DAVID LAWRENCE CENTER Restoring & Rebuilding Lives

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1 Restoring & Rebuilding Lives Health Insurance Portability & Accountability Act (HIPAA) Notice of Privacy and Security Practices & Notice of Client Rights Abbreviated Statement For more than 40 years David Lawrence Center has maintained an unwavering commitment to assure you, our client, that the privacy and security of your information is high priority throughout our organization. We have developed standards, policies and procedures to ensure that we treat your personal information properly at all times. This notice describes how your medical, mental health, and substance abuse information may be used and disclosed and how you may have access to this information. PLEASE REVIEW THIS INFORMATION CAREFULLY. The following are our standards on assuring that your information is protected. COLLECTION OF INFORMATION: The Center collects the information needed to assess and provide treatment for your mental health and/or substance abuse conditions. DISCLOSURE OF INFORMATION: The Center may disclose your information if there is a proper consent, court order or as allowed by Federal and Florida Law 42 C.F. Part 2 and 2.22 and HIPAA (Health Insurance Portability and Accountability Act) to conduct our business and to assure that you receive appropriate treatment and medications. Other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law, up to and including: sale of individual s PHI use of individual s PHI for marketing and fundraising uses and disclosures of psychotherapy notes certain disclosures to a health plan where the individual pays out of pocket in full for the healthcare item or service, including Medicare The information that is released will contain only the minimal necessary to meet the request or requirement. You have the right to file a complaint if you think we may have violated your privacy rights. You may contact our Privacy Officer by phone at (239) or by at info@dlcmhc.com You also have the right to notify the U.S. Department of Health and Human Services (DHHS) or their designee if you feel that David Lawrence Center has not been compliant with the Privacy and Security of your health information at the following address: United States Department of Health and Human Services (DHHS) Attention: Office for Civil Rights Sam Nunn Atlanta Federal Center, Suite 3B70 61 Forsyth Street SW Atlanta, Georgia There will be no retaliation for filing a complaint. CLIENT S RIGHTS TO DISCLOSE, REVOKE, ACCESS AND REQUEST CORRECTION OF INFORMATION: You have the right to make a written request to disclose, revoke, access and request correction of your protected information and you have the right to revoke your consent for disclosure of your protected information at any time except to the extent that action has been taken in reliance on it. You also have the right to review the information in your record and to request copies at a nominal charge, including electronic copies of information stored and maintained in our electronic medical record. We will also inform you as to whom we have disclosed information. If you need further information on this notice please contact our Privacy Officer by phone at (239) or via at info@dlcmhc.com ADM-314A Rev. 2/03, 6/12, 11/13

2 Restoring & Rebuilding Lives HIPAA ACKNOWLEDGEMENT FORM I have received David Lawrence Center s Notice of Privacy and Security Practices and Notice Of Client Rights Abbreviated format today and have read and I understand the statement NAME: (PLEASE PRINT) SIGNATURE: CLIENT #: DATE: ADVANCE DIRECTIVES / LIVING WILL / HEALTH CARE SURROGATE 1. Have you executed Advance Directives? Yes No 2. If yes, have you provided a copy to DLC for your file? Yes No 3. Have you received an Advance Directive Education Handout? Yes No 4. Have you named a Health Care Surrogate? Yes No If yes, Provide Name: Relationship to You: Contact Phone Number: SIGNATURE: DATE: Please sign this acknowledgement form and return to program administrative staff. This acknowledgement will be filed in your record. ADM-314E Rev. 2/10, 5/12

3 SCOPE OF DAVID LAWRENCE CENTER SERVICES The role of any David Lawrence Center provider is to provide an assessment of mental health and substance abuse needs and provide treatment recommendations and subsequent treatment. However, these services do not include evaluations for the purpose of rendering opinions relating to child custody, visitation, or placement decisions. CONSENT FOR ASSESSMENT AND TREATMENT: I hereby authorize the DAVID LAWRENCE Initial Below CENTER to assess my needs, provide services and/or administer treatment as deemed necessary and appropriate. I understand that I have the right to receive clear and reasonable information and explanation by my primary treatment provider, nurse, clinician/therapist, and/or physician of: The diagnosis and/or preliminary diagnosis as applicable; The nature and purpose of a proposed treatment or procedure; The risks and benefits of a proposed treatment or procedure; Alternatives including not receiving treatment; The risks and benefits of the alternative treatment or procedure; and The risks and benefits of not receiving or undergoing a treatment or procedure. I have received information on Advanced Directives/Living Wills and have received and reviewed a copy of the Customer Handbook, which includes but is not limited to information about Client Grievance Procedures, Client's Rights, Abuse Reporting procedures, infection control standards, patient safety guidelines, confidentiality, and exceptions to confidentiality. I have been oriented to DAVID LAWRENCE CENTER programs rules and regulations. I understand that my records are protected under the Health Insurance Portability & Accountability Act (HIPAA), Federal Confidentiality Regulations (42.CFR.Part 2), and Florida Law. It is also the practice of David Lawrence Center providers to coordinate care and treatment with your Primary Healthcare provider whenever medication services are provided. CONSENT FOR FOLLOW-UP: The David Lawrence Center is committed to providing the very best care for clients. Following your discharge from this agency, information via phone contact or in writing may be requested by agency staff in regard to the quality of services that we provided to you. In the event you are unavailable, you agree to give permission for the person(s) named below to answer questions on your behalf. I hereby authorize DAVID LAWRENCE CENTER to contact me (or the person named below) in order to obtain information about my progress following treatment. The consent for follow-up is valid for 18 months following discharge unless cancelled by me prior to that time. Name: Address: Relationship to Client: Phone #: (Initial) I do not wish to provide any follow up information CONSENT FOR URINALYSIS (for substance abuse programs only): I hereby agree, upon request, to provide urine samples to the David Lawrence Center for analysis by an independent laboratory. I understand that the results of the urinalysis may be utilized as follows: 1. To determine use of alcohol or drugs. 2. To monitor my progress toward my treatment objectives 3. For diagnostic purposes. 4. As a condition of employment, probation, parole and/or attendance in school. I understand that urinalysis results which indicate non-compliance with DAVID LAWRENCE CENTER program rules could result in termination of services. If I am court-ordered to provide urine samples, I may refuse; however, I understand that I will be totally responsible for the consequences of this action. Results of urinalysis will be released only in compliance with state and federal regulations. I am certifying that I am of legal age and understand that this Consent is valid for 365 days except the Consent for Followup which expires 18 months following discharge. My consent indicates that I understand the information, which has been explained to me in simple language and have had the opportunity to ask questions. I also understand I have the right to revoke, and/or withdraw consent either verbally and/or in writing at any time. I, therefore, provide informed consent and authorize treatment/services as indicated above on this form. Client Signature: Consenting Authority s Signature: Staff / Witness Signature: : : :

4 David Lawrence Center Authorizations, Agreement to Pay, Cancellations and Assignments to Pay Insurance Benefits AUTHORIZATIONS: RELEASE OF RECORDS AND INFORMATION I hereby authorize David Lawrence Center and all persons, firms, corporations or agencies employed by or contracting with the David Lawrence Center to share and release any records and information from my records that may be required to process my account to any federal or state agency, insurance company or other third party who are involved with, or may be responsible for, processing claims for the care that I receive. I waive any claim of privilege which may relate to such information and records for such purpose. I understand that both federal and state laws may restrict other disclosures concerning or relating to records of my history, diagnosis or treatment and I understand that I retain the right to claim that privilege as it may relate to further disclosure of such information or records without my written authorization or as otherwise permitted by such laws. AGREEMENT TO PAY: The undersigned agrees, whether he or she signs as guarantor or as client, that he or she is hereby individually obligated to pay the account of David Lawrence Center for all services rendered in full. IMPORTANT: FALSIFICATION OF FINANCIAL INFORMATION: Providing false or misleading information or omitting documentation in order to receive discounted services may result in the following: 1. Retroactive loss of the discount already provided. 2. Loss of the opportunity for future discounts. 3. Termination of services. CANCELLATION POLICY: If you cannot attend your scheduled appointment, please call 24 hours in advance to cancel. If you fail to do this, there will be a fee of $ Medicare and insurance DOES NOT cover this charge. AUTHORIZATION/ASSIGNMENTS TO PAY INSURANCE BENEFITS: In the event that the undersigned is entitled to health benefits of any type arising out of any policy of insurance insuring the patient or any other party liable to the patient, said benefits are hereby assigned to David Lawrence Center for application to the client s bill. Client Signature Guarantor Signature Witness Signature

