Financial Policy & Agreement

We are committed to providing you with the best possible care and would be happy to discuss our financial fees with you at any time. Copayments or Full payment if deductible applies, are due at the time of service. We do not accept checks, cash, or money orders. 

Insurance: If you have insurance, we will help you receive maximum benefits. You are responsible for providing all insurance coverage information and establishing the primary and secondary coverage between you and your insurance carrier. All co-pays must be paid at the time of service. If your insurance requires a deductible before they will pay, you will be responsible for your deductible until it is paid. Once we file your insurance, if payment is not received within 60-days, you will need to submit the payment for the balance due or make payment arrangements with our office.

Minor Children: The parent(s) or guardian who brings a child to therapy or psychiatrist appointments are responsible for the account. It is our policy to consider an 18-year-old who is still in high school a “minor”. Insurance billing for the minor is the same as the above section on insurance. As a 3H client, the following fees apply for services received.

This chart represents the cost of services, for out of pocket services.

ORIENTATION CHECKLIST

The following information has been provided as part of the consumer orientation. A check of the item and the signatures below indicate that each area has been fully explained and is understood by the consumer. 

• Client Rights and grievance and the appeals procedures
• Privacy Rights See 42 U.S.C. and U.S.C. 290ee-3 for Federal Law and 42 CFR Part 2 for Federal Regulations.
             * The client/legal guardian consents in writing.
             * A court order permits disclosure.
             * In a medical emergency, the disclosure is made to medical personnel.
             * The disclosure is made to personnel for auditing or evaluation.
• Access to emergency services, after hours
• Services provided, days and hours of operation, expected level of participation
• Code of ethics/conduct
• Confidentiality policy, limits of confidentiality
• Methods, opportunities, and policy on input
• Explanation of financial obligations, fees, and financial arrangements
• Fire, safety, and emergency precautions
• Policy on restraint
• Policy on tobacco products
• Policy on illicit or licit drugs being brought into the program or onto the premises
• Policy on weapons brought into the program or onto the premises
• Identification of the person responsible for service coordination
• Program rules, including restrictions and the loss and regaining of rights
• Requirement to report
• Individual plan development
• Discharge/transition criteria and procedures
• QA/QC questionnaire and reporting concerns
• Appointment Expectations for Doctor Day, Assessments, and Case Manager

CONDITIONS TO RECEIVE SERVICES

Welcome to 3H. Our program is designed to assist individuals and their family members that are seeking assistance for Mental Health, Behavioral Health, Substance Abuse, and/or Community Support, to gain the necessary skills and abilities needed to live a consistently healthy, balanced, and productive life. Through assessment and coordination of care with our qualified, caring staff; an individualized treatment plan will be conducted, so we may accommodate your personal needs and goals, regardless of where you are in your life. For 3H to successfully meet your needs, there are specific program requirements and standards that are set in place, for you to receive services with our agency.

The following conditions allow us to ensure you receive the best quality of care you deserve.  Individuals requesting services must be drug/alcohol free, and/or willing to become drug/alcohol free regardless of what services you desire. This includes, but is not limited to:
          * Non-FDA regulated drugs
          * Illegal/illicit drugs
          * Over-the-counter substances
          * Synthetic substances (Kratom & Mojo)
          * Methadone, Suboxone, and/or Subutex

3H is NOT a Methadone/Suboxone clinic, nor do we support the use of these highly addictive and abused substances.

Individuals are required to consent to being randomly urine drug tested (UDS) and Breathalyzed (ETOH) at any time the provider deems necessary.

Individuals requesting services are expected to make all scheduled appointments and remain compliant with any referring agencies. This includes, but is not limited to:
          * Probation and parole
          * Judicial and Court Representatives
          * Medications that are prescribed by our physicians.

Clients are expected to give a minimum of a 24-hour notice if you they are unable to keep their scheduled appointment(s).

Any individual that goes more than 7-days without making contact or becomes noncompliant, with any of the above stated conditions, will be subject to discharge. We can only help you if you are willing to help yourself.

We are happy that you have chosen 3H to assist you with your individual and/or family support needs. Accountability and accepting personal responsibility, is two of the first steps to leading a healthy and balanced lifestyle. If you are ready for help and desire positive change in your life, then you have come to the right place. By signing below, you are acknowledging that you agree to comply with, and understand what is required of you to receive services with 3H. If you have any questions or concerns prior to signing below, please speak with an available 3H representative. We look forward to working with you and being a part of your future success.

Consent for Electronic Signature

This is to certify my request for an electronic signature. Using an electronic signature, I agree that the information I provide is accurate and complete to the best of my knowledge. I agree that the electronic signatures appearing on this agreement (and other documents that require electronic signatures provided by 3H are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility. Please note that you may withdraw your consent to sign documents electronically at any time. To withdraw consent, I must notify 3H that I wish to withdraw consent and request that my future documents be prepared in paper format.

