Clinical Forms ? Jewish Family & Children's Service

For over 140 years, Jewish Family & Children’s Service (JF&CS) has provided families in the St. Louis community with the resources they need to meet the challenges of everyday living. Our services are specifically tailored for children, couples, families, adults and the elderly experiencing problems with daily living, as well as those with extremely serious physical and emotional difficulties. Our staff is committed to providing the highest quality services while recognizing your right to privacy and confidentiality.

The Agency’s fee to provide counseling, case management, and/or mental health services is $110 per hour. Fees for psychological, educational, vocational, and/or behavioral assessments are determined by type of assessment. A sliding fee scale for services is based upon need and is available should you not be able to meet the cost. The remainder will be subsidized using funds provided by the United Way and the Jewish Federation. If you choose to use the Agency’s sliding scale, it is your responsibility to demonstrate your financial situation (e.g., assets, income and outstanding debts). If your financial situation changes, your fee will be adjusted accordingly.

If you have insurance and it covers our services, at your request we file a claim with your insurance company. Unless arranged otherwise, all insurance payments must be assigned to JF&CS. You are responsible for your deductible and co-pay. Combined insurance and sliding scale payments in excess of $110 will be refunded to you upon the termination of services. If you choose not to use your insurance, your fee will be $110 per hour and you will be unable to submit your visits in the future for insurance reimbursement.

Payment is required before the start of each appointment, although billing is possible based upon prior arrangement with the Agency. If payment is due for more than two sessions, we will be unable to provide further counseling or other Agency services until your account is made current. If you need to contact your provider by phone to discuss something other than scheduling a visit, the Agency reserves the right to bill you for this time. If your conversation with your provider is at least 15 minutes, but less than 30 minutes, you will be billed 1/2 the hourly rate set for you. If your conversation is in excess of 30 minutes, you will be billed the full hourly rate. If your insurance prohibits billing for phone sessions (e.g., Medicare), you will be asked to schedule a visit with your provider.

If cancellation of an appointment is necessary, we request 24 hours notice so that your appointment time can be made available for another client of JF&CS. Cancellations without adequate notice will be charged at your regular fee with the exception of emergency situations as determined by the Agency. Either way, we request that you call the Agency, if possible, to let us know about your inability to make an appointment.

All clients of our Agency have a right to confidentiality and privileged communication, with a few limited exceptions. Missouri law dictates that if any individual intends harmful acts or dangerous action against others or against themselves, it is the Agency’s duty to break confidentiality with the client to ensure that the client and others are safe. Every effort will be made to resolve the issue before a breach of confidentiality takes place. If the Agency has reason to believe that a child or vulnerable adult is being physically abused, sexually abused, or neglected, we are mandated to report the incident to the proper authorities.

A case record is assembled documenting the services you receive at the Agency. You have the right to access your case record and obtain a copy of its contents. The original case record is the property of the Agency and will remain secured in the Agency in accordance with State law. You will be charged 15 cents per page plus a $10 handling fee to cover the costs of copying your case record and you must present yourself at the Agency with identification to obtain a copy. The Agency has 30 days to prepare a copy of your case record from the date of written request.

On occasion, clients call upon mental health providers to participate in legal proceedings (e.g., custody, divorce, etc.). It is this Agency’s policy that its staff only involves themselves in legal proceedings when ordered by the court. The Agency strongly believes that involving its staff in legal proceedings should be avoided because of the potential for it to negatively affect the therapeutic relationship and the potential for opening up the client to unnecessary scrutiny. Other than a mandate from the court, you will be charged for any time the Agency uses to deal with legal proceedings.

Should the need arise, as a client of the Agency, you may: (1) file a grievance; (2) have access to information in your written record; or (3) refuse or discontinue treatment.

