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NorthStar Counseling Group 39 E. Hawley St. Mundelein, IL 60060 (847) 400-02232 Financial Policy Insurance and Claims: If you have health insurance it may provide some coverage for mental health treatment. NorthStar Counseling Group (“NSCSG”) will bill insurance companies on your behalf. By signing this document, you certify that you have active and valid insurance as noted above and authorize insurance payment directly to NCSG. You are authorizing NCSG to exchange private healthcare information with your insurance company to verify insurance benefits, obtain treatment authorizations, process claims and/or engage in a collection process. Insurance coverage is determined at the time the claim is processed by insurance carrier. As such, insurance carrier (s) and/or provider cannot guarantee coverage. You will remain responsible for any balance that your insurance does not cover. Your contract with your health insurance company requires that you authorize NCSG to provide it with information relevant to the services that have been rendered. Typically, insurance companies require a clinical diagnosis toassist in reimbursement, and your insurance company may require additional clinical information such as treatment plans or summaries, or copies of your clinical record. In such situations, we will make every effort to release only the minimum information necessary for the purpose requested. This information will become part of the insurance company files. Though all insurance companies claim to keep such information confidential, we have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank.
Payment: NCSG charges a fee of $150 per session. If you will not be using insurance you will be expected to pay for each session at the time it is held, unless you and your therapist have made other arrangements. If insurance will be used, you will be expected to pay your co-insurance, co-pay, or deductible at the time of service, unless you and your therapist have made other arrangements. Returned checks will be charged a $30 fee for insufficient funds. In the event that insurance does not cover billed claims, whether in part or wholly, you will be liable for all incurred charges. NCSG does not bill secondary insurance. By signing this document, you will be the responsible party and will be billed on behalf of the client. If you feel someone else should be the responsible party/financial guarantor, please speak with your provider on how to proceed. Please note that NCSG will not bill multiple parties for services rendered. In the event that full payment for services is not received, NCSG shall be entitled to recover, in addition to the principal balance remaining, interest at the rate of 1.5% per month along with all costs incurred in collection efforts, including but not limited to court costs and reasonable attorneys’ fees.
Cancellations/Missed Appointments: Appointments that are not cancelled 24 hours in advance will be charged a fee of $100. Please note that insurance companies do NOT reimburse for missed appointments and the fee will become the sole responsibility of the client or parent/guardian.
Psychotherapy is not easily described in general statements. It varies depending on the personalities of the therapist and client, and the particular problems you bring forward. There are many different methods used to deal with the problems that you hope to address. Psychotherapy calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things you and the therapist talk about both during your sessions and at home.Psychotherapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. On the other hand, psychotherapy has also been shown to havesignificant benefits for people who are willing to put the effort in and engage the process long enough to reap the benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress.
Your provider is not always immediately available by telephone. Please leave a message on the office voicemail with your name, number, time of call, and purpose of call. The messages are received and answered at the therapist’s earliest convenience. Since this is an outpatient practice, emergency services are not available. Therefore, in case of emergency please contact either 9-1-1 or go to the nearest hospital emergency room. Emergencies may include, but are not limited to, being harmful to self or others, family or personal crisis. Please know that although technology is wonderful, voicemails, cell phones, etc. cannot be guaranteed to be confidential. IN AN EMERGENCY, DO NOT WAIT TO TALK TO THERAPIST. IT IS YOUR RESPONSIBILITY TO ACTIVATE EMERGENCY MEDICAL SERVICES BY CALLING 9-1-1 OR GO TO YOUR NEAREST EMERGENCY.
LIMITS ON (please see Privacy Practices for more information):
The law protects the privacy of all communications between a patient and a behavioral health treatment provider. In most situations, NorthStar Counseling Group can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA and/or Illinois law. However, in the following situations, no authorization is required: your therapist may occasionally find it helpful to consult other health and mental health professionals about a case. During aconsultation, the therapist will make every effort to avoid revealing the identity of the patient. The other professionals are also legally bound to keep the information confidential. If you do not object, the therapist will not tell you about these consultations unless she feels that it is important to your work together. Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement.
If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the therapist-patient privilege law. We cannot disclose any information without a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order your treatment provider to disclose information.
If a government agency is requesting the information for health oversight activities, NorthStar Counseling Group may be required to provide it for them.
If a patient files a complaint or lawsuit against a treatment provider, that treatment provider may disclose relevant information regarding that patient in order to provide defense.
If you file a worker’s compensation claim, and your therapist is rendering treatment or services in accordance with the provisions of Illinois Workers’ Compensation law, she must, upon appropriate request, provide a copy of your record to your employer or his/her appropriate designee.There are some situations in which we are legally obligated to take actions, which she believes is necessary to attempt to protect others from harm. We may have to reveal some information about a patient’s treatment.
If NorthStar Counseling Group has reasonable cause to believe that a child under 18 known to her in a professional capacity may be an abused child or a neglected child, the law requires that the therapist file a report with the local office of the Department of Children and Family Services. Once such a report is filed, your therapist may be required to provide additional information.If your therapist has reason to believe that an adult over the age of 60 living in a domestic situation has been abused or neglected in the preceding 12 months, the law requires that the therapist file a report with the agency designated to receive such reports by the Department of Aging. Once such a report is filed, your therapist may be required to provide additional information.If you have made a specific threat or acted violently or plan to act violently against another or if we believe that you present a clear, imminent risk of serious physical harm to another, she may be required to disclose information in order to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking your hospitalization.If we believe that you present a clear, imminent risk of serious physical or mental injury or death to yourself, she may be required to disclose information in order to take protective actions. These actions may include seeking your hospitalization or contacting family members or others who can assist in protecting you.
If such a situation arises, your therapist will make every effort to fully discuss it with you before taking any action, and the therapist will limit the disclosure to what is necessary.While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that you and your therapist discuss any questions or concerns that you may have now or in the future.
In accordance with protected healthcare information laws and professional ethical standards, healthcare providers are bound to maintain the confidentiality and privacy of their clients. While clients have the right to privacy, some courts have held that if an individual intends to cause harm or danger toward themselves or another person(s), it is the practitioner’s duty and obligation to share privileged communications to warn and/or protect the client him/herself and/or other persons who might suffer the results of client’s threats to cause harm. In such cases, emergency medical professionals, other healthcare professionals and any other person may be contacted to maximize the safety for the client and/or others. Client’s will be informed as soon as possible should clinicians “duty to warn” obligation be invoked.
I, as client (and/or legal guardian) acknowledge receiving, reading, discussing (as needed) and agreeing to abide by the terms of the Outpatient Services Agreement. In commencing therapy, I have been provided informed consent for treatment