Right to request how we contact you

It is our normal practice to communicate with you about health matters and appointments using your home address and daytime phone number you provided when you scheduled your appointment. We may leave messages on your voicemail, text, or e-mail you at the # and addresses you put on your intake paperwork. You have the right to request that our office communicate with you in a different way. Please be advised we cannot guarantee complete privacy when we communicate via phone, text, or e-mail. We will use the phone number and email you provided on your intake paperwork to text, leave voicemail, and e-mail. If you do NOT want us to contact you in these ways please state your preferred contact method below.

Right to release your medical records

You may consent in writing to release your records to others. You have the right to revoke this authorization, in writing, at any time. However, a revocation is not valid to the extent that we acted in reliance on such authorization.

Right to inspect and copy your medical and billing records

You have the right to inspect and obtain a copy of your information contained in our medical records. To request access to your billing or health information, contact the office manager. Under limited circumstances we may deny your request to inspect and copy. If you ask for a copy of any information, we may charge a reasonable fee for the costs of copying, mailing and supplies.

Right to add information or amend your medical records

If you feel that information contained in your medical record is incorrect or incomplete, you may ask us to amend the record. We will make a decision on your request within 90 days. Under certain circumstances, we may deny your request to add or amend information. If we deny your request, you have a right to file a statement of disagreement. Your statement and our response will be added to your record. To request an amendment, you must contact the office manager. We will require you to submit your request in writing and provide an explanation of your request.

Right to an accounting of disclosures

You may request an accounting of disclosures, if any, we have made related to your medical information. This DOES NOT include information we used for treatment, payment, health care operational purposes, information shared with you or your family, or information that you gave specific consent to release. It also excludes information we were required to release. To receive information regarding disclosure made for a specific time period (no longer than six years), please submit your request in writing to the Privacy Officer. We will notify you of the cost involved in preparing this list.

Right to request restrictions on uses and disclosures of your health information

You have the right to ask for restrictions on certain uses and disclosures of your health information. This request must be in writing and submitted to our office manager. However, we are not required to agree to such a request.

Right to complain

If you believe your privacy rights have been violated, please contact us personally to discuss your concerns. If you are not satisfied with the outcome, you may file a written complaint with the U.S. Department of Health and Human Services. An individual will not be retaliated against for filing such a complaint.

Right to receive changes in policy

You have the right to receive any future policy changes secondary to changes in state and federal laws.

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.

Effective date: July 1, 2017

Denise Wilburn, MS,LCPC and Renew Counseling Services is and always will be totally committed to maintaining all clients’ confidentiality. We will only release healthcare information about you in accordance with federal and state laws and the ethics of the counseling profession.

This notice describes our policies related to the use and disclosure of your healthcare information.

Uses and disclosures of your health information for the purposes of providing services

Providing treatment services, collecting payment, and conducting healthcare operations are necessary activities for quality care. State and federal laws allow us to use and disclose your health information for these purposes.

TREATMENT

We may need to disclose health information about you to provide, manage, or coordinate your care or related services including consultants and potential referral sources.

PAYMENT

We may need to disclose personal information to verify insurance coverage and/or benefit , to process your claims and collect fees. We may bill the person in your family who pays for your insurance.

HEALTHCARE OPERATIONS

We may need to use information about you to review our treatment procedures and business activity. Information may be used for certification, compliance, and licensing activities.

Other uses or disclosures of your information which do not require your consent

There are some instances where we may be required to use and disclose information without your consent. Examples include, but are not limited to: information you and/or your children report about physical or sexual abuse (Illinois State Law obligates us to report this to the Department of Children and Family Services), information that informs us that you are in danger of harming yourself or others, information to remind you of /or to reschedule appointments, information regarding treatment alternatives, information shared with law enforcement if a crime is committed on our premises or against our staff, or as required by law such as a subpoena or court order. Furthermore, if you present a clear and present danger to yourself or others or are developmentally or intellectually disabled, I am mandated to report you to the Department of Human Services.

Clinical records, psychotherapy notes and other disclosures require a separate signed release of information. You have a right to or will receive notification of a breach of any unsecured personal health information. You have a right to restrict any disclosure of personal health information where you have paid for services out-of-pocket and in full.

Office Manager: Denise Wilburn, MS, LCPC

Privacy Officer: Denise Wilburn, MS, LCPC

Thank you for choosing Renew Counseling Services. We realize beginning counseling is a major decision and you may have many questions. This document is intended to inform you of our policies, State and Federal Laws, and your rights.

During your appointments you will meet with Denise Wilburn, MS, LCPC. Denise has been a counselor since 1997 and currently specializes in Christian Counseling and the mental health needs of women.