I understand that if I or my child is receiving services funded by St. Louis County Children's Services that this funding group may audit both the financial and service delivery documentation of the services received.

l have read and been offered a copy of this letter. I have read and been offered a copy of Client Rights and Responsibilities. By signing below, I agree to receive services from Jewish Family & Children’s Service and agree to the aforementioned conditions for obtaining services from Jewish Family & Children’s Service.

.□Yes □No I consent to have emails sent to me by agency staff regarding appointment times, service paperwork, or other non-treatment related issues.

I understand that my therapist does not provide therapy by email. I agree that if I have a crisis situation outside regular office hours, I will call Behavioral Health Response or Life Crisis, go to the emergency room, or call 911. I will not use email to advise my therapist of the crisis.

JEWISH FAMILY & CHILDREN’S SERVICE

St. Louis, MO

WE GUARANTEE ALL OUR CLIENTS THESE RIGHTS

Civil Rights . . .

You have the right to be treated with dignity and respect.
You retain all rights, benefits and privileges guaranteed by law.
All Agency services are offered in a non-coercive manner using the least restrictive alternatives available.

Confidentiality . . .

All information concerning you is held confidential and released only through procedures consistent with the law and professional ethics.
The Agency will obtain your written consent prior to release of information.
To provide you with the best services available, your client record may be reviewed by other Agency staff members to formulate an appropriate service plan.

Non-Discrimination . . .

With the guidelines of the Agency’s eligibility criteria, services will be provided to you and/or your family members without discrimination based upon national origin, race, sex, religion or age.
You will not be refused services because of limited financial resources. Fees are based upon a sliding fee scale, and you are expected to pay the fee agreed upon.
Services will be accessible to persons with physical disabilities.
Agency service hours will be reasonably convenient to all clients requesting services. Regular service hours are:

Monday and Wednesday, 8:30 a.m. - 5:15 p.m.

Tuesday and Thursday, 8:30 am. - 8:30 p.m.

Friday, 8:30 a.m. - 5:00 p.m.

Grievance Procedure . . .

If you wish to lodge a complaint about services provided to you, the grievance procedure is available for all clients and applicants for service.
You have the right to legal recourse. You have the right to confer with family, attorney, physician, spiritual leader and others at any time.

Service . . .

You have the right to an individual service plan and will be expected to participate in your plan for service.
If in the judgment of the Agency an appropriate service plan cannot be developed or implemented, referral to another service provider will be made.
You have the right to refuse service or treatment unless your rights have been limited by law.
You have the right to know the name and professional credentials of anyone working with you.
Upon written request, your therapist will arrange to review your client record with you. You may add an addendum to your record and may review the Agency’s response to that.
You have the right to be informed and given a copy of the Code of Ethics.

Mutual Responsibilities of JF&CS and Client . . .

Deciding on the type of service.
Determining how often and how long service is necessary.
Involving your family members or significant others as needed.

JF&CS’ Responsibilities . . .

Assigning a therapist.
Maintaining an accurate client record.
Making referrals to other service organizations, if needed.
Charging an appropriate fee for service.
Determining the appropriateness or benefit of Agency services for you, including the decision to refer you to other service providers.
Reserving the right to make a decision regarding the appropriate need for service and and/or the need for discharge or termination of services.

Notice of Privacy Practices

Effective Date: February, 2010

Jewish Family & Children’s Service (JF&CS) collects specific information about you in order to provide you the services you need. The information we collect about your mental and physical health is considered “private,” and is protected by state and federal laws. We refer to this information as “Protected Health Information” or “PHI.”

JF&CS staff follows all state and federal laws protecting your PHI and we limit and protect any sharing of information about you to the minimum that is necessary to do our jobs. We expect all of our employees, volunteers and business partners to respect your privacy and abide by the same laws.

A record of your care is created at JF&CS in order to provide you with quality care and to document our services for legal and billing purposes. This notice informs you of the ways that we may use this information, to whom and how we may share it, and also what rights you have regarding your PHI.

