand the above written policies.
Electronics Communication Consent
Email, SMS, and video communication provides an efficient and effective way to communicate regarding issues that are non-emergent, non-urgent, and non-critical. Electronic communication can be used to request non- emergent appointment, cancel a future appointment, share new information, or request information.
The following summarizes the information that you need to know in order to determine whether you wish to supplement your experience at my practice to electronic communications.
General Considerations
Electronic communication communication will be considered and treated with the same degree of privacy and confidentiality as written medical records. Standard electronic communication servers, such as Yahoo, Gmail, or Hotmail, are not secure which means that, although the accounts are password-protected, the electronic communication messages are not encrypted. These messages can potentially be intercepted and read by unauthorized individuals. Your electronic communication will only be used as a means of communication between you and me, never for marketing or any other purpose.
Healthcare Office Responsibilities
Every attempt will be made to respond to your electronic communication message within two business days. If you do not receive a response from me within two business days, please contact me by phone. Copies of the electronic communications that you sent to me, and that I sent to you, maybe incorporated into your records with my office. You are advised to retain copies for your files well.
Client Responsibilities
Electronic communication messages should not be used for emergencies or time sensitive situations. In the event of a medical emergency, you should immediately call 911. For other emergent or time sensitive situations you should contact me by phone. Please arrange for an office appointment if issues too complex or sensitive to discuss via electronic communication. If I do not receive a response from you after two business days, I will follow-up with a phone call unless otherwise directed.
Client or guardian have read and understood the above description of the risks and responsibilities involved with electronic communications. I acknowledge that commonly used electronic communication services are not secure and fall outside of the security requirements set forth by the Health Insurance Portability and Accountability act for the transmission of protected health information.
Consideration of my desire to use electronic communication, I hereby consent to electronics communication over non-secure electronic communication services. I have read and knowledge to the “Client’s” responsibilities.
Client or guardian understand that I may revoke my consent to communicate electronically at any time by notifying Barton S. Sloan, LISW in writing. If I revoke consent, the revocation will have no effect on any actions Barton S. Sloan, LISW has already taken in reliance on my consent.
Client or guardian agree and release Barton S. Sloan, LISW and the practice from any and all liability that may occur due to the electronic communication over a non-secure network.