THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT THE PATIENT MAY BE USED AND DISCLOSED IN REGARDS TO HEALTH INSURANCE AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY AND INDICATE THAT YOU UNDERSTAND BY CLICKING THE BOX AND THAT YOU GIVE ASSIGNMENT FOR INSURANCE PAYMENTS TO ROBIN NANCE FROM YOUR INSURANCE COMPANY. 

Robin Nance, MSW, LISW-CP, is committed to protecting the personal and health information (PHI) of her patients in each of the settings in which such information is received or disclosed. When you complete an application for health coverage your signature authorizes your health plan to collect personal information that includes both your medical information and individual identifiable information about you such as your date of birth, address, telephone number, etc. As a patient of Robin Nance, MSW, LISW-CP, this general consent allows this office and its outside billing, Supporting Your Practice, LLC to communicate with your authorized providers and health plan about treatment and payment decisions. This office will not disclose, sell or otherwise use you PHI unless permitted by law for protection of personal safety and to extent necessary to administer to your benefit. This office will need to obtain written authorization from you to use your PHI for any other purpose than indicated above. Effective 4/14/03, you have the right, excluding psychotherapy notes, to inspect your medical records. You also have the right to request an accounting of disclosure of PHI made for purposes other than those stated above. If at any time you have a complaint regarding how your PHI was used and/or disclosed, you may contact this office and file a grievance, which will be investigated and outcome reported in writing to member and health plan. For more details regarding this privacy letter please contact our office at 843-437-5814.

Practice Policy, HIPAA and Consent for Treatment Agreements

The purpose of this agreement is to acquaint you with the policies and procedures of this office.   Please read the entire document carefully, acknowledge and agree to each section and the sign where indicated.  You can request a copy of this document by asking your provider, Robin Nance or by calling 843-437-5814.

Confidentiality:

In order to protect your best interests and personal rights, we would like you to be aware that professional ethics and law dictate what you say in a psychotherapy session will remain confidential and will not be shared with anyone without written permission.  For a complete explanation, please refer to the HIPAA Notice of Privacy Practices.  The following are standard exceptions to this confidentiality and may be clarified with you provider. 

Child or elder abuse.  We may be required by law to make referral to Protective Services and/or the authorities.

Intentions to harm yourself or someone else.  We are required to take reasonable precautionary measures to protect the person that is in danger.

Subpoena signed by a Judge.  If you are in legal proceedings in which your mental or psychological condition is at issue, the Judge may subpoena out records or your treatment.

Referral agency and third party payers request for information.  Depending on your referral agency, we may be required to furnish evaluation and treatment information.  This will be clarified with you by provider.

Minor status.  If you are under the age of 18, your parents are the holder of the confidentiality privilege and they have the right to be informed of your needs and progress.  Confidentiality will be reviewed with the minor and parents during the initial interview.

All information between therapist / Doctor and patient is held strictly confidential unless:

You authorize release of information with your (client and/or parent guardian) signature or digital signature.

You present a danger to others

You present a physical danger to self        

Child or elder abuse is suspected

In the latter two cases, we are required by law to inform potential victims and legal authorities so that protective measures can be taken.

Upon verification of health plan/insurance coverage and policy limits, we will bill your insurance carrier for you and your provider will be paid directly by the carrier. You (patient or guardian) will be responsible for any applicable deductibles and co-payments. If you are not eligible at the time services are rendered, you are responsible for payment. Co-payments are expected to be paid at the time services are rendered. If you are without health plan/insurance coverage, payment arrangements should be made prior to your first appointment. All charges or co payments are due and payable at the time of each session by the responsible party or the undersigned. You remain responsible for charges not covered by insurance such as telephones calls,crisis intervention, rewriting prescriptions, reports, etc. Any balances over 30 days may be subject to finance. If your check is returned, your account will be assessed a $25 returned check charge. In the even collection or legal action should become necessary any unpaid balance due for services rendered, I agree to pay for collection, attorney, and court costs.

By signing below you are indicating that you accept assignment of your insurance benefits to Robin Nance.

Appointments, Late Cancel and No-Show Fees Policy

A scheduled appointment means that time is reserved only for you. If an appointment is missed or canceled with less than 24 hours' notice, you will be billed according to the scheduled fee or according to the rules of your health plan. Frequent cancellations may result in the termination of your treatment; your compliance in keeping appointments and active participation in the treatment process are vital. $50 Cancellation or No Show fee applies.

By signing below I acknowledge that it is my responsibility to notify my provider Robin Nance at (843) 437-5814 at least 24 hours prior to a scheduled appointment if I am not able to keep the appointment. 

A scheduled appointment means that time is reserved only for you. If an appointment is missed or canceled with less than 24 hours' notice, you will be billed according to the scheduled fee or according to the rules of your health plan. Frequent cancellations may result in the termination of your treatment; your compliance in keeping appointments and active participation in the treatment process are vital. $50 Cancellation or No Show fee applies.

If you/the patient are in imminent danger call 911, or your nearest police department or emergency room. Your provider's policy regarding emotional crises and his/her availability/policy should be discussed during your first appointment.

You have the right to request reconsideration in the case that outpatient care (number of visits) is not authorized. This is called an appeal. You can request and appeal through your provider. You risk nothing in exercising this right. You have the right to submit a complaint directly to your provider or to the Clinical Group to which they belong at any time that you have a complaint about any aspect of your care. If you are not satisfied with the response you receive, you may submit the complaint to your Health Plan directly.

During the initial evaluation period, you and your provider will clarify together the nature of the problems for which you are seeking treatment, then define some reasonable treatment goals, and finally develop a treatment plan that will help you achieve those goals. Your provider can review with you what your health plan will cover. You are expected to be compliant with the agreed upon treatment plan between sessions and to keep your appointments. Research has shown that brief, time limited therapy focusing on specific goals results in more rapid reduction of symptoms and improvement in patient functioning. Daily homework is crucial when participating in PCIT. Parents are expected to have use the skills that they learn in PCIT with their child at least five minutes a day at least five times a week.

With this consent form, you are consenting to treatment by the provider.  Your provider will review with you the treatment plan as appropriate, and discuss alternative treatments available.

If you are using a third party insurance company for your health care benefits, your protected health information will be used for treatment, payment, and healthcare operations.  This may include faxing authorization and authorization request forms between your provider and the authorized entity.  It may also include electronic billing for treatment services provided and completed by Supporting Your Practice, LLC.

If we need to contact you regarding appointment scheduling or emergency cancellations, phone messages will be left on the phone number that you provide to us.  It may include contacting the person that you have listed as your emergency contact.

If you owe your provider money, statements will be mailed to the address that your provide to us.  This mailing includes the business name on the envelope.

There may be circumstances in which your provider chooses to consult with other licensed professionals regarding your treatment.  Efforts will be made to keep any identifying information confidential.

YOUR SIGNATURE BELOW INDICATES THE FOLLOWING:

I have read and I understand these procedures.

I consent to treatment for myself or the dependent indicated as the patient.

I agree to pay the provider's fee for missed appointments if I fail to give a 24 hours advance notice.

I understand that if my behavioral healthcare Clinician requests authorization for additional sessions from my managed care company, the medical necessity for further treatment and the effectiveness of treatment already provided will be weighed.

I understand that I have the right to formally appeal decisions regarding authorized treatment services by first contacting MY RESPECTIVE PROVIDER.  I further understand that I have the right to submit a complaint or grievance to MY RESPECTIVE PROVIDER regarding any aspect of my care, or I may submit complaints to my health plan.  I understand that I risk nothing in exercising these rights.

A photocopy of this consent form is to be considered as valid as the original.