In consideration of professional services already rendered and for professional services to be rendered in the future to
the patient (or parent or guardian) whose signature is placed below, the patient and/or responsible party and Canyon
Counseling Center hereby agree to the following:
Even though Canyon Counseling Center files insurance claims, this is only a professional courtesy.
The patient/responsible party agrees to accept final responsibility for filing and collecting all insurance claims and that in the
event your insurance carrier refuses payment, you agree to pay all amounts.
The patient/responsible party agrees that any
balance remaining as either a direct or indirect consequence of any communications with and/or action by and/or
lack of action by the insurer is the patient's/responsible party's responsibility.
By signing below, patient/responsible
party requests Canyon Counseling Center to file regular insurance claims to specified insurance companies and authorizes
Canyon Counseling Center to release information as to diagnosis, treatment, prognosis, and any other information necessary
to consider, process and approve payment of services. Patient/responsible party further authorize payment of medical
benefits to Canyon Counseling Center for any insurance claims processed in patient's behalf.
Patient/responsible party agrees to pay Canyon Counseling Center all sums incurred
for professional services within the time specified below.
Payment may be made at a reduced rate at the time of service or may be billed on a 30-day net agreement.
Any amounts not paid at the time of service and any insurance co-payments are due in full on the 15th day of the month
following the month in which service was provided.
If complete payment cannot be made at such time, formal payment
arrangements must be made with Canyon Counseling Center's financial assistant immediately after the initial service. Any
overdue balance shall bear interest at the rate of 18 percent per annum after 90 days delinquent until paid. Should the
patient/responsible party default in the payment of any installment on the date when it becomes due and payable, under these
circumstances, Canyon Counseling Center may elect to accelerate the maturity of all remaining sums so that the sum becomes
due and payable forthwith. There will be a $20 fee assessed for a returned check.
All accounts 90 days overdue will automatically be turned over to an outside agency for collection.
In the event that this agreement shall be placed in the hands of an outside agency for enforcement, or in the event that any other legal
action be taken, patient/responsible party agrees to pay costs of collection (50%), court costs, and any reasonable attorney's
fee. Patient/responsible party also agrees that should it be necessary, patient/responsible party will return from other
geographic locations and other responsibilities to the County of Utah, State of Utah for legal proceedings and that
patient/responsible party will pay all costs associated with this requirement. The accounts of Canyon Counseling Center are
verified by a Certified Public Accountant.
An unpaid balance in excess of $500.00 may result in the suspension of clinical services until such time as the
outstanding balance can be resolved. Your therapist may refuse to schedule an appointment until you have paid any
outstanding balance you have with our office. If you are unable to pay for your services in the future, you understand and agree
that your therapist will be unable to continue services. In that even, your therapist will provide a referral to another provider
more readily able to work within your budget.
FAILED APPOINTMENTS: Full charge will be made for missed appointments which are not canceled 24 hours in advance of the set time.
This 24 hours is in addition to weekends, holidays, or other time when the office is
closed. Parents are responsible for their minor child's actions as it relates to this office policy and are responsible to advise
children of this policy.
The undersigned person hereby agrees to all stipulations above and to pay all professional services rendered by Canyon
Counseling Center and its therapists in accordance with this agreement.
Welcome to Canyon Counseling Center. The purpose of this letter is to help you understand our office policies
and procedures. If you have any questions regarding policies, scheduling, or billing, please contact our office. The
front office is open Monday-Thursday, 9 a.m. to 5 p.m. and Friday 9 a.m. to 1 p.m.
Sessions are approximately 55 minutes in length, beginning 10-15 minutes after the hour. The therapists at Canyon
Counseling Center try to see their clients promptly at the appointment time scheduled. They request that you also
be responsible for keeping appointments on time. If you are late, your session will be shortened. Please do not
bring young children to therapy. In the case of appointments not kept or canceled with less than 24 hours notice,
you will be charged in full for that session. Insurance and other third party providers do not cover missed session
charges. (Exceptions can be made for emergency situations, such as sudden illness.)
If you miss a scheduled appointment, it is your responsibility to call the office to schedule another appointment if
you wish to continue your counseling effort. After a missed appointment, if you do not call our office within ten
days to reschedule, your counselor will accept that as your notice that you have terminated counseling with our
As a professional courtesy to you, our office will bill your insurance company, where appropriate, on a weekly basis.
We request that you pay a minimum $20.00 co-pay at the time of your session. We would greatly appreciate your
keeping current with your co-payments. If you do not have insurance, a payment schedule will be arranged with
you on your initial visit.
Limits of Confidentiality
Although confidence is very strict in therapy, there are some occasions when confidentiality must be broken:
- If there is ongoing child abuse. This includes physical, emotional, and/or sexual abuse.
