THERAPY CONSENT TO DISCLOSE AND RECEIVE INFORMATION

NOTICE OF PRIVACY AND CONFIDENTIALITY & BILL OF RIGHTS

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.

GENERAL INFORMATION

The confidentiality of alcohol and drug abuse client records maintained by Ark Alliance Recovery, LLC (AAR) are protected by two federal laws: the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 42 U.S.C. § 132d et seq., 45 C.F.R. Parts 160 & 164, and the Confidentiality Law, 42 U.S.C. § 290dd-2, 42 C.F.R. Part 2. Generally, Ark Alliance Recovery, LLC (AAR) may not say to a person outside the program that you attend the program, nor disclose any information identifying you as an alcohol and/or drug user, or disclose any other protected information except as permitted by federal law.

AAR must obtain your written consent before it can disclose information about you for payment purposes. For example, AAR must obtain your written consent before it can disclose information to your health insurer in order to be paid for services. Generally, you must also sign a written consent before 

AAR can share information for treatment purposes or for health care operations. However, federal law permits AAR to disclose information without your written permission:

1. Threatening to harm yourself or someone else

2. To appropriate authorities to report suspected child or elder abuse and/or neglect or exploitation;

3. As allowed by a court order.

Before AAR can use or disclose any information about your health in a manner which is not described above, we must first obtain your specific written consent allowing Ark Alliance Recovery, LLC to make the disclosure. Any such written consent may be revoked by you in writing.

Under HIPAA you have the right to request restrictions on certain uses and disclosures of your health information. AAR is not required to agree to any restrictions you request, but if it does agree then it is bound by that agreement and may not use or disclose any information which you have restricted except as necessary in a medical emergency. You have the right to request that we communicate with you by alternative means or at an alternative location. AAR will accommodate such requests that are reasonable and will not request an explanation from you. Under HIPAA you also have the right to inspect and copy our own health information maintained by AAR, except to the extent that the information contains psychotherapy notes or information compiled for use in a civil, criminal or administrative proceeding or in other limited circumstances. Under HIPAA you also have the right, with some exceptions, to amend health care information in AAR’s records, and to request and receive an accounting of disclosures of your health-related information made by AAR during the six years prior to your request. You also have the right to receive a paper copy of this notice.

Your Rights Under HIPAA and The Confidentiality Law

1. You  have the right to have information about you kept private and to be told about the times when the information can be released without your      permission. The right to confidentiality as provided for in Title 42, Code of Federal Regulations, Part 2 and HIPAA. You have the right to receive      covered entity’s Privacy Notice.

2. The  right to be accorded access to your file and the right to own the information within your file with the exception of psychotherapy notes.

3. The  right to request corrections or erroneous and/or incomplete information.

4. The  right to prohibit re-disclosure of client information.

5. The  right to request transmittal of communications in an alternative manner.

6. The  right to obtain an accounting of disclosures.

7. The  right to make a complaint to the HHS Office of Civil Rights without fear of retaliation.

INFORMED CONSENT FOR TELEHEALTH THERAPY/BEHAVIORAL SERVICE

The purpose of this Informed Consent for Technology-Assisted Education is to inform you, the client, about the process of online services, the facilitator, and the potential risks and benefits of these services. The purpose is to also help safeguard you, the client, and give you information regarding alternatives to online services. LACK OF NON-VERBAL CUES AND ASYNCHRONOUS COMMUNICATION The client should be aware that misunderstandings are possible with telephone, text-based modalities such as email, and real-time internet chat since non-verbal cues are relatively lacking. Even with video chat software, misunderstandings may occur since bandwidth is always limited and images lack detail. Facilitators are observers of human behavior and gather much information from body language, vocal inflection, eye contact, and other non-verbal cues. If you have never engaged in online treatment before, have patience with the process and clarify information if you think your Facilitator has not 3 understood you well. Be patient if your Facilitator asks periodically for clarification as well. Since asynchronous communication is “not in real-time,” turnaround time for responding to emails will “lag” a response. Be aware of different time zones as well. The Facilitator will make every effort to respond to email requests within a 12-24 hour period.

