1. I hereby consent to receive behavioral health services through Lake Cook BehavioralHealth as provided by psychotherapists, psychiatrists or other menthal health professionals of Lake-Cook Behavioral Health.
2. I authorize and request that Lake Cook Behavioral Health and my physician(s) perform assessments, administer treatments and medications, and obtain laboratory evaluations as may be considered advisable in the diagnosis and treatment of my condition.
3. I realize that no particular outcome/result can be guaranteed as a result of my consent to treatment at lake-Cook Behavioral Health.
4. I hereby release my psychiatrist, psychologist, social worker, counselor and Lake-CookBehavioral Health Resources and their employees from responsibility for any injury whichresults from my leaving Lake-Cook Behavioral Health services against clinicaland medical advice.
5. Your treatment is confidential within the limits prescribed by law. In general, noinformation about your treatment will be released without your written consent. However,relevant laws require that your therapist contact others about your safety if you present adanger to yourself or to others. If your therapist learns of child abuse or neglect, or ifordered by a court.
In addition, your therapist may consult with other therapists within Lake Cook BehavioralHealth to improve the quality of your treatment. Your therapist may releaseinformation about you to an insurance company or managed care company if you areusing these benefits.
If you (client) are younger that 12 years of age, your therapist may discuss your treatment with your parent or legal guardian. If you are older than 12 years of age and younger than 18 years of age, your therapist may discuss your treatment with your parent or legal guardian with your consent. If you are engaging in behavior that your therapist believes places you in danger of significantly harming yourself or others, your therapist will help you to discuss these issues with your parents.
6. I agree that I will provide 24-hour notice to cancel a scheduled appointment. If I do notgive proper notification, I understand I am responsible for the full session fee (insurancecannot be billed for a late cancellation or a failed appointment).
This consent form has been fully explained to me and I certify that I understand and agree with its contents.
I hereby authorize Lake-Cook Behavioral Health Resources to release any of the followingrequested information for the purpose of obtaining reimbursement/payment for treatment services provided directly to me or my dependents. Information may include: 1. Diagnosis 2. Designated clinical records, e.g., treatment 3. Discharge summary plans, progress notes, laboratory results, etc.
Information may be released to any or all of the following as needed:1. Any third-party payor having responsibility for payment of charges for treatment2. Review agents/auditors3. Managed care/utilization review agents
This consent is valid until such time that all claims have been settled to the satisfaction of LakeCook Behavioral Health or up to one year from the date of discharge from Lake CookBehavioral Health, whichever is longer.
I understand that in some cases, I and/or my dependents may be receiving services for which I am not the insured or for which there is more than one insured. In this case, I authorize Lake Cook Behavioral Health to contact the actual or additional insured (e.g., my spouse) and to share information necessary to obtain reimbursement for services.
I understand that I may revoke this consent at any time and that I may inspect and copy the information to be disclosed. I further understand that I can invalidate this consent any time before the expiration date so long as I submit revocation in writing to the address listed below. Finally, the agency reviewing the clinical information and/or records will be advised not to disclose my records to any other agency/person without my written informed consent.
I understand that I am ultimately responsible for any and all charges not paid for by my medical insurance, and that if I refuse to sign this Release of Information, I will likely have to pay for any and all charges incurred.
I certify that I am the client and that I have received a copy of this form. If I am not the client, I certify that I am adult authorized as the client’s general agent to execute the above and accept its terms.
ASSIGNMENT OF BENEFITS: In consideration of services to be provided to me or to mydependent, I hereby assign, transfer and set over to Lake-Cook Behavioral Health Resources, all of my rights, title and interest to reimbursement benefits under my insurance policy(ies), including any and all major medical benefits. I understand I am financially responsible to Lake Cook Behavioral Health for charges not covered by this assignment.