- If you are or become suicidal, or you pose a threat to the safety of another, we are required to protect you, notify the authorities, and warn whomever may be in danger.
- If you are ever in a court of law and use your mental status as a factor in your case, your notes may be subpoenaed by the court and we are required to provide all request information.
- Without going into extreme details, third party providers are entitled to know diagnosis, treatment, and/or prognosis.
Otherwise, you control the release of information.
Due to our heavy clinical schedules and as a matter of policy, we do not testify in civil or criminal court proceedings.
We also do not participate in child custody cases. We will, however, supply the court and/or attorneys with a
written summary of therapy if the client should so desire. A signed release of information is required for such a
summary to be supplied.
Therapists will try to return phone calls as quickly as possible. Because the therapists have limited time between
sessions, please be aware that calls may be returned at the end of the day or the following day. Issues that require
more than 10 minutes on the phone may require a scheduled office visit.
Our counselors are not allowed to accept gifts from clients. While we appreciate your thoughtfulness, we are
prohibited by the canons of our profession not to accept gifts from our clients.
By signing below you authorize our office to designate an appropriate professional to serve as custodian of your
record, and who will assume possession of, and responsibility for your treatment record in the event of your
counselor's death or disability. Notice will be posted, as necessary on your counselor's web page and telephone voice
There is a real possibility that you may feel worse at times in therapy than when you started.
This is because you may have to address some uncomfortable and painful issues.
This is normal and should be anticipated.
The length of therapy is determined by you. The amount of work that you are willing to do determines
the speed and direction of your therapy. Your therapist will make recommendations for continued service,
but feel free to give your input as well.
We will work with you to make changes, but we cannot promise anything about the results you will obtain.
The outcome you achieve will depend on many things.
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
This notice takes effect on 4/14/03 and remains in effect until we replace it.
1. OUR PLEDGE REGARDING YOUR MEDICAL INFORMATION
The privacy of your medical information is important to us. We understand that your medical information is personal and we are committed to protecting it. We create a record of the care and services you receive at our organization. We need this record to provide you with quality care and to comply with certain legal requirements. This notice will tell you about the ways we may use and share medical information about you. We also describe your rights and certain duties we have regarding the use and disclosure of medical information.
2. OUR LEGAL DUTY
Law requires us to:
- 1. Keep your medical information private.
- 2. Give you this notice describing our legal duties, privacy practices, and your rights regarding your medical information.
- 3. Follow the terms of the current notice.
We Have the Right to:
- 1. Change our privacy practices and the terms of this notice at any time, provided that the changes are permitted by law.
- 2. Make the changes in our privacy practices and the new terms of our notice effective for all medical information that we keep, including information previously created or received before the changes.
Notice of Change to Privacy Practices:
- 1. Before we make an important change in our privacy practices, we will change this notice and make the new notice available upon request.
3. USE AND DISCLOSURE OF YOUR MEDICAL INFORMATION
The following section describes different ways that we use and disclose medical information. Not every use or disclosure will be listed.
However, we have listed all of the different ways we are permitted to use and disclose information. We will not use or disclose your medical
information for any purpose not listed below, without your specific written authorization. Any specific written authorization you provide may
be revoked at any time by writing to us at the address provided at the end of the notice.
We may use medical information about you to provide you with medical treatment or services. We may disclose
medical information about you to doctors, nurses, technicians, medical students, or other people who are taking care of you. We may also
share medical information about you to your other health care providers to assist them in treating you.
We may use and disclose your medical information for payment purposes. A bill may be sent to you or a third-party
payer. The information on or accompanying the bill may include your medical information.
FOR HEALTH CARE OPERATIONS: We may use and disclose your medical information for our health care operations. This might
include measuring and improving quality, evaluating the performance of employees, conducting training programs, and getting the
accreditation, certificates, licenses and credential we need to serve you.
ADDITIONAL USES AND DISCLOSURES: In addition to using and disclosing your medical information for treatment, payment, and health
care operations, we may use and disclose medical information for the following purposes.
Notification: We may use and disclose medical information to notify or help notify: a family member, your personal representative or
another person responsible for your care. We will share information about your location, general condition, or death. If you are present,
we will get your permission if possible before we share, or give you the opportunity to refuse permission. In case of emergency, and if you
are not able to give or refuse permission, we will share only the health information that is directly necessary for your health care, according
to our professional judgement. We will also use our professional judgement to make decisions in your best interest about allowing
someone to pick up medicine, medical supplies, x-ray or medical information for you.