Privacy and Confidentiality

Maintaining client confidentiality is extremely important. The facilitator will take extraordinary care and consideration to prevent unnecessary disclosure. Information about the client will only be released with his or her permission with the following exceptions: If the facilitator believes that someone is seriously considering or likely to attempt suicide; 2) if the facilitator believes that someone intends to assault another person; 3) If the facilitator believes someone is engaging or intends to engage in behavior that will expose another person to a potentially life-threatening communicable disease: 4) if the facilitator suspects abuse, neglect, or the exploitation of a minor or incapacitated adult; leaves the person gravely disabled. Although the internet provides the appearance of anonymity and privacy in treatment, privacy is more of an issue online than in person. The client is responsible for understanding the potential risks of confidentiality being breached through non-encrypted email, lack of password protection, or leaving information on a public access computer in a library or internet cafe. Other potential risks of breaching confidentiality could include messages failing to be received if they are sent to the wrong address or if they are just not noticed by the counselor. Confidentiality could be breached in transit by hackers or internet service providers or at either end by others with access to the client’s account or computer. Clients accessing the internet from public locations such as a library, computer lab, or cafe should consider the visibility of their screen to people around them. Position yourself to avoid others seeing your screen. Using cell phones can be risky in that signals are scrambled but rarely encrypted. The facilitator has a right to his or her privacy and may restrict the use of any copies or recordings, taking photos the client makes of their communications. Clients must seek the permission of the facilitator before recording any portion of the session and/or posting any portion of said sessions on internet websites such as Facebook or YouTube. The client is responsible for securing their own computer hardware, internet access points, chat software, email, and passwords that are encrypted, secure, and HIPPA compliant when possible. If encryption is not made available to clients; clients should be aware that they are risking unauthorized monitoring of transmissions and/or records of internet treatment sessions. You agree to work with us online using any encrypted email/chat service determined to be suitable by us. Additionally, 1) If you call us, please be aware that unless we are both on landline phones, the conversation is not confidential. 2) Any computer files referencing our communication are maintained using secure and encrypted measures. We will not respond to personal and clinical concerns via regular email. 3) If you wish to use email as a way to "journal" information between sessions, you understand that we may not have the opportunity to review your journal emails until our next scheduled session. 4) You understand that emails between sessions that contain confidential information will be sent via encryption. We make every effort to keep all information confidential. Likewise, if we are working online together and we ask you to do the same, We ask that you determine who has access to your computer and electronic information from your location. This would include family members, coworkers, supervisors, and friends and whether confidentiality from your work or personal computer may be compromised due to such programs as a keylogger. We encourage you to only communicate through a computer that you know is safe i.e. wherein confidentiality can be ensured. Be sure your computer is safe and that you fully exist out of online sessions and emails. If you used location-based services on your mobile phone, you may wish to be aware of the privacy issues related to using these services. We do not place OUR practice as a check-in location on various sites such as Foursquare. However, if you have GPS tracking enabled on your device, it is possible that others may surmise that you are a therapy client due to regular check-ins are on a weekly basis. Please be aware of this risk if you are intentionally “checking in,” if you have a passive LBS app enabled on your phone. We may need to consult with other professionals regarding our clients, however, the client’s name or other identifying information is never disclosed. The client’s identity remains confidential and private.

POTENTIAL RISKS OF RECEIVING TECHNOLOGY-ASSISTED THERAPY & SAFEGUARDS

Ark Alliance Recovery, LLC uses HIPPA compliant email and ZOOM virtual platform means.

There are various risks related to providing technology-assisted treatment services related to the technology used, the distance between counselor and client, and issues related to timelines.

These risks of concerns for privacy and confidentiality are

• Environmental: Lack of private space for clients (home, work, public), smart speakers/devices overhearing, and difficulty controlling surroundings.

• Technological: Unsecured platforms, public Wi-Fi, data breaches, insecure app usage, and potential for malware.

• Operational: Ensuring patient and provider identity verification, lack of  staff training, and complexities with consent for recordings or third      parties (caregivers, translators). the distance between Facilitator and client, and issues related to timeliness.

Ark Alliance Recovery, LLC and your counselor is trained to provide telehealth services, we do not record sessions without client consent and has selected an email, chat, and videoconferencing account that is encrypted with a HIPPA-compliant secure platforms to allow for the highest possible security and confidentiality of the content of your personal information. Your personal information is encrypted and stored on a secure server.

The client is responsible for creating and using additional safeguards when the computer, tablet, phone used to access services, email, or chat may be accessed by others such as creating passwords to use the computer, keeping their Email and chat IDs and passwords secret, maintaining the security of their wireless internet access points (where applicable) by:

• Find a Private Spot: A parked car or a room with a door is ideal.

