ࡱ> bdaq` |HbjbjqPqP  e::t@T$D[(44444)))'''''''$)hy+v($^)$$(44(R'R'R'$44'R'$'R'R'^6R'4 B{l%TR''T+(0[(R'+&v+R'+R'4):R'!")))((6')))[($$$$  SEQ CHAPTER \h \r 1 Trauma Awareness & Treatment Center 32 West Winchester Street (6400 South) Suite 101 Salt Lake City, UT 84107 Client Information Therapist you are seeing: _______________ First name______________________ Middle Int.___ First Visit Date___________________________ Last name__________________________________ Social Security #_______-____-________ Address____________________________________ ____Male _____Female ____________________________________ Referred by ______________________________ City, State, Zip______________________________ Marital Status____________________________ Home Phone (____)____-_______ Employer________________________________ Birth Date____________________ Work Phone (____)-_____-______ Ext.________ - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Guardian/Responsible Party (If more than one use back) Nearest relative not living w/ you (Excluding Spouse) Name _____________________________________ First name____________________Middle Int___ Address____________________________________ Last Name_______________________________ City __________________________State ________ Address__________________________________ Ph (____)-_____-______ City __________State _____Ph(___)_____-_____ Relation to Client- Spouse__Parent__Other___ - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Primary Insurance Submit ? Yes No Insureds Name_______________________________ Card may be copied, please FILL OUT RIGHT SIDE Address (if different)___________________________ Insurance company_____________________________ City, State, Zip________________________________ Address______________________________________ Phone (____)_____-________SS#________________ City, State, Zip_______________________________ Employer_______________________Ph___________ Phone (____)____-______ Birth date__________________ Sex________ Policy Id___________________ Group____________ Relation to Client-Self__ Spouse__Parent__Other___ - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Secondary Insurance Submit ? Yes No  Insureds Name_______________________________ Card may be copied, please FILL OUT RIGHT SIDE Address (if different)___________________________ Insurance company_____________________________ City, State, Zip________________________________ Address______________________________________ Phone (____)_____-________SS#________________ City, State, Zip_______________________________ Employer_______________________Ph____________ Phone (____)____-______ Relation to Insured-Self__ Spouse__Child__Other___ Policy Id___________________ Group____________ Birth date__________________ Sex________ STATE Contract Clients only - Personal Physician __________________________________ Phone ( )____-________ In the event of an emergency you have my permission to provide first-aid from TATC staff and contact the following person. Name:_______________________________ Phone:( )____-_______ I give my consent for treatment at the Trauma Awareness and Treatment Center Responsible party - Signature _____________________________________________Date ____________________  SEQ CHAPTER \h \r 1CLIENT RIGHTS AND RESPONSIBILITIES RIGHTS A. The majority of the counselors at the Trauma Awareness and Treatment Center are licensed professionals in the field of clinical psychology, social work, and professional counseling. In addition masters level, students and graduated students working on their licences (under the proper licenced supervision), also provide services. B. Our counselors and therapists seek to provide the most effective interventions to help you with your particular challenges. They are well schooled in a variety of techniques for different problems. Your therapist will discuss the best approach for your treatment as you set up a treatment plan together. C. Client will have explained the potential risks of treatment, and how he/she can assess how the therapeutic process is progressing each step of therapy along the way. If it is desired treatment can change direction or course. There are no guarantees that therapeutic interventions use will bring about desired results due to the complicated nature of psychological problems. Nevertheless, the treatment of choice is used based on the presenting problem and supporting data from the professional literature. D. Information discussed in the therapy setting is held confidential and will not be shared without written permission except under the following legal and ethical circumstances: 1. The client threatens suicide, or threatens harm to another person(s). 2. The client is a minor (under eighteen) and reports suspected child abuse, including but not limited to physical beatings and sexual abuse. 3. The client reports abuse of the elderly. 4. The client reports sexual exploitation by a therapist. 5. Periodic collateral (with like-professionals, also held to confidentiality). 6. When it is suspected that you have communicable disease which is reportable under State Law 7. When you have a mental health condition as an element of legal claim or defense. 8. When relevant in proceedings for hospitalization for mental illness. 9. When you are seen for court ordered evaluation. 10. When a court orders copies of records or disclosure of privileged information. E. Client files and financial records will be kept for the legally prescribed period of time. Copies may be obtained by giving our staff notice of one week and by paying copy, handling and postage fees ( if applicable). F. Grievance Procedures: You have the right to present the TATC with grievances about denial of services, exclusion from a program or inadequacies or inequities in the programs and services provided and covered by our DHS contract. If TATC denies a grievance request or does not respond in a timely fashion, you may contact Lisa Peterson at 801-264-7564 or Scott Vincent at 264-7536, Contract Specialists, C/O DHS, 645 East 4500 South, Salt Lake City, UT 84107, to pursue further action. If not satisfied with DHS response, you may file a written appeal to the Director of DHS/DCFS which should be responded to in 30 days. If not satisfied with the directors response, you may file a request within 10 working days of directors response for a hearing with the DHS Office of Administrative Hearings who will review your request and applicable law. G. We will not discriminate regardless of fee charged for services, age, sex, ethnic origin, or mental or physical handicap, if required treatment is within the range of our expertise. We will treat each client with dignity. H. It is the prerogative of TATC to determine if it will become involved in any legal matter that may arise in connection with therapy. It may be in the best interest of the client and TATC to refer such therapy/legal matters to a Forensic Psychologist who can better deal with the legal aspects of the case. This determination will be made by the Clinical Director. I. TATC Child Care Policy - Children under the age of eight years old cannot be left unattended in the waiting area and are to be supervised by a parent, guardian or sibling over the age of 14 years old. Our liability policy will not allow the receptionist to provide any child care services for any amount of time. Your compliance with this policy is agreed to with your signature. RESPONSIBILITIES We request that you keep confidential the identity