Welcome to the Client Packet (Child, Age 12 & Under). This packet is designed as an all-inclusive packet of forms that are required for services at Wellness Grove and is to be filled out for clients who are 12 years of age or younger.

This packet experience allows you to save your progress and come back at any time before your first scheduled session. If you have any questions or need assistance completing this packet, please contact Wellness Grove Support at 330-915-2907.

Please note, if you utilize the Save & Continue Later option, please be sure to come back and complete all forms. Forms will only be sent to Wellness Grove after all required fields are filled out and you sign and submit this client packet.

Client Overview

Informed Consent

Definition of Counseling

Counseling, also known as psychotherapy, is defined by the American Counseling Association as “a professional relationship that empowers diverse individuals, families, and groups to accomplish mental health, wellness, education, and career goals.”

Consent to Counseling Services

I consent to counseling services provided by Wellness Grove. I understand that these services include assessment, diagnosis, and/or treatment, that are deemed necessary by my clinician’s professional judgment.

I understand that:

• For counseling to be most effective, it is important for me to take an active role in the process to include keeping scheduled appointments, being honest with my clinician, discussing the counseling process with my clinician, and maintaining ownership of mutually agreed upon goals.
• Counseling is a confidential process that involves sharing sensitive, personal, and private information that can be accompanied by an array of experiences, thoughts, and feelings.
• All confidentiality protections required by law or regulation will apply to my care.
• Counseling decisions will be discussed and negotiated between me and my clinician to include, but not limited to frequency of sessions, number of sessions, goals, type of counseling, and any alternative counseling methods.
• I am encouraged to regularly discuss progress and review goals with my clinician, and to address any concerns or questions regarding progress and goals should they arise.
• I can refuse to accept clinical recommendations from my clinician.
• I have the right to refuse, or discontinue, counseling services at any time without the decision impacting my right to future care or treatment, and without risking any service benefits to which I would otherwise be entitled.
• I will have access to all medical information resulting from counseling services as provided by law, and that my express permission is required before my medical information may be shared with a third-party, unless otherwise allowed by law.
• No staff member or clinician will discriminate clients on the basis of race, religion, age, sex, sexual orientation, gender identity, ethnicity, color, national origin, developmental disability, genetic information, human immunodeficiency virus status, physical or mental impairment, financial or social status, or in any manner prohibited by local, state, or federal law.
• I have the right to be treated with the upmost respect and courtesy by all Wellness Grove staff members and clinicians who participate in my care.
• I have the right to be treated with consideration and respect for personal dignity, automony, and privacy.
• I have the right to reasonable protection from physical, sexual, or emotional abuse, neglect, and inhumane treatment.
• I have the right to participate in any appropriate and available service that is consistent with an individual service plan (ISP), regardless of the refusal of any other service, unless that service is a necessity for clear treatment reasons and requires the person's participation.
• I have the right to give informed consent to or to refuse any service, treatment or therapy, including medication absent an emergency.
• I have the right to participate in the development, review and revision of one's own individualized treatment plan and receive a copy of it.
• I understand that Wellness Grove does not prescribe nor provide any form of medication management.
• I understand that Wellness Grove does not provide any unusual or hazardous treatment procedures.
• I have the right to be free from restraint or seclusion unless there is an immediate risk of physical harm to self or others.
• I have the right to be advised and the right to refuse observation by others.
• I have the right to have access to one's own client record unless access to certain information is restricted for clear treatment reasons. If access is restricted, the treatment plan shall include the reason for the restriction, a goal to remove the restriction, and the treatment being offered to remove the restriction.
• I have the right to be informed of the reason for denial of a service should this occur.
• I have the right to be verbally informed of all client rights, and to receive a written copy upon request.
• I have the right to exercise one's own rights without reprisal, except that no right extends so far as to supersede health and safety considerations.
• I have the right to file a grievance and to have oral and written instructions concerning the procedure for filing a grievance, and to have assistance in filing a grievance if requested (see Wellness Grove Review & Grievance Reporting below).
• I have the right to one's own condition and to consult with an independent treatment specialist or legal counsel at one's own expense.
• I have the right to be evaluated in a physical environment affording as much privacy as feasible.

Benefits of Counseling

I understand that counseling has numerous benefits. I understand and acknowledge that for many clients, the outcomes of counseling are positive and can include, but are not limited to: a greater understanding of self, learning effective personal and interpersonal copies strategies, a reduction of mental health symptoms, greater quality of life, and increased happiness and satisfaction.

Risks of Counseling

I understand that there are potential risks with any form of counseling. I understand that potential risks associated with participation in counseling can include, but are not limited to: experiencing increased stress or uncomfortable emotions (such as sadness, guilt, anxiety, frustration), relational difficulties, and no change or an increase in problematic symptoms despite personal and clinician efforts.

