bioClient Information
Reminders may be given up to 3 days in advance depending on the date of your appointment\
CLIENT’S FINANCIAL RESPONSIBILITY AND ASSIGNMENT OF BENEFITS
I hereby assign to Resilience Psychiatry and Wellness, LLC all money to which I am entitled for medical expenses related to the services rendered by my therapist, but not to exceed my financial obligation. It is understood that any money received from the above-named insurance company, over & above my obligation will be refunded either to me or my insurance company when my bill is paid in full. I agree to pay my co-payment/deductible at the time of service.
Self-Pay Rates
Please read then initial each statement below
Make checks payable to:Resilience Psychiatry and Wellness, LLC
Outpatient Therapy Cancellation and Missed Appointment Policy
In order to provide the best quality of care, we request that you provide Resilience Psychiatry and Wellness, LLC with 24 hours’ notice if you need to cancel or reschedule an appointment. Failure to do so may result in a $50.00 fee per cancelled/missed appointment. Cancelling/missing three appointments without 24 hours’ notice in a six-month period may result in termination of services. Please feel free to speak to your provider if you have any questions concerning this policy.
I have read the above statement and agree to abide by the policy as stated above.
Your health record contains personal information about you and your health. Resilience Psychiatry and Wellness, LLC (MFS)is committed to protecting this medical information. Upon request, we will provide you a copy of the full HIPAA regulations.
HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:
For Treatment and health care operations–To coordinate your treatment within our agency.
For Payment. MFS may use or disclose medical information so that we can receive payment for the treatment services provided to you.
Substance Abuse Information. All medical information regarding substance abuse is kept strictly confidential and disclosed only in accordance with federal regulation (42 CFR part 2)
As Required by Law.
Following is a list of the categories of uses and disclosures permitted by HIPAA without an authorization.
Verbal Permission. We may use or disclose your information to family members that are directly involved in your treatment with your verbal permission.
With Authorization. Uses and disclosures not specifically permitted by applicable law will be made only with your written authorization, which may be revoked.
YOUR RIGHTS REGARDING YOUR MEDICAL INFORMATION
You have the following rights regarding your personal medical information maintained by our MFS to exercise any of these rights, please submit your request in writing to your Baffour Agyema-Duah, at
Baffour.Agyeman-Duah@resiliencepsychiatryandwellness.com
1) Right of Access to Inspect and Copy. You have the right, which may be restricted only in exceptional circumstances, to inspect and copy medical information that may be used to make decisions about your care. We may charge a reasonable, cost-based fee for copies.
2) Right to an Accounting of Disclosures and to request restrictions.
3) Right to Request Confidential Communication. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location’
4) Right to a Copy of this Notice. You have the right to a copy of this full Notice and the privacy regulations
5) Electronic Transactions Standards. All electronic transmissions follow MFS established security guidelines necessary to protect your confidentiality.
Rights and Responsibilities
Each consumer has a right to exercise his/her legal, civil, and human rights, including constitutional rights, statutory rights and the rights contained in this document, except where specifically limited. Your rights are assured and protected in the code of Virginia (12 VAC35-115).You have a right to know what they are and we will freely give you a copy, and review with you, the entire chapter in the code of Virginia detailing your rights, the complaint process and appeals process.
1. Be able to exercise your legal, civil and human rights related to the receipt of these services.
2. Receive services that are provided consistent with sound therapeutic practices.
3. To have your human dignity respected and be protected from harm, including abuse, neglect, exploitation, retaliation and humiliation.
4. Have access to your records and pertinent information in a timely manner to assist with making decisions regarding these services.
5. Receive prompt evaluation and person-centered treatment which includes you in the development of your individualized service plan.
6. Not be the subject of experimental or investigational research without your prior written and informed consent or that of your authorized representative.
7. Be treated under the least restrictive conditions consistent with your well-being and not be subjected to physical restraint, isolation and seclusion beyond the constraints of our Handle with Care Non-Violent Restraint Intervention Policy.
8. Have access and be referred to legal entities for appropriate representation, self-help and/or advocacy support services.
9. You may file a complaint with your human rights advocate. Their role is to help protect your rights and to make sure you are being treated fairly.
Ann Pascoe Tel. 804.297.1503; Email: ann.Pascoe@dbhds.virginia.gov
1. Attend as scheduled and participate fully and honestly in counseling and therapeutic service activities;
2. Remain available for appointments with their MFS counselor(s);
3. Refrain from the use of any abusive, vulgar, obscene or demeaning language;
4. Refrain from any harassing, aggressive, threatening or assaultive conduct towards others to include the use of weapons and/ or firearms;
5. Refrain from the use of illegal or legal substances to include drugs, tobacco, alcohol or prescription medications during services;
6. Respect the property and right of others.
Insurance plans and managed care organizations (MCO) encourage the exchange of information between Resilience Psychiatry and Wellness and your Primary Care Physician (PCP) as well as other service providers to coordinate medical and psychiatric care.
I authorize Resilience Psychiatry and Wellness to disclose current healthcare information with the family/others listed below.
Authorization for Release of Information
hereby authorizes Resilience Psychiatry and Wellness (MFS) to exchange information with:
unless revoked by the undersigned.
This information has been disclosed to you from records protected by federal confidentiality rules (42 CFR Part 2). The federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR part 2. A general authorization for the release of medical or other information is not sufficient for this purpose. The federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug patient.
