1250 SE Maynard Road, Ste. 204 Cary, NC 27511 Ph: 919-371-4378 Fax 919-300-7943 www.slteletherapy.com
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. Yes No 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. Yes No I also give permission for (if desired, insert additional name here) 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. Yes No 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:
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