5 FINANCIAL POLICY-Outpatient Services Thank you for choosing David Lawrence Center as your behavioral health care provider. The Center is committed to providing you with quality services. It is important to us that you understand our Financial Policy so that you will know what your financial obligation will be. Commercial Insurance and Managed Care: We bill most insurance carriers as a courtesy for you if proper information is provided to us. This courtesy does not relieve you of your responsibility for payment of services rendered. Any outstanding balances, co-payments, and deductibles are your responsibility, and will be expected to be paid at time of service. If an insurance carrier has not paid within 60 days of billing, you may be billed. Preauthorization: If your insurance carrier requires prior authorization, we will try to assist you with obtaining the proper authorization. Be aware that if no authorization can be obtained, or if your insurance company denies the authorization of services (or if considered to be Out-of-Network), you will be responsible to pay the full fee at time of service. Medicaid and Medicare: Our office is a Medicaid and Medicare Part B participating provider (We are not a Medicare Part A provider) and we will bill these Payers for you. Any non-covered service will be your responsibility to pay at time of service. Any co-insurance and deductibles will be due at time of service. If you do not have insurance: Payment in full is expected at time of service, however you may qualify for a sliding fee discount if you do not have insurance. If you have no insurance and would like to qualify for the sliding fee scale, you will need to provide us with proof of income (prior to services) to receive the sliding fee scale discount. If not provided, you will be charged full fee. There may be instances where you are asked to pay a partial fee prior to providing us proof of income. This partial payment will not be considered payment in full until we receive your proof on income. We do enlist the assistance of a collection agency when payment is not made or there has not been an acceptable payment plan established and adhered to. Financial status reviews are performed annually, at a minimum, or whenever needed due to a change in your circumstances. Proof of Income will be required annually to continue to receive discounted services. Staff are available to meet with you during regular business hours if you have any questions regarding your fees, or you may contact us Discounts: Discount percentages are set by the State of Florida. They are based upon 1)Household Income and 2)the number of persons living in the household. Refunds: Overpayments will be refunded to you. However, before a refund is returned, it will be applied to any outstanding balances on your account. Cancellations and No Shows: If you cannot attend your scheduled appointment, please call 24 hours in advance to cancel or reschedule. If you do not call, you may be billed a no show fee of $ I have read and agree to the above terms: Client Name printed Signature David Lawrence Signature

6 PARENT/GUARDIAN LEGAL CUSTODY/AUTHORITY FOR TREATMENT I am the [Circle one:] Parent / legal guardian / step parent / grandparent / other family ) of (client s name) I have legal custody and I also have full legal authority to authorize David Lawrence Center, including its physicians, nurses, pediatrician, dietician, other consulting professionals and program staff to provide mental health, substance abuse or medical services for said child to include medication consultation and management, individual, group, family and recreational therapy or any other medically/ clinically necessary services. There are no court orders or judgments entered in any court, in this state or in any other state, limiting my authority to authorize David Lawrence Center, including its physicians, nurses, pediatrician, dietician, other consulting professionals and program staff, to provide mental health, substance abuse or medical services for said child to include medication consultation and management, individual, group, family and recreational therapy or any other medically/ clinically necessary services. No court order or judgment has been entered in any court, in this state or in any other state, requiring the consent of any person(s) before mental health, substance abuse, medical services to include medication consultation and management, individual, group, family and recreational therapy or any other medically/ clinically necessary services, may be provided for said child. I do not have information of any pending proceedings (including divorce, separate maintenance, child neglect, dependency or guardianship) concerning the custody or visitation of the child, in this state or any other state except: (If applicable) SPECIFY CASE NAME AND NUMBER AND COURT S NAME & ADDRESS I acknowledge a continuing duty to advise David Lawrence Center of any court order or judgment changing or limiting my authority to authorize David Lawrence Center, including its physicians, nurses and staff, to provide mental health, substance abuse or medical treatment for said child, or requiring the consent of any other person(s). Parent or legal guardian s signature signed Print Name Witness Signature signed Print Name