HIPAA PRIVACY INFORMATION
Informed Consent: I give my permission for Coastal Counseling Center to provide information to my insurance/EAP company for the purpose of billing for services provided. I also agree to pay any copay required by my insurance company. I further authorize the release of any information applicable regarding my care as required by the third-party payer.
Sliding fee scale is for uninsured or insurance with a high deductible:
CONSENT FOR TREATMENT: I hereby give my consent for treatment by Coastal Counseling Center clinical staff. I affirm that I am of legal age and competent to give such consent for behavioral health treatment. If not; however, the person who co-signs this consent represents me as parent, legal guardian, or person otherwise allowed by law to consent for my treatment.
CONFIDENTIALITY: I acknowledge that in accordance with state & federal laws, information about me at Coastal Counseling Center will be protected from unauthorized disclosure. No information will be sent to my employer, family, friends, or anyone else unless it is discussed with me ahead of time and written authorization is obtained.
Confidentiality may be broken, however, in certain situations that may endanger my health & safety as well as the health & safety of others (e.g., suspected suicide, homicide, abuse, neglect, and domestic violence).
Federal laws do not protect information about a crime committed by a client either at the Center or against any person who works for the Center or about a threat to commit such a crime.
Information regarding alcohol & drug abuse in a client’s medical record is protected by federal laws & regulations. Generally, the Center cannot disclose that a client is participating in a program or disclose information to anyone outside the Center unless: (1) the client consents in writing; (2) the disclosure is allowed by court order; or (3) disclosure is made to medical personnel in a medical emergency.
GRIEVANCE PROCESS: Clients may address administrative or treatment concerns and grievances with his or her counselor. Should this not be satisfactory, the client may then address concerns with the Center director. Should this not be satisfactory, the client may then request a consultation with the Center’s board/designees. The decision of the board/designees will be final.
DISCHARGE: Treatment is solution-focused and brief in nature, with a goal of successful discharge. Should a client have a sixty (60) day gap in services (e.g., no contact in this 60 days), the client’s medical record will be closed. He or she may contact the Center for re-admission after that period, provided all fees are up to date.
INVOLVEMENT IN TREATMENT: I hereby give permission for the following persons to be involved in my treatment at Coastal Counseling Center. It is noted that these persons do not have access to my medical record or Protected Health Information; they may participate with me and have or give information on a very limited basis:
I give my consent for assessment and treatment and understand the conditions of this informed consent and agree to its provisions. I also understand that my insurance or EAP company may request medical information for claims processing.
SNAP: Strengths / Needs / Abilities / Preferences
PERSONAL PROBLEM INDEX
In the PAST THIRTY DAYS, indicate how much you have been affected by or level of difficulty you have had in dealing with each area.
THIS IS A SECURE FORM. CLICK SUBMIT.