THIS NOTICE DESCRIBES HOW MEDICAL/MENTAL HEALTH INFORMATION
ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET
ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

“Use and disclosure of protected health information for the purposes of providing
services. Providing treatment services, collecting payment and conducting healthcare
operations are necessary activities for quality care. State and federal laws allow us to use
and disclose your health information for these purposes.”

TREATMENT Use and disclose health information to:
· Provide, manage or coordinate care
· Consultants
· Referral sources

PAYMENT Use and disclose health information to:
· Verify insurance and coverage
· Process claims and collect fees

HEALTHCARE OPERATIONS Use and disclose health information for:
· Review of treatment procedures
· Review of business activities
· Certification
· Staff training
· Compliance and licensing activities

OTHER USES AND DISCLOSURES WITHOUT YOUR CONSENT
· Mandated reporting
· Emergencies
· Criminal damage
· Appointment scheduling
· Treatment alternatives
· As required by law

CLIENT RIGHTS:

Right to release your medical records
· Written authorization to release records to others
· Right to revoke release in writing
· Revocation is not valid to the extent that you have acted in reliance
on such previous authorization
Right to inspect and copy your medical billing records
· Right to inspect and copy records
· Counselor may deny this request
· Charges for copying, mailing, etc.
Right to add information or amend your medical records
· May request to amend record
· Number of days to decide
· May deny the request
· If denied, right to file disagreement statement
· Disagreement state and your response will be filled in the record
· Amendment request must be in writing
Right to Accounting of disclosures
· For a six year period beginning with date the counselor came in to
compliance (no later than 4/14/03)
· Exceptions:
· Disclosure for treatment, payment or healthcare operations
· Disclosures pursuant to a signed release
· Disclosure made to client
· Disclosures for national security or law enforcement
Right to request restrictions on uses and disclosures of your healthcare
information
· Must be in writing
· You are not obligated to agree
Right to complain
· Please contact you first
· If not satisfied, right to complain to the U.S. Dept. of Health and
Human Services
· No retaliation
Right to receive changes in policy
· May request any future changes
· Request to privacy officer

Health Insurance Portability and Accountability Act of 1996 (HIPAA)

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. This document may be updated without notice so please review it each time you visit us. A copy of this statement is
always available upon request. Your Rights as a Counseling/Therapy Client under HIPAA

⇒ As a client, you have the right to see your counseling/therapy file. Psychotherapy notes
are afforded special privacy protection under the HIPAA regulations and are excluded
from this right.
⇒ As a client, you have the right to receive a copy of your counseling/therapy file. This file
copy will consist of only documents generated by us. You will be charged copying fees
@ $.20/page. Psychotherapy notes are afforded special privacy protection under the
HIPAA regulations and are excluded from this right.
⇒ As a client, you have the right to request amendments to your counseling/therapy file.
⇒ As a client, you have the right to receive a history of all disclosures of protected health
information. You will be charged copying fees @ $.20/page.
⇒ As a client, you have the right to restrict the use and disclosure of your protected health
information for the purposes of treatment, payment, and operations. If you choose to
release any protected health information, you will be required to sign a Release of
Information form detailing exactly to whom and what information you wish disclosed.
⇒ As a client, you have the right to register a complaint with the Secretary of Health and
Human Services if you feel your rights, herein explained, have been violated.

The majority of this document is mandated by both South Carolina State law and Public Law 104-191; it is provided for your protection. Anderson Counseling and Education has tried to anticipate any risks you may face as a result of being in therapy. If you have any questions regarding the documents you have received, please feel free to discuss them with Jerlinda Anderson.

Contact Information: Anderson Counseling and Education is located at 100 Stone Village Drive Suite 104 B, Fort Mill, SC. This is also our mailing address. Our usual office hours are Monday - Friday 8 AM through 5 PM. Our clients are seen by appointment only and special appointments for evenings, weekends, and other selected times will be considered. Our telephone number is 980-404-2365 (the voicemail is confidential) and our fax number is 803-403-8916. Our email address is jerlinda@andersonedcounsel.org and it is checked at least once every working day. Our webpage is www.andersonedcounsel.org and contains more information regarding Anderson Counseling and Education.

Personal Qualifications: Jerlinda Anderson is the Clinical Director of Anderson Counseling and Education. Please note some of
her credentials listed below:

- South Carolina Licensed Professional Counselor
- Certified Health Education Specialist

Bachelor of Science - Community Health Education - Southern Illinois University
Master of Science - Community Psychology - Martin University
Education Specialist - Curriculum and Instruction - Liberty University

Areas of Specialization:

Child and Adolescent Counseling
Trauma and Abuse
Learning Disabilities
Pregnancy and Post Partum Issues
HIV/AIDS
Health Promotion and Medical Issues to include Obesity and Diabetes

Trainings Include:

US Airforce School of Aerospace Medicine - Health Promotion Academy

US Department of Justice - Dealing with Unexpected Death

Indianapolis Healthy Start - Understanding Post-Partum Depression

Centering on Pregnancy Advanced Training

Indiana Child Welfare Academy - to include person centered case work, impact of child abuse and neglect on child development, sexual abuse and legal issues

University of South Carolina School of Medicine- Trauma Focused Cognitive Behavioral Therapy with Child Sexual Abuse and Traumatic Grief

University of Florida - Tree of Life Suicide Assessment Training

Additional Information:

Any type of sexual behavior between therapist and client is unethical. It is never appropriate and will not be condoned.