• Use Headphones: Prevents others from hearing the conversation.

• Secure Your Device: Use strong passwords and avoid public Wi-Fi.

• Disable Smart Devices: Turn off smart speakers and home security cameras that might  record.

• Choose Secure Platforms: Use patient portals or approved apps, and HIPPA compliant  emails/text, not standard text/email.

Please discuss any such concerns with your counselor/staff before or during your first session and any time during your treatment so as to develop and maintain ways to limit risks. If there is ever a disruption or disconnection of services on the internet, the client will need to call the counselor/staff at 346-874-0683.

I Confirm That I Have Read, Accept And Agree to Receiving Technology-Assisted Therapy at Ark Alliance Recovery, LLC.

CONSENT TO DISCLOSE AND RECEIVE INFORMATION AND ELECTRONIC DISCLOSE AND RECEIVING OF INFORMATION

I hereby authorize:

ARK ALLIANCE RECOVERY, LLC

16510 North Chase dr. Ste. 134 Houston, Texas 77060

To disclose and receive by face to face, mail, email or fax to and from:

• Any legal entity ( including courts )  required by the law, either state or federal

My health information is listed below, which may include information concerning communicable diseases such as Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS), mental illness, chemical or alcohol dependency, laboratory test results, medical history, treatment, and related information. I understand that this information is voluntary, and I may refuse to sign this authorization.

I understand that if the recipient authorized to receive this information is not a covered entity as defined under federal privacy regulations, the disclosed information, except for chemical dependency information, may no longer be protected by federal privacy regulations.

DESCRIPTION OF INFORMATION TO BE DISCLOSED

• Assessments

• Psychological Evaluations

• Psychiatric Evaluations

• Diagnosis

• Educational

• Medical History

• Treatment Plans

• Medications Prescribed

• Progress Notes

• Financial

• Discharge Summaries

• Physicians Orders

• Laboratory Reports

• Vocational

• Clinical

  
  

DESCRIPTION OF THE PURPOSE OF THE USE AND/OR DISCLOSURE

• Follow-up / Case Management

• Verification of maintaining appointments

• Determining Eligibility

• Referral for Treatment

• Referral to community services

• Continuity of Care

• Monitor Medical Stat

• To Aid in Treatment Planning

• Financial Assistance / Verification

• Medication Verification

• Assess / Monitor Treatment Goals

• Legal Preceding / Legally required as per state or federal law

• At Clients Request

• Third-party payer

I understand this authorization will expire in 12 months.

I understand that I may revoke this authorization at any time by notifying Ark Alliance Recovery, LLC in writing. I also understand that the written revocation must be signed and dated no later than the date on this authorization. The revocations will not affect any actions taken before the receipt of the written revocation.

A photocopy of the fax transmission of this authorization is as valid as the original

THIRD PARTY CONSENT- FINANCIAL INSTITUTIONS

I hereby authorize:

ARK ALLIANCE RECOVERY, LLC

16510 North Chase dr. Ste. 134 Houston, Texas 77060

To disclose and release any financial, attendance, and any other documents required for Ark Alliance Recovery, LLC to respond to a client refund request and disputed payments to, but not limited to, WIX and SQUARE.

CONSENT TO TEXT APPOINTMENT AND PAYMENT REMINDERS

I hereby authorize:

ARK ALLIANCE RECOVERY, LLC

16510  North Chase   dr. Ste. 134 Houston, Texas 77060

To text me appointment and payment reminders and to reply to my responses to their text.

CLIENT REFUND POLICY

COUNSELING/THERAPY SESSIONS

1)       Clients will not be eligible for refunds for sessions rendered, where the client and counselor undertook the client’s session. 

2)       Clients will not be eligible for refunds for sessions rendered, where the client and counselor undertook the client’s session.

3)       If it is absolutely necessary for clients to cancel or reschedule a session, the client will contact Ark Alliance Recovery at 346.874.0683 at least 2 hours in advance for a 1-hour reschedule session or it will be considered a “No Show” or missed appointment.

4)       Missed appointments (“no show and/or no call”) are billed at the same rate as the individual session. Payment for a missed appointment must be paid prior to the start of the next scheduled appointment. Payments for missed appointments will be accepted on our website or over the phone.

No Refunds Reasons:

1)       If a client leaves the COUNSELING/THERAPY Against Medical Advice (AMA): Leaving AMA usually means forfeiting refunds for uncompleted treatment.