I understand that should any of these risks occur, I will discuss my experienced concerns, discomfort, behavior changes, or questions with my clinician who may be able to help me better understand my experience and/or use different methods or techniques that may be more satisfying. I understand that when appropriate my clinician may desire to coordinate care with another provider or entity, but only with my written consent. I understand that if my clinical needs exceed the scope of services offered by Wellness Grove, I will be offered appropriate referrals.

Confidentiality

I acknowledge and understand that discussions between a clinician and client are confidential. I understand that no information concerning my care will be released without written consent unless mandated by law. I understand that possible exceptions to confidentiality include, but are not limited to the following situations: danger of harming myself or others, child abuse, elder abuse, criminal prosecutions, suits in which the mental health of a party is in issue, and the filing of a complaint with a licensing board or other state or federal regulatory authority.

I also understand that my clinician may disclose my confidential information to any other person or entity of my choice upon receipt of a valid and executed release of information from me.

I also understand that if I am using insurance for services, Wellness Grove is required to communicate information about my treatment to my carrier such as, but not limited to, my clinical diagnosis for the purposes of reimbursement.

Confidentiality policy for minors (for clients under 18 years of age): I acknowledge and understand that parent(s)/guardian(s)/legal representative(s) have a legal right to examine a minor’s counseling records. However, in order for many minor clients to feel comfortable in counseling, it is beneficial for them to talk with their clinician about the counseling process and to know that what they tell the clinician will be kept private/confidential except in cases of imminent danger to themselves or others, or in instances when the clinician considers the information to be so serious that the parents’/guardians’/legal representatives’ be kept informed to promote the client’s welfare.

By signing this agreement, you are agreeing to this informal waiver of your right to full disclosure of the minor’s records. If you choose not to informally waive this right, please talk with the clinician about your concerns prior to signing this form.

Clinician Incapacity or Death

I understand and acknowledge that in the event that my clinician becomes incapacitated or dies, it will become necessary for another clinician to take possession of my records and provide continued care. I understand that I have the right to seek counseling services elsewhere, and if I should choose to do so my records will be communicated once I complete and sign a release of information form.

Counseling Records

I understand that my counseling sessions shall not be audio/video recorded, through audio/visual technology, in any way unless agreed to in writing by mutual consent. I understand that my clinician will maintain a record of the sessions using a HIPPA-compliant electronic health records system. I understand that correspondence via email will also be through a HIPPA-compliant email service.

I understand that upon written request I may review my counseling records. I acknowledge and understand that in order to ensure the information in my records is clearly understood, I will be asked to schedule an appointment with my clinician or another member of the counseling staff to review the information.

Client-Clinician Boundaries and Relationships

I understand that personal and/or business relationships can undermine the effectiveness of the therapeutic relationship and cause my clinician’s professional judgements to be compromised. I understand that my clinician is responsible for monitoring and discussing issues related to professional boundaries with me and is required to ensure that professional boundaries are upheld as ethically necessary.

Social Media and Online Engagement

I understand that as a client I am free to share (or not share) about my counseling experiences at Wellness Grove at any time, in any way, and with anyone of my choosing. I understand that my clinician, and all clinicians at Wellness Grove, are bound to confidentiality and cannot publicly acknowledge or respond to any inference or possible interpretation of their connection with current or former clients.

I understand the following:

• To maintain confidentiality and keep the clear, professional boundaries in the counseling relationship, my clinician will not respond to or accept friend or contact requests from current or former clients on any social networking sites to include, but not limited to: Facebook, Instagram, LinkedIn, and Twitter.
• To maintain confidentiality and keep clear, professional boundaries in the counseling relationship, my clinician will not use social media platforms for any direct communication with current or former clients.
• If I wish to share my online experiences with my clinician I will do so during the session where information/experiences can be reviewed together during the counseling session.
• Wellness Grove maintains a social media presence for educational and marketing purposes and there is no expectation for me to access, follow, or like it.
• Should I choose to engage with social media platforms for Wellness Grove, I have a right to do so using my own discretion, and my choice has no bearing on access or utilization of the counseling services available to me.
• My clinician does not engage in the practice of looking up clients should they have a social media presence.

Access to Services

I understand that counseling services are generally available during normal business hours. Those hours are: (in Eastern)

Monday through Friday: 7am to 9pm
Saturday: 9am to 5pm
Sunday: CLOSED

Wellness Grove offices are closed on the following designated holidays:

• New Year's Day
• Martin Luther King Jr. Day
• Memorial Day
• Independence Day
• Labor Day
• Veterans Day
• Thanksgiving Day
• Christmas Day

Wellness Grove offices close at 5pm on the following days:

• Christmas Eve
• Thanksgiving Eve
• New Year’s Eve

I understand that in the event of experiencing a crisis I can come to the office location at any time during office hours and be worked into a schedule for a brief evaluation. I acknowledge and understand that in the event of experiencing an imminent crisis, I will call 911 or visit my local emergency room.