of any individual whom you observe receiving services at the Trauma Awareness and Treatment Center as well as any information you may learn about others during group counseling sessions. We request that you give your best effort to help the therapist resolve your particular psychological problem. This would include the keeping of appointments, and adhering to the attached Financial Agreement I have read the above information and understand my rights and responsibilities as a client of the Trauma Awareness and Treatment Center. Signature of Client, Parent (if client is minor child), or legal guardian: Signed:___________________________________ Date:_____________________  SEQ CHAPTER \h \r 1 NOTICE OF TATC PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL & MENTAL HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. Our Legal Duty We are required by the Health Insurance Portability and Accountability Act (HIPAA) to maintain the privacy of your health information. We are also required to notify you of our privacy practices, our legal duties and your rights concerning your health information. We must follow the privacy practices that are described in this Notice as of April 14, 2003, and while it continues to be in effect. Uses and Disclosure of Health Information: TC \l1 " TATC may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes, for example: Payment: We may use and disclose your health information to determine eligibility or coverage and/or obtain payment from your health insurance company and/or any collection agency we may have to employ to collect funds for services rendered. Treatment: We may use or disclose your health information in consultation with other therapist at TATC, a case worker with the contracting entity who has referred and is paying for services, ecclesiastical contact and any other person involved in your treatment at TATC. Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations which includes quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities, etc. Non-Authorized Disclosures: TATC will not disclose any health information to physicians, attorneys, teachers, non-custodial parents, family members of legal age or any other person not directly involved with TATC treatment without a signed and witnessed Authorization for Release of Information form, provided by our office. For Division of Workforce Services Clients: Your signature authorizes TATC to communicate with your DWS case worker regarding your case for one year as of this date. Client's Rights Rights: Permission to receive treatment, Client Rights, Responsibilities, Limits of Confidentiality and Financial Terms & Agreements are signed by clients or legal guardians at the clients initial visit to TATC. Please reference these documents for information contained therein. Rights Requests: All the following requests must be made in writing: You have the right to request restrictions on certain uses and disclosures of your PHI. You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. You have the right to inspect or obtain a copy (or both) of PHI for mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record, with limited exceptions. The cost for copies is $15.00 plus a .10 per page copy fee and any applicable postage. The TATC has 2 weeks after payment is received to respond to your request. You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. The request must include an explanation why the information should be amended. You generally have the right to receive an accounting of disclosures of PHI regarding you. The TATC reserves the right to review and/or deny any request for information listed above. Therefore, you have the right to file a complaint if you disagree with decision made about access to your records, or have other concerns about your privacy rights. You may contact Dr. Larry Beall, Clinical Director, by phone at 801-263-6367 or in writing at the address on this notice. You may also contact the U.S. Department of Health and Human Services. I the undersigned have read, understand and agree to the terms and conditions above as either a client or legal guardian and/or representative of a minor client. I understand that I may request and obtain a copy of this document. This document will remain in effect unless revoked in writing. Signed________________________________________________________Date_______________________ Witness ______________________________________________________ Date_______________________  SEQ CHAPTER \h \r 1FINANCIAL AGREEMENT _____________________________________________ Client Responsibility I understand it is my responsibility to know and understand my insurance plan and the out-patient mental health coverage available. I accept responsibility for obtaining any pre-authorization or prior approval required by my insurance company. I agree to be responsible for payment of all charges resulting from my consultations and therapy sessions, including any charges denied by my insurance company. Payment for Services Rendered I understand that payment is due at the time of service unless other arrangements are made prior to the beginning of treatment. I agree to make any co-payment and/or deductible payment required by my insurance company at the time of service. I understand that an insurance form will be submitted by the staff at the Trauma Awareness and Treatment Center to my primary/secondary insurance companies. Scheduled Appointments ____ (Initial Here) I agree to keep my scheduled appointments and understand that a missed appointment fee may be charged when I do not give 24 hours advanced notice. (*If appointment is missed, it is my responsibility to call and reschedule. T.A.T.C. cannot keep standing time open.) Finance Charges and Collection Action I, the undersigned give permission to release information to third party carrier(s) and do assign all insurance benefits for the treatment to be paid directly to the above named provider and request that this assignment remain on file with my insurance carrier. I certify that a copy of this assignment is as valid as the original. I authorize the referring clergy to exchange information with the provider. I, the undersigned recognize that the provider cannot accept responsibility for collecting any insurance claim or negotiating any settlement on a disputed claim. I also agree that in the event of default in payment of any amount due, and if this amount is placed in the hands of a collection agency, or attorney for collection of legal action, to pay the additional charge equal to the cost of collection including agency and attorney fees and court costs incurred and permitted by laws governing these transactions. A finance charge of 1.5% per month (annual rate of 18%) will be added on all balances over 45 days, regardless of pending insurance. FEE Scale(Basic rates listed may be adjusted according to insurance or other contract.) Psychologist LCSW/Counselor Consultation or therapy 50 min $100 $85 25 min $50 $42.5 Testing analysis (MMPI) $100 (Ph. D authorized only) N/A Psychological Evaluation or assessment Negotiated according to kind and detail N/A ______ _______ _______ ______ _______ _______ _______ _______ I certify that I have read this agreement and by my signature I agree to the terms set forth above. I hereby authorize direct payment of insurance benefits for services rendered to Trauma Awareness and Treatment Center/or individual therapist. 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