Disaster Relief: We may share medical information with a public or private organization or person who can legally assist in disaster relief
Research in Limited Circumstances: We may use medical information for research purposes in limited circumstances where the research
has been approved by a review board that has reviewed the research proposal and established protocols to ensure the privacy of medical
Specialized Government Functions: Subject to certain requirements, we may disclose or use health information for military personnel and
veterans, for national security and intelligence activities, for protections services for the President and others, for medical suitability
determinations for the Department of State, for correctional institutions and other law enforcement custodial situations, and for government
programs providing public benefits.
Court Orders and Judicial and Administrative Proceedings: We may disclose medical information in response to a court or
administrative order, subpoena, discovery request, or other lawful process, under certain circumstances. Under limited circumstances,
such as a court order, warrant, or grand jury subpoena, we may share your medical information with law enforcement officials. We may
share limited information with a law enforcement official concerning the medical information of a suspect, fugitive, material witness, crime
victim or missing person. We may share the medical information of an inmate or other person in lawful custody with a law enforcement
official or correctional institution under certain circumstances.
Public Health Activities: As required by law, we may disclose your medical information to public health or legal authorities charges with
preventing or controlling disease, injury or disability, including child abuse or neglect. We may also disclose your medical information to
persons subject to jurisdiction of the Food and Drug Administration for purposes of reporting adverse events associated with product defects
or problems, to enable product recalls, repairs or replacements, to track products, or to conduct activities required by the Food and Drug
Administration. We may also, when we are authorized by law to do so, notify a person who may have been exposed to a communicable
disease or otherwise be at risk of contracting or spreading a disease or condition.
Victims of Abuse, Neglect, or Domestic Violence: We may use and disclose medical information to appropriate authorities if we
reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may
share your medical information if it is necessary to prevent a serious threat to your health or safety or the health or safety of others. We may
share medical information when necessary to help law enforcement officials capture a person who has admitted to being part of a crime or
has escaped from legal custody.
Workers Compensation: We may disclose health information when authorized or necessary to comply with laws relating to workers
compensation or other similar programs.
Health Oversight Activities: We may disclose medical information to an agency providing health oversight for oversight activities
authorized by law, including audits, civil, administrative, or criminal investigations or proceedings, inspections, licensure or disciplinary
actions, or other authorized activities.
Law Enforcement: Under certain circumstances, we may disclose health information to law enforcement officials. These circumstances
include reporting required by certain laws (such as reporting of certain types of wounds), pursuant to certain subpoenas or court orders,
reporting limited information concerning identification and location at the request of a law enforcement official, reports regarding suspected
victims of crimes at the request of a law enforcement official, reporting death, crimes on our premises, and crimes in emergencies.
Appointment Reminders: We may use and disclose medical information for purposes of sending you appointment postcards or otherwise
reminding you of your appointments.
Alternative and Additional Medical Services: We may use and disclose medical information to furnish you with information about
health-related benefits and services that may be of interest to you, and to describe or recommend treatment alternatives.
4. YOUR INDIVIDUAL RIGHTS
You have a Right to:
- 1. Look at or get copies of certain parts of your medical information. You may request that we provide copies in a format other than
photocopies. We will use the format you request unless it is not practical for us to do so. You must make your request in writing. You
may get the form to request access by using the contact information listed at the end of this notice. If you request copies, we will charge
you $.25 for each page, and postage if you want the copies mailed to you. Contact us using the information listed at the end of this
notice for a full explanation of our fee structure.
- 2. Receive a list of all the times we or our business associates shared your medical information for purposes other than treatment, payment,
and health care operations and other specified exceptions.
- 3. Request that we place additional restrictions on our use or disclosure of your medical information. We are not required to agree to these
additional restrictions, but if we do, we will abide by our agreement (except in the case of emergency).
- 4. Request that we communicate with you about your medical information by different means or to different locations. Your request that
we communicate your medical information to you by different means or at different location must be made in writing to the contact person
listed at the end of this notice.
- 5. Request that we change certain parts of your medical information. We may deny your request if we did not create the information you
want changed or for certain other reasons. If we deny your request, we will provide you a written explanation. You may respond with
a statement of disagreement that will be added to the information you wanted changed. If we accept your request to change the
information, we will make reasonable efforts to tell others, including people you name, of the change and to include the changes in any
future sharing of that information.
- 6. If you have received this notice electronically, and wish to receive a paper copy, you have the right to obtain a paper copy by making a
request in writing to the contact person listed at the end of this notice.
QUESTIONS AND COMPLAINTS
If you have any questions about this notice or if you think that we may have violated your privacy rights, please contact us. You may also
submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with their address. You may
contact us to submit a complaint or submit requests involving any of you rights in section 4 of this notice by writing to the following address:
ATTN: HIPAA Officer; 3319 North University Ave. Suite 100, Provo, Utah, 84604. We will not retaliate in any way if you choose to file a complaint.