2)       If a client is administratively discharged for violating session rules, or program guidelines, successfully discharged, unsuccessfully discharged.

3)       Clients will not be eligible for refunds for sessions rendered, where the client and counselor undertook the client’s session.

4)       The refund policy written in our Counseling/Therapy packet are clearly explained and Ark Alliance Recovery, LLC will provide services to the client up to the discharge date.

By signing this contract (Counseling/Therapy packet) with Ark Alliance Recovery, LLC and Discover & Recover Counseling Services, LLC you agree that you understand, accept and will comply with Ark Alliance Recovery, LLC and Discover & Recover Counseling Services, LLC refund policy.

THERAPY SESSION FOR CLIENTS REFERRED BY THE COURTS RULES

You will be required to:

1.     Use a private place and quiet place to do your sessions

2.     Sign in with your first and last name. When you enter the platform

3.     Ensuring a stable internet connection

4.     Mute your microphone

5.     Camera on at all times and stable

6.     No blurred or imaged backgrounds

7.     Eliminate distractions like pets or other people

8.     The grace period for attending group is 5mn

9.     No driving, working, watching TV or playing video games, laying down or sleeping while in class

10.  If you need to use the bathroom, cut off your mike, camera and chat with the facilitator where you're going. Return promptly

11.  Dress appropriately (WEAR CLOTHING THAT DOES NOT REVEAL BREASTS, CHEST, REER

12.  CHEEKS OR ANY OTHER PRIVATE BODY PART ON THE PLATFORM. DO NOT WEAR ROBES. THOUGH YOU’RE IN A VIRTUAL CLASSROOM, TREAT IT AS IF YOU’RE IN A PHYSICAL CLASSROOM IN A BUILDING).

13.  Report all drug and alcohol use to your therapist.

14.  Repeated substance use could result in enhanced program, program attendance and higher level of care.

15.  Failure to report substance use could result in termination of services.

16.  A prescription that a doctor prescribes to a client must be reported to the therapist immediately.

17.  Attend all individual sessions.

18.  Be on time for individual sessions. Grace period is 5mn.

19.  Work on your issues.

20.  Complete all assignments. Failure to do so could result in program extension.

21.  If you miss an individual session you will need to make it up.

22.  If clients miss attending 3 weeks of sessions, the client is considered for unsuccessful discharged at that time. Clients are allowed to reschedule during the same week of their original appointment to avoid non-compliance behavioral contracts.

23.  If client relapses their therapy is enhanced and client must inform their probation officer within 24 hours (if applicable) or the counselor will intervene and inform probation of clients relapse.

24.  The second relapse client’s probation officer is contacted by the therapist, is staffed (treatment team) and considered for unsuccessfully discharged, and recommended for a higher level of care.

25.  If it is absolutely necessary for clients to cancel or reschedule a session, the client will contact Ark Alliance Recovery at 346.874.0683 at least 2 hours in advance for a 1-hour reschedule session or it will be considered a “No Show” or missed appointment.

26.  Missed appointments (“no show and/or no call”) are billed at the same rate as the individual session. Payment for a missed appointment must be paid prior to the start of the next scheduled appointment. Payments for missed appointments will be accepted on our website or over the phone.

27.  If clients are going to be late for their scheduled appointment, clients are given a 5 minute grace period. If client has not arrived within the grace period a no show will be given and the client will be responsible to cover that session missed at the same rate as their regular session.

28.  If a client does not attend a session for 14 consecutive days the client will be unsuccessfully discharged.

29.  Clients are required to attend a minimum of 1 session 1xweekly, no exceptions.

30.  If a client has accumulated 4 non-compliances during the client's episode of care, the client will be considered for unsuccessful discharge.

31.  Clients are responsible for their belongings during the attendance of their sessions. Counselor renders all responsibility of client’s possessions at that time.

TROUBLESHOOTING

1.       IF YOU ARE HAVING ISSUES WITH TECHNOLOGY ON OUR PLATFORM

LEAVE THE PLATFORM AND COME BACK IN. 

2.       IF YOU ARE USING DATA WHEN THE ISSUES OCCUR SWITCH TO WIFI

OR VISE VERSA.

3.       IF 36 OR 37 DO NOT WORK SWITCH DEVICES OR CALL OR TEXT MRS. HINDS AT 346-874-0683 FOR ASSISTANCE.

By signing your name you agree to accept and comply with all content of this packet.