Consent to Treat

I consent/I consent for my child to participate in the proposed treatment as recommended by the undersigned LifeWay provider in accordance with standards of professional practice. I hereby certify that the LifeWay clinician providing services has informed me of his/her professional qualifications, certifications, and/or licensure.

Assignment of Benefits and Release of Information

I hereby assign, transfer, and set over to LifeWay Counseling Centers, Inc. all of my rights, title and interest to my medical reimbursement benefits under my insurance policy. I authorize the release of any medical information needed to determine these benefits. This authorization shall remain valid until written notice is given by me revoking said authorization. I authorize LifeWay to release my financial information to my guarantor or third party collection agency if further collection assistance is required.

Payment Responsibility

I understand that verification of insurance benefits, eligibility, pre-approvals or authorizations are my responsibility and that LifeWay provides insurance filing and inquiry as a courtesy to our patients. Those claims that are denied by the insurance company and which and are not required to be written-off due to a contract with the insurance company are my responsibility. If my insurance company does not pay on claims submitted within 90 days, or if claims are denied, charges become my responsibility and payment is due to LifeWay Counseling Centers. It will then become my decision whether or not to pursue reimbursement from my insurance company.

I understand it is LifeWay’s policy to collect co-pays at the time of service. If my dependent or I arrive for a session and do not have the co-pay and/or patient responsible balance, the session may be rescheduled for a later date, so that payment arrangements can be made to bring the account up to date. I also understand cancellations will incur a $60 charge. (See our cancellation policy.) We cannot bill a spouse or former spouse regardless of the divorce decree.

Self-Payment Discount Agreement

Patients who self-pay save LifeWay substantial time and expense in obtaining authorization and filing insurance claims. Therefore, we are able to offer a self-payment discount to these patients. LifeWay will not file a claim after self-payment nor accept any payment from an insurance company for claims filed by the patient for any prepaid services, because of the additional costs of managing claims, follow-ups and appeals. I understand that I cannot bill my insurance company for services I receive under this agreement.

Statement of Confidentiality

I understand that the personal information shared in this consult and/or therapy session will be kept confidential or private within the boundaries of the law and by what are considered best practices of the field. Information will not be shared beyond the staff of LifeWay Centers without written consent of the patient or legal guardian/parent, except where mandated by law or legal precedent for safety factors, including where there is a danger of harm to self or others.

Mandated Reporters

I understand that State law mandates certain professionals or officials, acting in their professional capacity, must report concerns about any child or disabled/impaired adult who may be, or is at risk of being, abused or neglected. (Most mandated reporters work in schools, health care, counseling/psychology, child care, camps for children, the legal field, social work, or developmental disability programs.) More specific information on mandated reporters, and a complete list, is available at Ohio Revised Code 2151.421.

Obtaining Medical Records

I understand that in order to obtain a copy of my records I will first have to sign an authorization for release of confidential information from either the office of LifeWay Counseling Centers or from the requesting physician’s office. (While in most cases medical records can be obtained within 10 days, please allow up to one month for those records that may be stored off site.) There may be a charge for records obtained for the courts, disability claims, and other agencies as per the Ohio Revised Code Section 3701.742.

Additional Services and Fees (Please keep in mind that all office policies and fees are subject to change at any time without notice.)

Additional fees are charged for:

• missed appointments (see below)
• telephone consultations
• correspondence
• court appearances, and psychological testing (and associated letter and report preparation)
• other special services
• returned checks

Payment terms are to be made in advance of the service. Court testimony will require fees paid in advance. Phone sessions and aforementioned services are not covered by insurance.

Cancelling Your Appointment

LifeWay understands that at times it may be necessary to cancel or reschedule an appointment. We ask that you please be considerate of our staff and other patients by providing 24-hour notice, if you need to cancel or reschedule. Please leave a voicemail if you are unable to reach the front desk. Failure to give a 24-hour notice will result in a $60.00 fee that is not billable to your insurance company.

Refunds

LifeWay will be more than happy to refund patients for all services in which pre-payment or an over-payment has been made. However, if there is still an outstanding balance (patient or insurance), you will not be refunded until your account is paid in full. Please allow 2-4 weeks after your account has been paid in full for your refund to be complete. To initiate a refund, please contact the billing department.

Billing Questions

For billing questions please call our billing office at (513) 769-4600

Child Supervision

Children may not be left unsupervised in the waiting room. We ask that you make alternate arrangements for childcare during your visits to our office. Siblings will not be able to accompany parents or the patient into a session (unless specifically requested by the doctor or therapist prior to the session.) Noncompliance with this policy will require us to reschedule your appointment for a date in which you are able to obtain childcare. This policy is in effect for the safety of your children as well as out of concern and respect for our patients. We appreciate your cooperation in this matter.

HIPAA Policy

Copies are available on our website www.lifewaycenters.com and at the front desk.

Emergency Treatment

In case of emergency, please go to the nearest emergency room or dial 911.