Please click here to download a PDF copy of our Consent and Policies.
Consent to Treat
I consent/I consent for my child to participate in the proposed treatment as recommended by the undersigned provider in accordance with standards of professional practice. I hereby certify that the clinician providing services has informed me of his professional qualifications, certifications, and/or licensure.
Assignment of Benefits and Release of Information
I hereby assign, transfer, and set over to Lifeline Counseling LLC all of my rights, title and interest to my medical reimbursement benefits under my insurance policy. I authorize the release of any medical information needed to determine these benefits. This authorization shall remain valid until written notice is given by me revoking said authorization. I authorize Lifeline Counseling LLC to release my financial information to my guarantor or third party collection agency if further collection assistance is required.
Payment Responsibility
I understand that verification of insurance benefits, eligibility, pre-approvals or authorizations are my responsibility and that Lifeline Counseling LLC provides insurance filing and inquiry as a courtesy to our patients. Those claims that are denied by the insurance company and which and are not required to be written-off due to a contract with the insurance company are my responsibility. If my insurance company does not pay on claims submitted within 90 days, or if claims are denied, charges become my responsibility and payment is due to Lifeline Counseling LLC. It will then become my decision whether or not to pursue reimbursement from my insurance company.
I understand it is policy of Lifeline Counseling LLC to collect co-pays at the time of service. If my dependent or I arrive for a session and do not have the co-pay and/or patient responsible balance, the session may be rescheduled for a later date, so that payment arrangements can be made to bring the account up to date. I also understand late cancellations or missed appointment will incur a $60 charge. (See the cancellation policy.) We cannot bill a spouse or former spouse regardless of the divorce decree.
Recording of Sessions
No part of the counseling session may be recorded by any means without the written consent of all parties and providers involved.
Self-Payment Agreement
Patients may elect to self-pay for various personal or financial reasons. In cases where a patient chooses to self-pay, Lifeline Counseling LLC will not file an insurance claim after self-payment nor accept any payment from an insurance company for claims filed by the patient for any prepaid services, because of the additional costs of managing claims, follow-ups and appeals. I understand that I cannot bill my insurance company for services I receive under this agreement.
Statement of Confidentiality
I understand that the personal information shared in a consultation and/or therapy session will be kept confidential or private within the boundaries of the law and by what are considered best practices of the field. Information will not be shared beyond Lifeline Counseling LLC without written consent of the patient or legal guardian/parent, except where mandated by law or legal precedent for safety factors, including where there is a danger of harm to self or others.
Mandated Reporters
I understand that State law mandates certain professionals or officials, acting in their professional capacity, must report concerns about any child or disabled/impaired adult who may be, or is at risk of being, abused or neglected. (Most mandated reporters work in schools, health care, counseling/psychology, child care, camps for children, the legal field, social work, or developmental disability programs.) More specific information on mandated reporters, and a complete list, is available at Ohio Revised Code 2151.421.
Obtaining Medical Records
I understand that in order to obtain a copy of my records I will first have to sign an authorization for release of confidential information from either the office of Lifeline Counseling LLC or from the requesting physician’s office. (While in most cases medical records can be obtained within 10 days, please allow up to one month for those records that may be stored off site.) There may be a charge for records obtained for the courts, disability claims, and other agencies as per the Ohio Revised Code Section 3701.742.
Additional Services and Fees
Additional fees are charged for : missed appointments (see below); telephone consultations; written and email correspondence; court appearances, and psychological testing (and associated letter and report preparation); other special services; returned checks. Payment terms are to be made in advance of the service. Court testimony will require fees paid in advance. Phone sessions and aforementioned services are not covered by insurance. (Please keep in mind that all office policies and fees are subject to change at any time without notice.)
HIPAA Policy
Please see our Privacy Practices page.
Cancelled/Rescheduled Appointments
Lifeline Counseling LLC understands that at times it may be necessary to cancel or reschedule an appointment. We ask that you please be considerate of the provider and other patients by providing 24-hour notice, if you need to cancel or reschedule. Failure to give a 24-hour notice will result in a $60.00 fee that is not billable to your insurance company.
Refunds
Lifeline Counseling LLC will refund clients for all services in which pre-payment or an overpayment has been made. However, if there is still an outstanding balance (patient or insurance), clients will not be refunded until the account is paid in full. Please allow 2-4 weeks after the account has been paid in full for the refund to be complete.
Legal, Custody, and Court Related Matters
Lifeline Counseling LLC is not a forensic certified provider and cannot serve as a specialist testimony for legal, custody, or court related or ordered services. Providers of ongoing counseling cannot provide assessments/reports for custody matters, and providers who provide assessments/reports for custody matters cannot provide ongoing counseling services.
Child Supervision and Attendance at the Office
We ask that you make alternate arrangements for childcare during your visits to Lifeline Counseling LLC. Siblings will not be able to accompany parents or the patient into a session (unless specifically requested by the therapist prior to the session.) Noncompliance with this policy will require a rescheduling of the appointment to a date in which childcare can be obtained.
Emergency Treatment
In case of emergency, please go to the nearest emergency room or dial 9-1-1.
Please click here to download a PDF copy of our Consent and Policies.