Appointments last between 30-55 minutes.

PAYMENT

Agreed upon payment is due at the beginning of each session. Renew Counseling Services regularly accepts cash as a form of payment. Check payment may be accepted with prior approval. In the event a check is rejected by the bank, all bank fees AND an additional $25 fee will be the responsibility of the client. Checks will no longer be accepted if there is a rejection by the bank. Credit cards are only accepted for HSA and FSA WHEN there is no option to write a check. It is our policy to bill for TWO intake sessions in most cases. Some insurance companies may not cover the second evaluation session and you may be responsible for this fee. See our fee agreement for more information re: our fees. AS A COURTESY we will bill your insurance company for you. If there are issues with your insurance company (bills not paid, payments not correctly processed, etc.) it is THE CLIENT’S responsibility to pay the agreed upon rate and deal with the insurance company. Unfortunately, we are a limited practice and do not have the capability to work out insurance problems on your behalf. Renew Counseling Services will bill your primary insurance only. If there is a secondary insurance, the client will be responsible for paying according to the primary insurance and sending a super bill to their secondary to be personally reimbursed.

NO SHOW/LATE CANCEL POLICY

We charge a $75 no show/late cancel fee. Any appointment not canceled 24 hours prior to the appointment time or any missed appointment will incur a $75 fee. We are strict on this policy and do mean an ACTUAL 24 hour notice. This fee will not be paid by insurance or Counseling/Church Ministry Funds. This fee must be paid in full before another

appointment is scheduled.

CONFIDENTIALITY

We take your privacy very seriously here at Renew Counseling Services. We are aware we live in a small town and our practice is in a church setting. Some of our clients attend this church and some of our clients and our therapist have similar ties in our small community. It is also very likely our therapist may see some clients outside of the office, as it is unavoidable in a small town. Please be assured, our therapist is bound by ethics and law to keep your privacy and your sessions absolutely confidential. We do not share our relationship with anyone. We will not acknowledge you first if we see you outside the office. If you acknowledge us, we will respond, but you must initiate the contact. There are some limits to confidentiality as explained later in this document (insurance billing, duty to report, etc.)

COMMUNICATION

We are happy to communicate with you via phone, text, or e-mail. If you reach out to us via one of these avenues, you are giving permission to us to respond to you in the same manner at the same # you contact us or the # you leave on a message. Please be advised phones, texts, and emails are not 100% secure and you are forfeiting your complete privacy when you grant permission to communicate in these ways. We are unable to communicate with you about your therapy via social media.

We are a limited practice meaning we are not available every day of the week. Phone calls and leaving a message are the best ways to contact us. We check office email only on Wed. and Sat. We check phone messages throughout the week, but will not guarantee a call back on the same day.

CRISIS COVERAGE

We DO NOT provide 24-hour crisis coverage. In the event of an emergency, call 911 or visit your local ER.

SUBPOENAS, DEPOSITIONS, COURT APPEARANCE, BECOMING A WITNESS

Our goal as a counseling service is to provide treatment, education, and a safe environment for clients to heal, discover coping, and learn to become their best selves. We will not participate in or provide opinions in any custody arrangements, visitation schedules, or other family court matters. We will not participate in court matters re: divorce, career, accidents, etc. We do not respond to subpoenas not signed by a judge specifying mental health records or testimony. If we are subpoenaed by a judge and mandated to participate in a deposition, appear in court, provide records or other documents, we will respond accordingly. We charge a minimum of $150 to respond to any subpoena. We charge $150 per hour for every hour we must prepare to respond, travel to and from an appearance, or be present for the matter we are subpoenaed. The hourly rate begins at the time we leave our office and continues until we return to our office. Mileage will be charged at the federal rate. Any expenses incurred (parking, tolls, etc.) will be added to the bill. The fees must be paid before or at the time of the appearance. We reserve the right to send an additional bill after the appearance/request for items not predicted (parking, tolls, etc.). The client is ultimately responsible for ensuring the fees are paid.

COUNSELING RELATIONSHIP AND THERAPISTS/CLIENTS RIGHT TO TERMINATE

The success of counseling is based on the relationship between the therapist and client, the client’s willingness/ability to follow through on changing behavior, and the therapist’s skill/knowledge in the presenting problem. At any time if the therapist/client feels the counseling relationship is not working, the client is unable to follow through with change, or the therapist is not skilled in the area of concern, either party may terminate counseling giving at least a 24 hour notice.

PERMISSION TO TREAT

I give my permission to treat myself or the below named minor. I give my permission to charge my insurance and I understand my rights and the limits of confidentiality as described in this document.