New Client Information
Welcome to ICHANGE! Before your first visit please read this document carefully, as it contains information about our professional services and business policies. Please click the link to the right and complete all new client forms prior to your first session. Should you have any questions, please contact your therapist or us via email at firstname.lastname@example.org.
* Please be sure to read the HIPAA and Service Agreement forms first.
The Consent and Payment Authorization forms are required prior to your appointment.
Health Insurance Portability and Accountability Act (HIPAA)
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.
• 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.
Payment for Services
You will be expected to pay for each session at the time it is held, unless we agree otherwise or you have insurance coverage that requires another arrangement (ie. balance to be billed to you upon receipt of the insurance processing). You are responsible for payment for all services you receive, whether or not your insurance reimburses for a portion of the charges. “No show” or “late cancel” appointments may also be billed to you. If there have been no payments on your account for more than 60 days and arrangements for payment have not been agreed upon, we have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court, which will require us to disclose otherwise confidential information. In most collection situations, the only information we release regarding a client’s treatment is his/her name, the nature of services provided, and the amount due.
We do not anticipate collections procedures, but have established this policy so that all clients are clear as to our office procedure. If you have questions about fees, payments or your balance, please speak directly with your therapist, contact us via email at email@example.com .
• 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: Notice of Privacy Practices.