Common use of AUTHORIZATION FOR COLLECTION Clause in Contracts

AUTHORIZATION FOR COLLECTION. I understand that if I fail to pay, the account can be turned over for collection and that I will be responsible for all costs involved. 5. ACNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES I have been provided a copy of Journey Counseling Services Notice of Privacy Practices. We have discussed these policies, and I understand that I may ask questions about them at any time in the future. I acknowledge that the above items have been reviewed with me and I fully understand and agree with them. Signature: Printed Name: Date: 0 Xxxxxxx Xx, Xxxxx 000 Xxxxx Xxxxxxx, XX 00000 AUTHORIZATION TO RELEASE/EXCHANGE INFORMATION Patient name: Birthdate: Social Security No: I understand that the specific information to be disclosed includes the following and that I have a right to inspect the disclosed information at any time. I understand that I can revoke my consent in writing at any time, and if I do not revoke this consent, it will expire automatically one year after the date signed below. I hereby authorize (Name of individual or institution) (Address) to disclose, exchange with, and deliver information to (Name of individual or institution) (Address) for the purposes of evaluation, treatment planning, security, claims evaluation and payment. Further disclosure of this information to another party is unlawful and can result in criminal and civil penalties unless authorized by the client. Initial YES NO (Please place check mark under yes or no and initial beside each option) MENTAL HEALTH INFORMATION SUBSTANCE ABUSE(drug or alcohol)INFORMATION AIDS-RELATED INFORMATION DISCLOSURE necessary for claims processing/third party payor I acknowledge that information released may include material that is protected by federal or state laws applicable to the diagnosis and treatment of substance abuse, mental illness, and AIDS-related conditions. I understand that my Records may be protected under the Federal Confidentiality Regulations (42 CFR Part 2) and, if so, cannot be disclosed without my written consent unless otherwise provided for in the regulations. I understand that I may revoke this authorization at any time, except to the extent that action has already been taken in reliance upon it, by giving written notice to Journey Counseling Services.. Revocation is effective upon receipt of such request. Signature of Client Date Signature of Parent/legal guardian Signature of Counselor Psychosocial History - Minors Instructions: Please complete the following information about your child and family. If any questions do not apply to your child, simply write ”DNA” (does not apply) in the space provided or leave the space blank. It is best if this form is completed by all parents or primary caretakers. This information will be helpful to your child’s doctor or other professionals to better understand your child and your family.

AUTHORIZATION FOR COLLECTION. I understand that if I fail to pay, the account can be turned over for collection and that I will be responsible for all costs involved. 5. ACNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES I have been provided a copy of Journey Counseling Services Notice of Privacy Practices. We have discussed these policies, and I understand that I may ask questions about them at any time in the future. I acknowledge that the above items have been reviewed with me and I fully understand and agree with them. Signature: Printed Name: Date: 0 Xxxxxxx Xx, Xxxxx 000 Xxxxx Xxxxxxx, XX 00000 AUTHORIZATION TO RELEASE/EXCHANGE INFORMATION Patient name: Birthdate: Social Security No: I understand that the specific information to be disclosed includes the following and that I have a right to inspect the disclosed information at any time. I understand that I can revoke my consent in writing at any time, and if I do not revoke this consent, it will expire automatically one year after the date signed below. I hereby authorize (Name of individual or institution) (Address) to disclose, exchange with, and deliver information to (Name of individual or institution) (Address) for the purposes of evaluation, treatment planning, security, claims evaluation and payment. Further disclosure of this information to another party is unlawful and can result in criminal and civil penalties unless authorized by the client. Initial YES NO (Please place check mark under yes or no and initial beside each option) MENTAL HEALTH INFORMATION SUBSTANCE ABUSE(drug or alcohol)INFORMATION AIDS-RELATED INFORMATION DISCLOSURE necessary for claims processing/third party payor I acknowledge that information released may include material that is protected by federal or state laws applicable to the diagnosis and treatment of substance abuse, mental illness, and AIDS-related conditions. I understand that my Records may be protected under the Federal Confidentiality Regulations (42 CFR Part 2) and, if so, cannot be disclosed without my written consent unless otherwise provided for in the regulations. I understand that I may revoke this authorization at any time, except to the extent that action has already been taken in reliance upon it, by giving written notice to Journey Counseling Services.. Revocation is effective upon receipt of such request. Signature of Client Date Signature of Parent/legal guardian Signature of Counselor Psychosocial History - Minors InstructionsClient Name Date / / Therapist Family/Relationship History Marital status: Please complete the following information about your child Married Separated Divorced Single Widowed Previous marriages: Self Yes No Date married Date divorced Spouse Yes No Date married _ Date divorced Children from previous marriages: (Circle those living in home) Self: sex/age Spouse: sex/age: Children from present marriage : (Circle those living in home) Name Sex Age Adopted/Biological Brothers and family. If sisters: (Circle any questions do not apply to your childproblematic relationships) M F Age M F Age M F Age M F Age M F Age M F Age M F Age M F Age M F Age Any major health problems, simply write ”DNA” (does not apply) alcohol/drug abuse, other addictive behaviors or mental health issues in the space provided or leave the space blank. It is best if this form is completed by all parents or primary caretakers. This information will be helpful to your child’s doctor or other professionals to better understand your child and your family.: Parents divorced? Y N Your age when divorced? Current issues with parent(s)? Y N Work/Education: Parents living? Father Y N Mother Y N Highest level of education Occupation: Employer: Length of employment: Problems related to career/vocation? Military involvement present/past? _ _ Nutrition/Exercise: Currently on a special diet? Yes No Describe: Balanced diet including fruits and vegetables? Yes No Intake of highly sweetened and/or caffeinated drinks? Amount/day Exercise? Recreation/hobbies? Spirituality: Church affiliation: Home Church: Attendance(how often): Church related activities (faith family, bible study groups, etc…): Importance of own faith/spirituality(scale 1-10)? Regularity of devotional/quiet time/meditation time? Current spiritual/religious issues needing help with?