Service Agreement

"*" indicates required fields

Step 1 of 3

33%

Which best describes you?*

First Name*

First

Last Name*

Last

Relationship to Client*

Please Specify*

Client's First Name*

First

Client's Last Name*

Last

Date of Birth*

Phone*

Email*

Office Location*

Before continuing, did you read our Service Agreement, HIPAA Notice of Privacy Practices, and Telehealth Informed Consent supporting documentation?*

By clicking this box, I have read, understand, and agree to the Treatment Consent and the Telehealth Informed Consent. I also Acknowledge the HIPAA Notice of Privacy Practices.*

Section 1 of 4

Communicating With You

Communication Consent

We offer many forms of communication to meet your needs and convenience here at Renewal: call, text, email, appointment reminders, etc. In fact, one of the best ways to communicate with us is via text messaging. With that said, help us best communicate with you!

I consent to the following forms of communication from Renewal Center: Text, Email, and Promotions.*

Yes

Customize my communication preferences

How can we communicate with you?*

You can text me.

You can email me.

You can send me promotional emails and updates.

All of the above.

May we communicate account and billing information via text? We need additional permission before we can do this for you.*

Yes

I consent to the receive appointment reminders in the following methods of communication from Renewal Center: Text and Email.*

Yes

Customize my communication preferences

Check all that apply.*

Text Reminder

Email Reminder

Phone Call Reminder

No Preference (Default is Text Reminder)

Mobile Phone*

Current Mailing Address*

Street Address City State ZIP Code

We take your private health information seriously. While text and email messaging allow us to exchange information conveniently and efficiently, at the same time, we recognize that email and text messaging are not a completely secure means of communication because these messages can be addressed to the wrong person or accessed improperly on your device or during transmission. You are not required to use text messaging or email and this decision will not affect your health care in any way. Renewal does not sell, trade, or otherwise transfer to outside parties your personally identifiable information (PII or PHI). For more info, see our Privacy Policy.

Emergency Contact

Communication Consent

In the case of an emergency, whom may we contact?

First Name*

First

Last Name*

Last

Relationship to Client*

Phone*

Communicating With Others

Communication Consent

Please list anyone you would like to give permission to access your appointment and billing information. This is often your spouse, family member, or caretaker. If you are the parent or guardian of the client who is a minor, please fill out your information below. NOTE: This consent does not release private mental health information or diagnosis. Only permission to access appointment and/or billing information. An additional consent form is required to release private and confidential mental health information.

List any contacts you approve for us to communicate with other than you.*

What info do you want shared?*

Relationship to Client*

Name*

Phone*

Would you like to list someone else?*

What info do you want shared?*

Relationship to Client*

Name*

Phone*

Section 2 of 4

Payment For Services

Financial Responsibility

We accept nearly all major insurance plans. Here are a few: Aetna, Blue Cross Blue Shield, Blue Care Network, Cofinity, Beacon Health, Cigna, Hap, McLaren, Medicaid, Medicare, Tricare, and more!

We also want therapy to be affordable and accessible to all. In order to assist our clients who do not have insurance coverage, we have established a cash sliding fee scale that is applied based on family income levels. You may take advantage of this fee reduction if your family income is below $120,000 per year and you can provide Renewal Center with your 1040 tax report or other proof of income to demonstrate your income level.

Who is the Responsible Party for Billing?*

How would you like to pay for services?*

Insurance

Medicaid

Out-of-Pocket

Please select your family household income:*

Responsible Party - Individual Responsible for Financial Liability Incurred for Services

Providing a name and/or contact information below signifies that you have given Renewal Christian Counseling Center permission to share billing correspondence with the individual named and that they have agreed to be responsible for any balance due for services rendered.

First Name*

First

Last Name*

Last

Relationship to Client*

Phone*

Address*

Street Address City State ZIP Code

Auto-Pay Enrollment

Payment for Services

Payments are due at the time service is provided. Renewal Christian Counseling Center, like many other healthcare agencies, implemented a credit card on file policy due to the increase in virtual Telehealth appointments as a virtual office to collect payments whether your session is in-person or via Telehealth. The information will be held securely to be used to pay balances on your account such as deductibles and copays. You will receive a text/email notification with your current account balance and the amount you will be charged automatically within 48-hours.

* Fees apart from normal services such as insurance rejections, no-show late fees, bounced checks, etc will not automatically be charged.

Auto-Pay Enrollment*

I understand that I must put a card on file for services.

Cardholder's Name*

Type of Card*

Card Number*

Expiration Date*

CVV*

Billing Zip Code*

Payment Method Consent*

By clicking this box, I, the Responsible Party, understand I am liable for payment of services on the day of services with Renewal Center. I agree to make necessary arrangements for timely payment by those companies and acknowledge that I am responsible for any cost of service that the insurance company does not pay. I understand that all unpaid balI authorize Renewal Center and its insurance billing staff to communicate with my insurance provider and to bill my insurance company using the information I have provided to him/her.*

Appointment Cancellation Policy

Financial Responsibility

24-hour Cancellation Notice: A $45 fee will be charged for any appointments that are canceled less than 24 hours prior to the scheduled session or are missed without any notification. The Responsible Party will be required to pay the fee before rescheduling or attending any scheduled future appointments.

Appeals: While we know life is filled with many uncertainties, we understand there may be times when things are simply outside our control. Unexpected illnesses, emergencies, etc. If you find yourself in a situation where you need to cancel your appointment less than 24-hours before your appointment, an appeal form is available if you would like to dispute your charge or case closure. Appeals can be submitted up to 60 days after the date of the missed appointment. Our agency depends financially upon our clients keeping scheduled appointments; therefore, our policy is to close your case if you accumulate 2 "no-shows" within 6 months.

If you need to make an appeal, we recommend that you would pay the $45 late notice cancellation fee, even in emergency situations, so you can continue scheduling future appointments. If your appeal is approved, your $45 fee will be reimbursed or can be applied to your account if you choose.

Per our Billing Policy, our Administrative Support Staff are prohibited from scheduling anyone with an outstanding balance. The Responsible Party will be required to pay the fee before rescheduling or attending any scheduled future appointments.

Cancellation Policy*

By clicking this box, I have read and understood my financial responsibilities related to Renewal Christian Counseling Center’s Financial Responsibility Policy outlined in the Treatment Consent and the above Appointment Cancellation Policy section.*

Section 3 of 4

HIPAA Notice of Privacy Practices

HIPAA Consent*

By clicking this box, I hereby acknowledge that I have received and have been given an opportunity to read a copy of Renewal Christian Counseling Center, Inc.'s HIPAA Notice of Privacy Practices and Treatment Consent which outlines our practices and procedures regarding your rights and responsibilities. I understand that I have the opportunity to ask my therapist questions regarding the policy. I understand that if I have any further questions, I may contact Michelle Briggs, Privacy Officer at (586)-783-2950. If I have any further clinical questions or concerns, I may contact the Director of Renewal Center, Mr. Steve Fair LMSW, at the same number.*

Section 4 of 4

Telehealth Informed Consent

Online Therapy Services

Renewal Christian Counseling Center offers both in-office psychotherapy sessions and online therapy. Your therapist will discuss all available treatment options with you at your first session.

Online Therapy, also known as Telehealth, involves the use of electronic communications to enable mental health professionals to connect with individuals using interactive video and audio communications. Telehealth includes the delivery of psychotherapy, including diagnosis, consultation, treatment, and referral to resources, education, and the transfer of medical and clinical data.

By agreeing to the Telehealth Informed Consent, I agree that certain situations, including emergencies and crises, are inappropriate for audio/video computer-based psychotherapy services. If I am in crisis or in an emergency, I should immediately call 911 or seek help from a hospital or crisis facility in my area.

Payment for Telehealth Services: Renewal Christian Counseling Center will bill your health insurance provider for Telehealth services when these services have been determined to be covered by your insurance plan. If your insurance is not accepted, the Responsible Party agrees to pay out-of-pocket.

Telehealth Consent

I AGREE to give my informed consent to participate in the use of Telehealth services for treatment under the terms described within the Telehealth Informed Consent document. I have read this document and understand my rights, benefits, and risks related to the use of telehealth services. I understand I have the right at any time to discuss the Telehealth Informed Consent documentation with my therapist.

I DECLINE to give my informed consent to participate in the use of Telehealth services for treatment under the terms described herein.

Mobile Phone Verification*

Email Verification*

You're almost done! You must sign and date the form or it WILL NOT be submitted.

Consent For Treatment

This agreement for psychotherapy between you and Renewal Christian Counseling Center shall govern all professional relations between the parties. It is agreed that any disputes or modifications of agreement SHALL BE NEGOTIATED DIRECTLY BETWEEN THE PARTIES. If these negotiations are not satisfactory, then the parties agree to mediate any differences with a mutually acceptable third-party mediator WHICH CAN BE OUR Advisory Board members, per our client's request. Should this fail to reach a mutually satisfying agreement, all disputes will be submitted to binding arbitration with a certified mediator.

As a consumer/parent/guardian, I understand the rationale for the procedures, risks, consequences, and other relevant factors in treatment here at Renewal Center. I acknowledge receipt of the Recipient Rights and Responsibilities found within the Treatment Consent that outlines my rights as a consumer of mental health services, and I consent to mental health services at Renewal Christian Counseling Center under the terms and responsibilities listed above.

Treatment Consent*

By clicking this box, Treatment Consent and the Telehealth Informed Consent. I also Acknowledge the HIPAA Notice of Privacy Practices.*

Relationship to Client*

Date*

MM slash DD slash YYYY

First Name*

First

Last Name*

Last

Client or Parent/Guardian Signature:*

Phone

This field is for validation purposes and should be left unchanged.

For support, please email us at support@renewalcenter.org