Counseling Appointments

I understand that my clinician is responsible for conveying respect by keeping counseling appointments or contacting me if a change in date/time is necessary, giving their complete attention during session, and avoiding interruptions during sessions. I understand that on rare occasions sessions may be interrupted if my clinician is called to respond to a crisis situation. I acknowledge and understand that I am responsible for attending appointments on time and will call in advance in the event that I will be more than a few minutes late or have to miss an appointment.

I acknowledge and understand that I am responsible for scheduling appointments and will contact Wellness Grove for all scheduling requests and/or concerns. I further understand that I will receive automated text and phone reminders prior to each scheduled appointment and can choose to opt-out at any time.

Counseling Fees

Service Item:	Cost:
Psychiatric Diagnostic Evaluations	$150.00
53-60 minutes of Psychotherapy	$125.00
38-52 minutes of Psychotherapy	$90.00
16-37 minutes of Psychotherapy	$75.00
53-60 minutes of Psychotherapy for Crisis	$200.00
Group Psychotherapy Non-Family	$40.00

I acknowledge and understand that while most insurance companies offer coverage for counseling services, some do not. I understand that it is my obligation to contact my insurance provider before engaging in counseling services to determine if there are applicable co-pays or fees which I am responsible for. I understand that if my insurance, HMO, third-party payor, or other managed care provider does not cover counseling services, I will be solely responsible for the entire fee of the session.

I acknowledge and understand that I am responsible for notifying Wellness Grove of any changes to my insurance coverage. I understand that I am responsible for the entire fee of a session in the event of an insurance change that was not communicated and not reimbursed with the new coverage.

I acknowledge and understand that any fees that I incur on my account must be paid in full before my next scheduled appointment.

No-show/late cancellation fees: I acknowledge and understand that prompt arrival for appointments is important for my care. I understand that I will notify Wellness Grove should I be more than a few minutes late or have to miss an appointment. I understand the fee schedule for no-show/late cancellations is as follows:

Service Item:	Cost:
No-Show (arriving more than 10 minutes after session start time)	$125.00
Late Cancellation (24 hours or less from session start time)	$60.00

Court-related fees: I acknowledge and understand that the following fee schedule applies when there is any court-related work that my clinician is requested/mandated to perform. I understand that court-related services may include, but are not limited to phone calls, court appearances, depositions, written documentation, and travel. I understand that these charges are not covered/reimbursed by insurance plans.

Service Item:	Cost:
Court-Related Work	$250.00/hour
Court-Related Work (48 hour or less notice)	$500.00/hour

Non-court-related fees: I acknowledge and understand that the following fee schedule applies when there is any non-court-related work that my clinician is requested to perform. I understand that non-court-related services may include, but are not limited to: preparing and writing treatment summaries, letters, and accommodations/disability paperwork. I understand that these charges are not covered/reimbursed by insurance plans.

Service Item:	Cost:
Non-Court-Related Work	$30.00/15 minutes

Payment fees: I acknowledge and understand that the following fee schedule applies when there are any issues with making or processing payments.

Service Item:	Cost:
Non-Sufficient Funds	$25.00
Returned Checks (due to insufficient funds)	$50.00

Consultation fees: I acknowledge and understand that the following fee schedule applies to instances when my clinician is requested to provide expert knowledge outside of performing direct clinical counseling duties which include, but are not limited to: assessment, diagnosis, and treatment. I understand that these charges are not covered/reimbursed by insurance plans.

Service Item:	Cost:
10-29 minutes of Consultation	$75.00
30-44 minutes of Consultation	$90.00
45-60 minutes of Consultation	$125.00

Medical Records fees: I acknowledge and understand that the following fee schedule applies to the costs of physical medical records requested to be processed.

Service Item:	Cost:
Digital Communication of Medical Records (Secure Email or Secure Fax)	FREE
Physical Communication (Pickup Only)	$1/page
Physical Communication (Certified Mail)	$2/page

* For minor children: I acknowledge and understand that I am the parent/guardian/legal representative responsible for financial billing.

For Parents/Guardians/Legal Representatives

If the client is under 18 years old, I understand that Wellness Grove will need to have a copy of court documents or custody papers that prove I am a legal guardian.

I understand that if there is a shared parenting agreement in my custody agreement, Wellness Grove will need a copy of this paperwork demonstrating my right to make decisions concerning my child’s mental health treatment.

I understand that if I am in a co-parenting arrangement, it is most beneficial for both parents to be involved in my child’s treatment in some capacity. I understand that decisions will always be based upon what is in the best interest for my child.

