1250 SE Maynard Road, Ste. 204
Cary, NC 27511
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:
• 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:
Touch Screen: use finger or stylus to sign
Desktop Monitor: use mouse or touchpad to sign
Therapist Name and Signature: