Privacy Policy

SERVICE AGREEMENT AND CONSENT FORM

Effective Date: 01/01/2025

Thank you for choosing Insight Clinical Counseling and Wellness, LLC. Our utmost concern is providing you with excellent services. This document contains important information about our professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and client rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations. HIPAA requires that we provide you with a Notice of Privacy Practices (the Notice) for use and disclosure of PHI for treatment, payment, and health operations. The Notice, which is attached to the Agreement, explains HIPAA and its application to your personal health information in greater details. The law requires that we obtain your signature acknowledgement that we have provided you with this information. Although these documents are long and complex, it is important that you read them carefully and that you ask questions you have about the procedures or treatments at any time. When you sign the document, it will also represent an agreement between us unless we have taken action in reliance on it; if there are obligations imposed on us by your health insurer in order to process or substantiate claims made under your policy; of if you have not satisfied any financial obligations you have incurred. If you have any questions or concerns, please feel free to discuss them with us.

SERVICES OFFERED

We will provide services specifically designed to help you (and/or minor child) or otherwise provide you with referrals to other professionals. Our clinical and behavioral services consist primarily of individual assessments (psychological and behavioral evaluations), mental health treatment, and substance abuse treatment.

APPOINTMENTS

Except for rare emergencies, we will see you (or your child) at the scheduled time. We understand that circumstances (such as an illness or family emergency) may arise which necessitates the occasional cancellation of appointments. In these cases, in order to avoid any misunderstanding, we ask that you speak with us personally and give us as much notice as possible to cancel or reschedule. This will allow us to offer your time to another person. You will be charged $75 for appointments unkempt or cancelled on the same day as your appointment. Please note that insurance companies will not reimburse you or Insight Clinical Counseling and Wellness, LLC for missed appointments and you remain responsible for these charges.

CONFIDENTIALITY, RECORDS, AND RELEASE OF INFORMATION

Psychological services are best provided in an atmosphere of trust. Because trust is so important, all services are confidential except to the extent that you provide us with written authorization to release specified information to specific individuals, or under other conditions and as mandated by Ohio and Federal law and our professional codes of conduct/ethics.

TO PROTECT THE CLIENT OR OTHERS FROM HARM

If we have reason to suspect that a minor, elderly, or disabled person is being abused, we are required to report this (and any additional information upon request) to the appropriate state agency. If we believe that a client is threatening serious harm to him/herself or others, we are required to take protective actions which could include the police, an intended victim, a minor’s parent(s), or others who could provide protection, or seeking appropriate hospitalization.

PROFESSIONAL CONSULTATIONS

Counselors routinely consult about cases with other professionals. In so doing, we make every effort to avoid revealing the identity of our clients, and any consulting professionals are also required to refrain from disclosing any information we reveal to them. Unless you object, we do not typically tell clients about these consultations; however, these consultations will be so noted in your Private Health Information. If you want us to talk with or release specific information to other professionals with whom you are working, you will first need to sign an Authorization that specifies what information can be released and with whom it can be shared.

SUPERVISION NOTIFICATION

Insight Clinical Counseling and Wellness, LLC believes in providing training opportunities for new professionals in the field, from CACREP accredited colleges and universities with the highest level of academic standards, and Licensed Professional Counselors. At times, supervisors licensed by the Ohio CSWMFT board provide supervision to Counseling Trainees (CT), Licensed Professional Counselors (LPC), Social Worker Trainees (SW-T) and Licensed Social Workers (LSW). Your clinician may be under supervision. This means that your clinician may review your case with his or her supervisor, or any other supervising licensed professional at Insight Clinical Counseling and Wellness, LLC. You have the right to meet with the supervisor at any given time, and all guidelines for protection of your Protected Health Information applies. In addition, you may ask for verbal permission for a supervisee to shadow your session, at which time you can grant or deny consent. If you deny consent, this does not impact your access to services and it’s an integral part of your client rights. All clinicians with a CT, SW-T, LPC or LSW are under the supervision of a LPCC-S or an LISW S.

PAYMENT FOR SERVICES

If you have a question or objection to fees assessed, objections or inquiries must be made within 60 days of receipt of the relevant invoice in order to allow review and consideration. Inquiries regarding invoices over 60 days old will be deemed untimely and payment will be expected for services. Insurance claims are sent electronically as necessary. In addition, we may seek assistance from an outside party in order to collect payment for services. In such cases, any disclosures are limited to the minimum that is necessary to achieve the purpose. The laws and professional standards governing these issues are quite complex, and it is important that we discuss any questions or concerns that you (or your minor child) may have at our first meeting, and as they may arise in the course of our work together. If any of these types of situations arise, we will make every effort to fully discuss it with you before taking any action, and we will limit disclosure of any information to what is necessary. We are not attorneys, however, and you may wish to obtain formal legal consultation if you need specific advice.

You are responsible for paying any non-covered services, co-pays, and deductibles as outlined by your insurance. These payments must be collected and cannot be waived, per insurance rules. Insight will collect co-pays and deductibles at the time of service. If your balance is not paid in a timely, your appointment can be cancelled, and a late cancellation charge will be added to the balance. A credit card is required to be kept on file and will be used for any unpaid balances If a balance remains unpaid for 60 days, your card will be charges $100 weekly until: The balance is paid, or You set up a billing approved payment plan. If you balance reaches $300, your services will be paused until payment is made.

HEALTH CARE INSURANCE

If we do not file your insurance claim at this time, we will provide you with statements that you may submit to your insurance carrier or complete forms as required by your insurance carrier in order to obtain reimbursement for out-of-network providers. In order to assist you with obtaining reimbursement for our services, your insurance carrier may require that we provide a clinical diagnosis, or additional clinical information such as treatment plans, or copies of your Medical Record. In such situations, we will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Although all insurance companies claim to keep such information confidential, we have no control over what they do with it once they possess this information. By signing this Agreement, you agree that we can provide requested information to your insurance carrier if you choose to file a claim for any services provided. You may request that we do not submit any claims for services provided to your insurance carrier. In this situation, you agree to pay in-full for all services rendered and acknowledge that you are financially responsible for any expenses incurred. Payment for such service is required when services are rendered.

PATIENT RIGHTS

HIPAA provides you with several rights regarding your Clinical Record and disclosures of protected health information. These rights include requesting that we amend your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized.; determining the location to which protected information disclosures are sent; having any complaints you make about our policies and procedures recorded in your records; and the right to a paper copy of the Agreement and our privacy policies and procedures. We are happy to discuss any of these rights with you.

PROFESSIONAL RECORDS

You need to be aware that Insight Clinical Counseling and Wellness, LLC keeps clients’ Protected Health Information in our professional records. This information includes, but not limited to: reasons for seeking our professional services; the impact of any current or on-going problems on concerns; assessment, consultative, or therapeutic goals; progress towards those goals, a medical, developmental, educational, and social history; treatment history; and treatment records that we receive from other providers; reports of any professional consultations; billing records; releases; and any reports that have been sent to anyone, including statements for your insurance carrier and the billing service agency we utilize. Except in unusual circumstances that involve danger to yourself or others, or makes reference to another person (unless such person is a health care provider) and we believe that access is reasonably likely to cause substantial harm to such other person, you or your legal representative may examine and/or receive a copy of your Clinical Record, if you request it in writing. We encourage you to discuss your Clinical Record information with your provider at Insight Clinical Counseling and Wellness, LLC.

CONTACTING US

Given our many professional commitments, we are often not immediately available by telephone. If you need to leave us a message, we will make every effort to return your call promptly (within 24 to 48 hrs. with the exception of holidays and weekends). If you are difficult to reach, please leave some times when you are available. Because of the nature of the services we provide, we do not provide on-call coverage 24 hrs. per day, 7 days per week. In emergency or crisis situations, please contact your physician, or call 911 and/or go to the nearest hospital emergency room. Please be advised that due to issues of confidentiality, Insight Clinical Counseling and Wellness, LLC and its staff and/or agents will not correspond about specific clients via email or other electronic communication methods.

FOR WORK WITH MINOR CLIENTS

If a client is under eighteen (18) years of age, the law may provide parents with the right to examine the minor child’s records. Privacy, however, is often crucial to successful progress in treatment and valid evaluation results. If, in the course of an evaluation, treatment, or consultation, a minor child reveals to us information that he or she does not want to share with his or her parents or guardian, we usually do not reveal such information unless we believe that there is a high risk that the minor will seriously harm him/herself or others, and in which case we will notify him or her of our intent to notify his/her parents or legal guardians. I agree to not request to review the records of the minor client if the minor client does not want records to be released.

42 CFR Part 2 Privacy Practices (as referenced in our Client Handbook)

Our organization is not a 42 CFR Part 2 program; however, we may receive or maintain Substance Use Disorder (SUD) treatment records from programs that are subject to 42 CFR Part 2 (“Part 2”). These records are protected by federal law and include information identifying a patient as having sought, received, or been referred for SUD treatment.

Part 2 places heightened confidentiality requirements on these records. When we receive SUD records from a Part 2 program, we are required to protect, use, and disclose them only as allowed under 42 CFR Part 2, the HIPAA Privacy Rule, and any patient authorization you provide.

How We May Use or Disclose Part 2 Records

1. With Your Written Authorization

We may use or disclose Part 2 records only with your written permission, unless a specific Part 2 exception applies.
Your authorization must clearly describe what will be disclosed, to whom, and for what purpose.

2. For Treatment, Payment, and Health Care Operations (TPO)

If a Part 2 program has provided us with your SUD records under a general consent allowing disclosure for TPO, we may use and disclose those records in accordance with HIPAA for purposes such as:
Coordinating your care
Processing billing and payment
Running our health care operations

We will not re-disclose your information in a manner that is prohibited by Part 2.

3. Disclosures Not Allowed Without Authorization

We cannot use or disclose your SUD treatment records in any civil, criminal, administrative, or legislative proceeding against you without your specific written authorization or a court order that meets strict Part 2 requirements.

Your Rights Regarding Part 2 Records

You have the right to:
Request a copy of your Part 2–protected records
Request restrictions on how your Part 2 records are used or disclosed
Revoke your authorization at any time, unless we have already acted on it
Ask for an accounting of disclosures of your Part 2 records made with your consent within the last three years
(as required by the 2024 Final Rule)

Some rights under Part 2 may differ from your general HIPAA rights, and we will follow whichever law provides greater protection.

Prohibition on Redisclosure

Federal law (42 CFR Part 2) prohibits unauthorized redisclosure of SUD treatment information.
Any disclosure we make that includes Part 2 information will contain a notice stating that redisclosure is not permitted unless allowed by Part 2 or authorized by you.

If you have questions about how we protect your SUD treatment information or about your privacy rights, please contact:

Joanna Jones
Phone: 330-623-7442
Email: jjones@insightccw.org
Address: 3685 Stutz Dr Suite 103, Canfield, OH 44406