2100 18th Avenue, Suite 6
Rock Island, IL 61201
Telephone: 309-762-3931 or 309-788-0730
Fax: 309-788-0733
This document contains important information on professional services, patient rights and responsibilities, privacy procedures and financial policies. After reading through this packet, please discuss any questions you may have with your provider. When you sign this document, it becomes a binding agreement between you and your provider.
PROFESSIONAL SERVICES
The initial session, and possibly the first few sessions, will involve an evaluation of your needs and goals. You may be asked to complete questionnaires about your current symptoms, or those of your child. Your provider will work with you on specific goals for treatment. Typical sessions are 45 minutes in length and are scheduled based on your needs, treatment plan and provider’s recommendations. If you plan to use insurance, you should check for prior authorization requirements. Our staff are happy to help, but this is the patient’s responsibility. Insurability is no guarantee of coverage for specific services.
Emergency or crisis procedures are in place. Your therapist may not be immediately available to you in crisis, but the independent providers in this office share a crisis line and contact can be made through the on-call staff. If you call 309-751-8301 you will reach a provider who can then reach your provider for you, or help determine how you might proceed in handling the crisis. If you cannot reach a provider, or cannot wait for a return call, you should call the emergency room at the local hospital and ask for the therapist or psychiatrist on call. By calling the crisis line you are waiving confidentiality for the interval of the emergency contact.
Parents of minors hold the legal privilege for authorizing treatment and releasing confidential information. For clients between 12 and 18 years of age in Illinois, the minor also has legal privilege and must provide written release of confidential information. For clients over the age of 18 who are on their parent’s insurance, releases are obtained from the young adult allowing parents to contact the billing office to discuss financial information only.
In cases of divorce, custody arrangements dictate the privilege for authorizing treatment and release of information. A copy of your divorce decree may be requested for the record. The parent bringing the child to the appointment will be responsible for co-payments and out of pocket costs, such as deductibles. A notification letter is generally sent to the other parent, if he or she is not attending sessions, per the best practices model.
All Personal Health Information (PHI) is contained in either paper charts or in our computer records. All computers are encrypted according to HIPPA laws. However, electronic communications by email or text message are not encrypted. If you want to communicate with your provider electronically, those communications may be lost, delayed, intercepted, corrupted or even fail to be delivered. Electronic communications cannot be guaranteed to be secure and may be vulnerable to access by unauthorized third parties. Your provider shall not have any liability should you choose this form of communication.
Patient/Guardian Signature ______Date ______