PERMITTED USES AND DISCLOSURES

1. Upon your signing of this notice, JF&CS is permitted to use and share with others involved in your care your protected health information for treatment, payment and health care operations, as described in the following examples:

a. For treatment – A doctor or nurse you are seeing may need to consult with your psychologist or social worker to provide the best care.

b. For payment – Our staff member who does our billing needs to provide information to your health insurance company so we can receive payment for our services. If, however, you request restriction on a disclosure to a health plan, for purposes of payment or healthcare operations (not for treatment), we must grant the request if the health information pertains solely to an item or service for which we have been paid in full.

c. For health care operations – We may use information in your record to review the quality of our care and the performance of our staff.

2. JF&CS is permitted or required, under specific circumstances, to use or share protected health information without your written authorization. For example, we are obligated by law to report suspected abuse of a child or a vulnerable adult, notify a person exposed to a communicable disease, disclose health information to federal and state government oversight committees, disclosed information in response to law enforcement’s official request regarding a crime against a person, for purposes of research, to avoid harm to another person, for worker’s compensation purposes, for appointment reminders, and to contact you to raise funds for us to continue or expand our services.

3. Other uses and disclosures will be made only with your written authorization, and you may revoke such authorization.

4. JF&CS may contact you to provide appointment reminders or information about treatment alternatives or other heath-related benefits and services that may be of interest to you.

5. You have the following rights regarding protected health information:

a. The right to request restrictions on certain uses and disclosures of protected health information. JF&CS is not required to agree to a requested restriction, however.

b. The right to receive confidential communications of protected health information, as applicable.

c. The right to inspect/copy protected health information, as per the Privacy Regulation.

d. The right to amend protected health information, as provided in the Privacy Regulation.

e. The right to receive an accounting of disclosures of protected health information. The accounting must include the following information:

Date of each disclosure.

Name and address of the organization or person who received the protected health information.

Brief description of the information disclosed.

Brief statement of the purpose of the disclosure that reasonably informs you of the basis for the disclosure or, in lieu of such statement, a copy of your written authorization or a copy of the written request for disclosure.

f. The right to obtain a paper copy of JF&CS Notice of Privacy Practices upon request.

g. The right to obtain within 30 days of a written request a summary of your protected health information. We may charge a fee for copying or preparing a summary for you.

6. JF&CS is required by law to maintain the privacy of protected health information and to provide individuals with notice of its legal duties and Privacy practices with respect to protected health information.

7.JF&CS is required to abide by the terms of the Notice currently in effect.

8.JF&CS reserves the right to change the terms of this Notice. The new Notice provisions will be effective for all protected health information that it maintains.

9. JF&CS will provide individuals or patients with a revised Notice by mail or e-mail.

Individuals may complain to JF&CS or to the Secretary of the Department of Health and Human Services, without fear of retaliation by JF&CS, if they believe their privacy rights have been violated. Complaints may be made in person to any JF&CS staff member who will then forward the complaint to the appointed Privacy Officer. You may file a complaint directly with the Privacy Officer (listed below) in person, by telephone, or in writing. Please remember to include details of the exact nature of your complaint, the names of any staff persons involved, your name and a daytime phone number.

Martha Kreipke, Privacy Officer; (314) 993-1000;

Jewish Family & Children’s Service; 10950 Schuetz Road, St. Louis, MO 63146

I hereby acknowledge that I have received a copy of JF&CS Notice of Privacy Practices and consent to JF&CS using my protected health information as permitted or required by law.

Client Name: _____________________________________________________

Date:_________________________

Client Signature: ______________________________________________________________________

Witness

□ Client was informed of the Notice of Privacy Practices and chose to share PHI prior to receiving a copy of the Notice of Privacy Practices.

Client’s Signature:_________________________________________________

Witness

□ Client was informed of the Notice of Privacy Practices and chose not to sign a copy prior to the collection of PHI and/or the delivery of services, but agrees to receive services under JF&CS’ Privacy Practices.

Client's Signature:_______________________________________________________

Witness

Fee Determination Form for Counseling Clients