1250 SE Maynard Road, Ste. 204
Cary, NC 27511


Ph: 919-371-4378
Fax 919-300-7943

www.slteletherapy.com

 

CONSENTS RIGHTS INFORMATION

I. Consent for Treatment:  

I hereby give my consent for my Silver Linings Therapist, to provide mental health services to me.  I have been informed of the scope and purpose of the service and understand that I may withdraw my consent at any time.  I understand I may also refuse any services offered at any time.
  
II. Financial and Billing Information Release:
I understand that Silver Linings may use confidential information about me to bill and be paid for services.  I hereby authorize Assignment of Benefits for Silver Linings to submit medical information to my insurance carrier or authorized agent or representative to determine benefits and facilitate payment.  I understand there may be a co-payment, co-insurance and/or deductible according to my policy provision.  I agree to notify Silver Linings of any and all changes to my insurance policy.  I understand and agree I will be held financially responsible for any and all fees not covered by the policy on record.

I also give permission for to contact Silver Linings regarding two-way communications for financial matters.

III. Notice of HIPAA Privacy Practice:  
I have received and/or read the Notice of HIPAA Privacy Practices.  I understand these rights are designed to protect my privacy.
   

IV. The Silver Linings Promise:   

We Promise:                    

•    To protect your legal rights.            
•    To treat you with respect.             
•    To honor your privacy.                
•    To respect your dignity.             
•    To help you see your choices.                
•    To keep confidentiality.     
•    To inform you of emergency procedures.        
•    To include you in writing your service plan.    
•    To provide you humane care.
•    Freedom from mental and physical abuse, neglect, and exploitation.
•    To provide an individualized service plan.    
•    Not to sell any goods to you or buy any goods from you.   

What We Do:

  • We will not share any information about you or your family without your written permission, except:
    • When you sign a release form
    • When we believe that you or a family member might harm yourself or someone else, or that you have committed a crime
    • In an emergency, medical situation
    • When a judge issues a court order directing the release of your records
  • If we come to your home and we suspect abuse or neglect, we are required by law to make a report to The Department of Social Services.


Signature Instructions:
Touch Screen: use finger or stylus to sign
Desktop Monitor: use mouse or touchpad to sign

Signature:
Signature:

Therapist Name and Signature:

Date: