JMFCS Patient Information & Consent Form

    PATIENT INFORMATION

    Student:

    Full time:

    RESPONSIBLE PARTY INFORMATION

    INSURANCE INFORMATION

    Are you covered by health insurance?

    If no, then please make payment arrangements with our business office

    CONSENT FOR PAYMENT

    I hereby authorize payment of medical benefits billed to my insurance by Jackson Marriage and Family Counseling Services. I have listed all health insurance plans from which I may receive benefits. I hereby accept responsibility for payment for any service(s) provided to me that is not covered by my insurance. I agree to pay all copayments, coinsurance, and deductibles at the time services are rendered. I also accept responsibility for fees that exceed the payment made by my insurance, if Jackson Marriage and Family Counseling Services does not participate with my insurance.

    No Show Fee

    I agree to inform Jackson Marriage and Family Counseling Services within a minimum of 24 hours whenever I cannot keep a scheduled appointment. In the event that I feel to keep an appointment and also fail to inform Jackson Marriage and Family Counseling Services within no less than 24 hours, then I consent to pay a No Show Fee of $50.00 and I authorize Jackson Marriage and Family Counseling Services to charge my credit/debit card a one-time fee of $50.00 to cover the No Show Fee charged for my missed scheduled appointment.

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    Authorization to Use PHI

    I hereby authorize Jackson Marriage and Family Counseling Services to use and/or disclose my personal health information (or PHI) which specifically identities me or which can reasonable be used to identify me to carry out my treatment, payment, and healthcare operations.
    I understand that while this consent is voluntary, if I refuse to sign this consent, the Jackson Marriage & Family Counseling Services practitioners can refuse to treat me. I understand this authorization can only be revoked in writing. If I revoke my consent, such revocation will not affect any actions that Jackson Marriage and Family took before receiving my revocation.

     

    Confidentiality & Privacy Policy

    The law protects the relationship between a client and a psychotherapist, and information cannot be disclosed without the client's permission. However, clinicians have mandated reporters and are required by law to contact the authorities if children, elders, and other vulnerable community members are at risk of harm. Such as:

    • Suspected child abuse or dependant adult or elder abuse

    • If a client is threatening serious bodily harm to another person

    • If a client intends to harm himself or herself and efforts to obtain their cooperation for prevention and intervention are futile