Consent for Treatment

I agree and consent to participate in behavioral health care services offered and provided at/by 3H, a behavioral healthcare provider. I understand that I am consenting and agreeing only to those services that the above-named provider is qualified to provide within:

(a) Scope of the provider’s license, certification, and training; or

(b) Scope of license, certification, and training of the behavioral healthcare providers directly supervising the services received by the patient. If the patient is under age 18 or unable to consent to treatment, I attest that I have legal custody of this individual and am authorized to initiate and consent for treatment and/or legally authorized to initiate and consent to treatment on behalf of this individual.

Financial Release

I understand that Therapist may use confidential information about me to bill and be paid for services. I hereby consent for Therapist to release information to our Electronic Health Record Company, Integrity Support Inc., and its contracted clearinghouse, and/or to the funding source, and for the funding source to release information to Therapist and Integrity Support, Inc. for this purpose.

Permission to Transport

I hereby grant permission for Therapist, to provide transportation to myself and/or my child and agree to hold 3H harmless for any accident/injury that results from the provision of transportation. 

Permission to Seek Emergency Medical Care

I hereby give consent for Therapist, to seek and sign consent for emergency medical care if I am unable to do so for myself. It is understood that Therapist will attempt to locate me, or another legally responsible adult, as quickly as is possible in an emergency.

Telehealth Consent

I agree to participate in Telehealth services offered through 3H. including outpatient therapy and medication management. I understand that I have the option to schedule appointments with 3H, Psychiatrist, Medical Psychologist, Psychiatric Nurse Practitioner, or Outpatient Therapist in another 3H office that supports an on-site practitioner. However, such a face-to-face appointment may require a wait time from one to 4 weeks and commuting from out of town will be at my own expense. By signing below, I acknowledge that:

Eligibility:

Service recipients must meet traditional eligibility services for requirements as determined by prevailing state, MCO or third-party insurance practice guidelines. In addition, the person served must be willing, able, and have the equipment and internet connection to use telehealth services.

Equipment:

Prior to the delivery of services and throughout services the agency will determine if the person-served and the assigned staff have the necessary equipment and internet access to use telehealth at their respective locations.

Privacy:

Prior to the start of each session all staff in the session will identify themselves to the person served. A company ID should be displayed to verify the staff identity. 

Prior to the start of each session all persons served and any other persons in attendance in the session will identify themselves to the staff.  Staff may verify the person served’ s identity by comparing to a photograph on record or asking to see a personal ID. The person served may vouch for others.

The staff will ask the person served to pan the camera around the persons served’ s location. If others are present the staff will ask the person served if any others in attendance are permitted to be in the session. If not, the session will be rescheduled.

People served will be advised to use headset/ear buds.  The staff must be in a private space to ensure conversations are private.

Emergency Procedures:

If applicable, the staff providing telehealth will become familiar with the emergency procedures of the remote site, if the procedures exist. For example: the fire evacuation procedure of an assisting living facility. Staff providing telehealth services will have access to the persons served’ s emergency contacts and crisis/safety plan when providing telehealth services.

If the telehealth service is not provided at a street address the staff will obtain a descriptor of the person served’ s location in case of emergency. For example, at the ABC Park in Anytown, KY at the bench by the main entrance. Staff providing telehealth services will have access to the persons served’ s local emergency resources, including phone numbers.

Communication

I understand that one of my rights is to be able to choose how I am contacted. I give permission for 3H to contact me at the phone numbers that I provide them. 

Consent to Photograph

I give permission for 3H to use my photo/video or likeliness in their Social Media Outlets, as it pertains to events held by 3H.

Consent to Record Sessions

I hereby give consent to 3H to record (audio/video) our counseling sessions, as needed. I acknowledge and understand that these recordings will be used solely for the professional development of employees of 3H. I understand that the organization may/may not receive feedback from the professional community as well, when needed. I understand that myself or my family may or may not be the focus of any discussion during a month of recording. I understand that these recordings are anonymous and will only be heard by licensed counselors or unlicensed providers that have signed HIPAA agreements. All recordings will be promptly erased when no longer needed. I understand that refusal to sign this form will not affect my eligibility for receiving services nor affect the therapeutic relationship between myself and 3H.

Consent to Visit School, When Needed

I understand that there may be times when staff members of 3H, may need to visit my child’s school, to visit his/her teacher or school administration; observe the child’s classroom behavior; or to intervene in the event of a crisis. By signing this document below. I acknowledge and/or grant the agency staff permissions to enter the school on my behalf.