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Terms and Policy

Informed Consent
Informed Consent


I understand that I am eligible to receive a range of services from my provider. The type and extent of services that I receive will be determined following an initial assessment and thorough discussion with me. The goal of the assessment process is to determine the best course of treatment for me. I understand that treatment is often provided over the course of several weeks. I agree and consent to participate in the behavioral healthcare services offered and provided by Anchor Family Counseling. I understand that I am consenting and agreeing only to those services that Anchor Family Counseling is qualified to provide within the scope of the provider's license, certification, and training.


I understand that I have the right to ask questions throughout the course of treatment and may request an outside consultation. (I, also, understand that my provider may provide me with additional information about specific treatment issues and treatment methods on an as-needed basis during the course of treatment and that I have the right to consent to or refuse such treatment.) I understand that I can expect regular review of treatment to determine whether treatment goals are being met. I agree to be actively involved in the treatment and in the review process. No promises have been made as to the results of treatment or of any procedures utilized within it. I further understand that I may stop treatment at any time and agree to discuss this decision first with my provider.


I am aware that I must authorize my provider, in writing, to release information about my treatment (including to any consulting entity that maybe involved in my medical or mental health care)  but that confidentiality can be broken under certain circumstances. I authorize Anchor Family Counseling to release information to my insurance company, managed care organization, state agency(ies), health care financing administration, third party administrators, and/or Worker's Compensation or its agents any information needed to process my claim and/or determine benefits payable to related services. I understand that once information is released that my provider cannot guarantee that it will remain confidential. When consent is provided for services, all information is kept confidential to the best of our ability, except in the following circumstances, in which my provider is ethically or legally bound to break confidentiality:

     -When there is a risk of imminent danger to myself or to another person

     -When there is suspicion that a child or elder is being sexually, emotionally, neglected, or physically abused, or is at risk of such abuse

     -When a valid court order is issued for medical records


I agree and consent to Anchor Family Counseling sharing my information with the collection agency to collect any fees associated with services provided by Anchor Family Counseling and its employees after reasonable attempts have been made to collect debt.


While this summary is designed to provide an overview of confidentiality and its limits, it is important that you read the Notice of Privacy Practices, which has provided to you for more detailed explanations, and discuss with your provider any questions or concerns you have.


By my signature below, I voluntarily request and consent to behavioral health assessment, care, treatment, or services and authorize my provider to provide such care, treatment or services as are considered necessary and advisable. I understand the practice of behavioral health treatment is not an exact science and acknowledge that no one has made guarantees or promises as to the results that I may receive. By signing this Informed Consent to Treatment Form, I acknowledge that I have both read and understood the terms and information contained herein. Ample opportunity has been offered to me to ask questions and seek clarification of anything that is unclear to me.

( Type Full Name )
( Full Name )
Rights and responsibilities

YOUR INFORMATION. YOUR RIGHTS. OUR RESPONSIBILITIES.


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.


Your Rights


When 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.

Your Choices


For 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.


Our Uses and Disclosures


How do we typically use or share your health information? 

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 including collection services as we contract. 

Example: We give information about you to your health insurance plan so it will pay for your services

How else can we use or share your health information

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.

Our Responsibilities

-       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.


Changes to the Terms of this Notice

* We 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.
( Type Full Name )
( Full Name )
Scheduling Appointments and Therapist Availability

Scheduling Appointments 

upon completion of your session you will need to log into your client portal via online outside of the office OR via the computer provided in office to schedule future appointments. You will be required to utilize your client portal to schedule your next session so please ensure you have access to your client portal and email for your ability to do so. You will be assisted in learning how to utilize our online system. You are limited to scheduling ONE individual appointment per week, and you may sign up for as many group therapy sessions as you would like, with the limitation of not scheduling an individual therapy session and group session on the same day. You and your therapist will discuss the frequency and session time you are able to schedule for. 


Please note that you are required to contact the office via text message, Mail feature on your client portal if you need to cancel a session if there is less than 72 hours until your appointment. 


If you see an open appointment and would like to schedule, it is up to you to "request" appointment via your online client portal, it is not officially scheduled until it is confirmed by office staff. The spot is held until approved or denied. 


You are limited to what you are able to schedule so please be respectful of others who need appointment times as well. 


You will no longer be getting reminder text of your appointments from Jessica/Caitlin prior to your appointment. You will still receive the auto populated reminders from counsol prior to appointments if you have selected to receive them. 


AVAILABILITY BETWEEN SESSIONS

If needed, you can leave your therapist and or office staff a message on our 24-hour voicemail box or text 423-715-3904, or through your client portal utilizing the "Mail" feature. Our therapist will respond when they are available to do so. If you need a response from your therapist outside your individual session time there will be a charge applied to your account that is not reimbursable through insurance. (Please see fee schedule for the cost of these services.) When you leave a voice message, include your telephone number even if you think we already have it, and best times to reach you along with a brief reason for your call. Therapist do not return phone calls or text messages unless specifically requested and there will be a charge associated with the returned phone call. We make every effort to return calls in a timely manner. In the rare occurrence that a message is missed or accidentally deleted, if you do not hear back from us within two business days, please leave a second message. If we are unavailable for an extended time, such as on vacation, we will inform you of the contact information for the therapist on-call during our absence.


If you are in an emergency situation and cannot wait for us to return your call, go to the nearest emergency room or call 911. Anchor Family Counseling is not a crisis facility. Do not contact us by email or fax in an emergency, as we may not get the information in a timely manner. 



( Type Full Name )
( Full Name )
Telehealth Consent
Definition of Telehealth: 

Telehealth involves the use of electronic communications to enable Anchor Family Counseling to connect with clients using live interactive video and audio communications. Telehealth includes the practice of psychological health care delivery, diagnosis, consultation, treatment, referral to resources, education, and the transfer of medical and clinical data. I understand that I have the following rights in respect to telehealth: 

1. The laws that protect the confidentiality of my personal information that I have already signed also apply to telehealth. 

