I, the undersigned, certify that I or my dependent will be making payment in cash/check/credit card payable to Zen Imago, PLLC in the amount of ____ dollars per session. Payment is due at the time services are rendered. There will be a $80.00 cancellation fee for any session cancelled without 48hrs advance notice. There is a $100.00 paperwork preparation fee for any requested documents. There is a $150.00 court appearance fee for any requested or ordered appearance. I understand that I am financially responsible for all charges and failure to pay results in theft of service. If paying by insurance I hereby authorize Zen Imago, PLLC to release all information necessary to secure the payment of benefits. I furthermore authorize the use of this signature on all insurance submissions.
CONSENT FOR COUNSELING:
I, the undersigned do hereby voluntarily agree to counseling, coaching, consulting services either by group, individual, family counseling, or supervision to be provided by a
Licensed Professional of Zen Imago, PLLC. I am aware that the practice of counseling is not an exact science. As a consequence, I acknowledge that no guarantee has been made to me concerning the result of any evaluation or treatment that may be rendered. Further, I understand that evaluation and treatment may involve discussion of personal events in my own history that, at times, can be discomforting.
LIMITATIONS ON CONFIDENTIALITY:
Information about the diagnosis, evaluation, or treatment of a client with Medicaid coverage and most private health insurance plans is usually confidential information that this office may disclose only to the authorized people. Only the client may give written permission for release of any pertinent information before information can be released to another person or agency. Confidentiality will be maintained in all other respects.
The following are exceptions to confidentiality that every client needs to understand in advance:
In regards to the Health Insurance Portability and Accountability Act (HIPAA) of 1996, I have been made aware of how my medical information may be used and disclosed and how I can get access to this information.
BASIC RIGHTS FOR ALL CLIENTS
I certify that I have received a copy of this document prior to treatment. Staff have explained its content to me in a language I understand.
f you have any questions concerning these rights or complain about your care, contact TDMHMR Office of Consumer Services and Right Protection at 1-800-252-8154.