LIFEWAY INFORMED CONSENT & POLICIES

On behalf of myself or my minor child or other client named below, I acknowledge and consent to the statements made in this form. Changes or alterations to this form are not binding on LifeWay Counseling Centers, Inc. (referred to as “LW” in this form).

Consent to Treat: I voluntarily consent to receive medical treatment and healthcare services that I and my provider at LW determine to be appropriate. Services may include in-person, telehealth, or other healthcare-related services provided by LW.

I understand that LW may provide certain services by remote telehealth technology. Such telehealth services involve a health provider who is at a site remote from my location at the time of the service, and, as such, telehealth often involves the transmission of video, audio, images, and other types of data. The remote health provider will determine whether the condition being diagnosed or treated is appropriate for telehealth, and I understand that there is no guarantee of diagnosis, treatment, or prescription.

Further, I understand that I may have to travel to see a health provider in-person for certain diagnosis and treatment matters.

There are inherent benefits, risks of confidentiality, security, and technical issues when using telehealth and online communications. Please understand that you may opt out of this service at any time.

Benefits to Telehealth:
• The client and provider can engage in services without being in the same physical location.
• Telehealth allows for continued care even during national crises or personal travel.
• Providers are trained and competent in telehealth methods.
Risks, Confidentiality, and Security:
• Telehealth may not be suitable for all conditions, and I may need to attend in-person sessions for certain matters.
• I am responsible for ensuring that I have a private and secure location for telehealth sessions.
• My provider will verify my identity for telehealth services as needed.
• If technical issues occur, the session may be rescheduled.

• I agree to inform my provider of my physical location at the beginning of each telehealth session in case of an emergency.
• Telehealth is not suitable for emergency situations. In a crisis, I must call 911 or go to the nearest emergency room.

Encryption and Security of Electronic Communications: LW will use encryption
technology for electronic communications (email, text) where feasible to protect your information. However, absolute security cannot be guaranteed, and clients are responsible for maintaining the security of their own devices and accounts.

Electronic Communications (Email/Text): I consent to receive communications from LW via email and text for appointment scheduling, billing, and general non-urgent matters. I acknowledge and understand:
• These communications are not fully secure and may carry privacy risks.
• I should not include sensitive health information in emails or texts.
• LW will take reasonable measures to secure communications, but absolute security cannot be guaranteed.
• I am responsible for securing my own devices and accounts (e.g., strong passwords, avoiding public Wi-Fi).
• I may revoke this consent at any time by notifying LW in writing, by phone, or via email. Revocation will be effective once acknowledged by LW staff.
• Communications may become part of my medical record.
Confidentiality & Mandated Reporting: Information shared will be kept confidential within the boundaries of the law and best practices. LW is required to report concerns of abuse or neglect involving any child or disabled/impaired adult.
Treatment of Minors and Individuals Under Court Orders: LifeWay Counseling Centers requires the submission and review of all relevant legal documents, including custody agreements, court orders, and guardianship papers, prior to initiating treatment for minors or individuals subject to legal constraints. It is the responsibility of the client, parent, or legal guardian to provide these documents to LW. LW is not responsible for identifying the existence of such documents or ensuring they are provided. Treatment will not commence until these documents have been thoroughly reviewed and understood by our clinical
team.

Child Safety and Supervision: For the safety of your children, they may not be left unsupervised in the waiting room. Please make alternative arrangements for childcare during office visits and telehealth sessions, unless your child is part of the therapy. Siblings will not be able to accompany parents or the client into a session unless specifically requested by the doctor or therapist prior to the session.

Financial Responsibility: Subject to applicable law and the terms and conditions of any applicable contract between LW and a third-party payer, and in consideration of all healthcare services rendered or about to be rendered to me (or the below-named client), I agree to be financially responsible and obligated to pay LW for any balance not paid under the “Assignment of Benefits/ Third Party Payers” paragraph below.
Assignment of Benefits/Third-Party Payers: In consideration of all healthcare services rendered or about to be rendered to me (or the below-named client), I hereby assign to LW all right, title, and interest in and to any third-party benefits due from any and all insurance policies and/or responsible third-party payers of an amount not exceeding LW’s regular and customary charges for the health care services rendered. I authorize such payments from applicable insurance carriers, third party payers, and other third-parties. A list of usual and customary charges is available upon request. I consent to any request for review or appeal by LW to challenge a determination of benefits made by a third-party payer. Except as required by law, I assume responsibility for determining in advance whether the services provided are covered by insurance or other third-party payer. I agree to be financially responsible for all services rendered that are not covered by my insurance or third-party payers. I authorize LW to bill my insurance directly and receive payments on my behalf.
Credit Card Authorizations & Fees: I authorize LW to charge my card on file for copays, deductibles, no-show fees, and outstanding balances. This authorization will remain in effect until it is revoked by me in writing. A list of usual and customary charges is available upon request.

Self-Pay Discount Arrangements: Clients may elect to self-pay for services and qualify for discounted fees. LW will not file claims for self-pay services.
Cancellation Policy: LW asks that you provide 24-hour notice for cancellations. Failure to give a 24-hour notice will result in a $75.00 fee that is not billable to your insurance company.

Legal Proceedings Policy: Participation in legal proceedings, including responding to subpoenas, preparing documents, providing testimony as a fact or expert witness, and travel time, will be billed at $250 per hour. A retainer of $500 may be required in advance of any scheduled appearance.

Secure Electronic Medical Record: LW providers use a secure, HIPAA-compliant electronic medical record (EMR) system to store, access, and maintain your health information, including scheduling sessions and maintaining clinical notes.
Technology-Assisted Documentation and Care

Support: LifeWay may use secure technology tools to assist with documentation, transcription, digitization of records, and other clinical or administrative support functions. These tools are used to support treatment, care coordination, payment, and health care operations, and are subject to applicable privacy and security protections. Information generated through these tools is reviewed by your provider or another appropriate workforce member as needed before
being finalized in your record. You may opt out of audio-assisted transcription, when offered, at any time by notifying your provider.

Disability Filings: LW providers are unable to evaluate and provide documentation for disability due to the dual-agency nature of those requests.
HIPAA Policy & Disclosure of Health Information: I have reviewed LW’s Notice of Privacy Practices available at
https://www.lifewaycenters.com/forms/
which explains how my health information may be used and disclosed.

Revision : Apr-22-2026