2. I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of my treatment at any time, without affecting my right to future care or treatment.

3. I understand that there are risks and consequences involved in telehealth, including but not limited to the possibility that in spite of reasonable efforts on the part of the counselor, that: the transmission of my personal information could be disrupted or distorted by technical failures, the transmission of my personal information could be interrupted by unauthorized persons, and/or the electronic storage of my personal information could be unintentionally lost or accessed by unauthorized persons. Anchor Family Counseling utilizes secure, encrypted HIPAA compliant audio/video transmission software to deliver telehealth. 

4. Anchor Family Counseling follows Tennessee state codes for telehealth: 56-7-1002 and 63-1-155, as well as respective board regulations and ethics and we have also received training to provide telehealth services. 

5. By signing this document, I agree that certain situations, including emergencies and crises, are inappropriate for audio-/video-/computer-based psychotherapy services. If I am in crisis or in an emergency, I should immediately call 911 or seek help from a hospital or crisis-oriented health care facility in my immediate area. 


Payment for Telehealth Services: 

Anchor Family Counseling will bill insurance for telehealth services when these services have been determined to be covered by an individual's insurance plan. The standard copay and/or deductibles would apply. If insurance does not cover telehealth, you assume responsibility for fee's due and will be required to pay out-of-pocket.


Patient Consent to the Use of Telehealth:

I hereby authorize Anchor Family Counseling and its associates to use Zoom and/or Counsol as a means for psychotherapy. Zoom and Counsol are  HIPAA compliant platforms for telecommunication.  I further attest that since I have chosen this form of communication I have been advised that it may not be covered by my insurance company and that I am responsible for any fees incurred during psychotherapy which incorporates telecommunication. ="margin-right:>


I understand that I may revoke this authorization at any time by giving written notice, except to the extent Anchor Family Counseling, has already taken action in reliance on it. I may specify the date, event, or condition on which this consent expires. If none is stated, and if no prior notice of revocation is received, this consent will expire one year after the date it was initiated. 


I hereby give my informed consent to participate in the use of telehealth services for treatment under the terms described herein. 

By my signature below, I hereby state that I have read, understood, and agree to the terms of this document.

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( Type Full Name )
( Full Name )
Court and Legal proceedings

We do not provide or perform evaluations for custody, visitation or other forensic matters. Therefore, it is understood and agreed that we cannot and will not provide any testimony or reports regarding issues of custody, visitation or fitness of a parent in any legal matters or administrative proceedings.


If you are requesting a letter to be sent to an attorney or court you will be charged a fee associated with the time spent and any legal fee's we incur as a result of this letter. This estimated to be between $35-$250 depending on the nature of the letter and will be discussed with you when request is submitted before proceeding with the letter. 


If we are contacted by an attorney regarding your treatment (either at your behest or related to a legal matter you are involved in) please note the following:

      We charge  $1000, to prepare for and/or attend any legal proceeding and for all court related services.

      Charges for court related services are not covered by insurance.

      Court related services include: talking with attorneys, preparing documents, traveling to court, depositions and court appearances.

      If the court or attorneys do not pay our fee, you will be charged for the time we spend responding to legal matters

      You will also be charged for any costs we incur responding to attorneys in your case, including but not limited to fees we are charged for legal consultation and representation by our attorneys.

* Collection agency may be utilized if all fees are not paid within agreed within time limit set forth in this agreement. 


Your electronic signature is acknowledgement of this policy and agreement to adhere to fees and costs of collections. 

( Type Full Name )
( Full Name )
Natural Disaster, Fire, and Public Health Crisis Procedures

Procedures for fire and events of natural disaster or public health crisis. 


1. Fire - in the event of a fire staff and clients are to egress through the front door of office, turn left down the hall way, follow to end of hall utilizing back exit of building. Everyone is to meet at the mail boxes by the fence to complete check-in and move further towards safety. 


2. Tornado - In the event of a tornado, clients and staff should maintain location in suite 156 until all clear is given. 


3. Flooding - In the event of weather that would cause flooding we will close the office. The process for determining whether to close the office or delay opening:

          (A) If the weather begins to deteriorate during the late evening or early morning hours, the office staff will begin to gather information            from local authorities and assessing the conditions surrounding the office, and we will communicate pertinent information to clients. 

          (B) The office staff will work together and will make the decision to close the office, delay opening, or to operate a regular schedule.

          (C) Once a decision is made to delay opening or to close the office, the office administrator will alert clients scheduled for that day of             our decision. If weather conditions deteriorate at some point after the office is in session, a decision will be made to close           immediately to allow clients and employees ample time to get to safety.


4. Public health crisis- 

          (A) All state recommended protocols will be followed and updated as soon as they are available. 

          (B) Tele-health service protocol will implemented. 

          (C)  Clients and staff are to use protective precautions and not enter office if they are showing signs or symptoms. 


( Type Full Name )
( Full Name )
MEDICATION MANAGEMENT SERVICES POLICY

MEDICATION MANAGEMENT SERVICES

For some people psychiatric medications can play a beneficial role in mental health recovery. Anchor Family Counseling is unable to prescribe medication at this time. However, we do have a variety of resources that we can coordinate care if you are currently on medication and or needing an evaluation for medication, to work with to ensure that treatment is most beneficial for you. We will make a referral with your permission and a signed authorization on file. If you are already seeing someone for medication management we are able to discuss with your provider after authorization to release health related information is obtained. 


Anchor Family Counseling does not administer medication or supervise self-administration of any medication.

( Type Full Name )
( Full Name )