Note on Cancellations: Due to the long-term nature of my practice, I must hold you responsible for all regularly scheduled consultation sessions whether or not you are able to attend. Should it be necessary for you to cancel an appointment, I must have 24 hours notice in order to waive the fee. Missed appointments for which I am not notified will be subject to a $60 service charge. You nor I can bill your insurance for missed sessions.

Note on Insurance Reimbursement: Due to the complexities and time delays of insurance reimbursements, unless otherwise agreed I must ask that you pay at the beginning of each session. Or if I agree to send a bill, that you pay in full no later than the tenth of each month. Bills will include a Diagnosis for insurance companies to provide reimbursement.


Fees: The fee for service generally covers a 50-minute session and will be agreed upon in the first treatment session. The client will pay at the beginning of each session.

Availability: The therapist is available for regularly scheduled appointment times. Dates of vacations and other exceptions will be given out in advance if possible. Telephone appointment times can be made by calling the office number during regular office hours.


Termination of Treatment: The therapist may terminate treatment if payment is not timely, if prescriptions are not filled (such as seeking consultation, refraining from dangerous practices, coming to sessions sober, etc.), or if some problem emerges that is not within the scope of competence of the therapist. Not all people experience improvement from psychotherapy and therapy may be emotionally painful at times. Patients have the right to refuse or to discontinue services at any time.

Agreement for Psychotherapy Consultation

I have read this informed consent completely and have raised any questions I might have about it with my therapist. I have received full and satisfactory response and agree to the provisions freely and without reservations. I understand that my therapist is responsible for maintaining all professional standards set forth in the ethical principles of his/her professional association as well as the laws of the state of South Carolina governing the practice of psychotherapy and that he/she is liable for infractions of those standards.
I understand that I will be fully responsible for any and all legal and/or collection costs arising as a result of my contact with my therapist, including appropriate compensation for his time involved in preparing for and doing court work. I understand that my therapist from time to time makes teaching and research contributions using disguised client material. By consenting to treatment I am giving consent to this process of professional contribution and the right to use disguised material without financial remuneration.


Arbitration Agreement

I agree to address any grievances I may have directly with my therapist immediately. If we cannot settle the matter between us, then a jointly agreed-upon outside consultation will be sought. If not, an arbitration process will be initiated, which will be considered as a complete resolution and legally binding decision under state law. NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL or COUNSELING MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE ONE OF THIS CONTRACT.

Article 1:A It is understood that any dispute as to medical/counseling malpractice, that is as to whether any medical/counseling services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by submission to arbitration as provided by South Carolina law, and not by lawsuit or resort to court process except as [state ]law provides for judicial review or arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration. Any arbitration process will be considered as a complete resolution and legally binding decision. The client will be responsible for the costs of this process. In agreeing to treatment, you are consenting to the above identified grievance procedures. This agreement constitutes the entirety of our professional contract. Any changes must be signed by both parties. I have a right to keep a copy of this contract.

Insurance Verification & Billing

I herby authorize ANDERSON COUNSELING AND EDUCATION, acting as Service agent for JERLINDA ANDERSON to contact my insurance carrier in order to determine eligibility for medical services. I understand that my insurance will be billed for services rendered by both
JERLINDA ANDERSON and CASE MANAGEMENT staff providing treatment. I agree that if my insurance carrier issues a check in my name for reimbursement for services rendered by either the counselor and/or facility, I will within five days of receipt of this check make payment in the amount of said check to the counselor facility.

The following also applies to the use of my insurance to cover the cost of services rendered:

Authorization To Release Medical Information For Billing

I herby authorize the release of any information regarding services by the Physician/Facility to
process insurance claims and allow a photocopy of my signature to file insurance claims.

Assignment Of Insurance Benefit

I herby authorize irrevocably assignment of payment for my benefits due me for the services
rendered by the Jerlinda Anderson and the facility made directly to the counselor and/or the facility.

Financial Responsibility

I understand that if I am utilizing an "out of network" provider for the services rendered by the
physician and facility. Therefore I understand, regardless of my insurance benefits, that I alone
am fully financially responsible for the fees for the services rendered. I agree to collect charges
which will be added to my past due accounts.

Authorization For The Release Of Medical Information For Treatment

I herby authorize the above counselor and facility to obtain and release copies of my medical
records and information regarding my medical history, mental or physical conditions for the
purpose of further treatment and evaluation.

INFORMED CONSENT TO MENTAL/BEHAVIORAL HEALTH TREATMENT
PLEASE READ CAREFULLY BEFORE SINGNING THIS FORM.

I hereby give consent for mental health/behavioral health treatment and supports from:

Anderson Counseling and Education

for the purpose of addressing mental health/behavioral health concerns/symptoms. I understand
that additional information about the probable consequences of not receiving treatment, side
effects and potential risks and benefits, as well as information about feasible alternative
treatments, will be further explained to me during the therapeutic treatment process.

1. Right to Withdraw Consent: I have the right to withdraw my consent for evaluation and/or
treatment for myself/my child at any time by providing a written request to the treating clinician.

2. Expiration of Consent: This consent to treat will expire 12 months from the date of signature,
unless otherwise specified.