I understand that parents/guardians/legal representatives are encouraged to participate in ongoing communication with the clinician who is providing services to a child or youth. Ongoing communication can include, but is not limited to: participating in clinical sessions, scheduling individual sessions with a clinician without a child or youth present, phone or email consultation, completing standardized assessment for clinical data, and record review. I understand that I have a right to discuss the ways in which communication can occur with my child’s clinician in order to promote my child’s mental health and wellness. I understand that if I have concerns regarding my child’s care, I can discuss them with my child’s clinician or clinical leadership upon request.

Wellness Grove Review & Grievance Reporting

I understand that Wellness Grove will periodically send out electronic review requests to the primary email address on file in order to gain feedback for the continual improvement of quality client care. I understand that these requests are optional and should I opt-in to provide a review, my responses will be reviewed by Wellness Grove management and kept confidential.

I acknowledge and understand that I have the right to file a grievance at any time with Wellness Grove should I ever have any issues in my interactions with any Wellness Grove staff member or clinician. I further understand that my grievance will be reviewed by management and taken seriously, that my grievance will be investigated fully, with a resolution/remedy, within twenty business days, unless extenuating circumstances require an extension for resolution (determined on a case-by-case basis), and that reporting a grievance will not result in retribution or impact my continuation of care at Wellness Grove. To file a grievance, please visit the following link:

Client Grievance Reporting
https://wellnessgrove.jotform.com/210881220390144

All Client Grievance Reporting submissions are automatically sent to the Client Rights Advocate for Wellness Grove (listed below).

If you are unable to access the online form or would like the grievance made verbally, please contact the Client Rights Advocate, as follows:

CLIENT RIGHTS ADVOCATE CONTACT INFORMATION:
Xavier Swiger (Vice President of Operations)
4522 Fulton Dr NW
Canton, OH 44718
Phone: (330) 915-2907 (Option 1, ask for Xavier Swiger)
Availability: Monday through Friday, 9am to 5pm

All client grievance submissions are kept confidential and secure. All client grievance submissions are dated and signed by the individual filling out the grievance and all submissions are automatically placed into a written format by the forms system. All reports are kept for a minimum of ten years as it relates to our standard records retention policy.

I acknowledge and understand that I have a right to file a grievance with an outside organization. Those organization include, but are not limited to, the following:

Alcohol, Drug Addiction and Mental Health Services (ADAMHS) Board
121 Cleveland Ave SW
Canton, OH 44702
Phone: (330) 455-6644

Counselor, Social Worker, and Marriage and Family Therapist Board
77 S High St 24th Floor, Room 2468
Columbus, OH 43215
Phone: (614) 466-0912

Ohio Department of Mental Health
30 E Broad St
Columbus, OH 43215
Phone: (614) 466-2596

Disability Rights Ohio
200 S Civic Center Dr #300
Columbus, OH 43215
Phone: (800) 282-9181

U.S. Department of Health and Human Services, Civil Rights Regional Office (Chicago)
230 South Dearborn Street, Suite 3187
Chicago, IL 60604-1505
Phone: (312) 886-1709

Wellness Grove is nationally accreditated by The Joint Commission. To file a grievance with The Joint Commission, please use the following:

The Joint Commission
1 Renaissance Blvd.
Oakbrook Terrace, IL 60181
Website: https://www.jointcommission.org/contact-us/

Termination of Treatment

I acknowledge and understand that termination is a valuable part of the treatment process. I understand that ending treatment should not be done casually, although either my clinician or I may decide to end treatment if either of us believes it is in my best interest. I understand that should I wish to stop treatment at any time, I am encouraged to meet for at least one additional session to review my treatment goals and progress with my clinician, and to receive any clinical recommendations that my clinician believes are important to my well-being.

I acknowledge and understand that termination may occur as a result of excessive no call/no shows, late cancellations, cancellations in general, and/or unpaid balances. I understand that I will be contacted the moment that the decision is made at Wellness Grove to terminate services and will be informed of this decision and the reasons why. I also understand that, should I choose, Wellness Grove will provide a referral, unless the service is unavailable or not necessary.

 

Acknowledge & Sign Informed Consent

I have read and understand the information provided within this Informed Consent Form. I understand that I will have an opportunity to discuss the terms of this consent with my clinician at the start of my counseling session. I acknowledge and agree to present all of my questions to my clinician, if any, and to not proceed with my counseling session until all of my questions have been answered to my satisfaction. I understand that by continuing my participation in the counseling session I am asserting my understanding and agreement to the information provided in this consent form.

I hereby give my informed consent to participate in the use of counseling services under the terms described herein with Wellness Grove.

Telemental Health Consent

Telemental Health

Telemental Health, also known as telehealth, refers to providing counseling services remotely through the use of interactive audio and video communication. The telehealth systems used will incorporate network and software security protocols to protect client confidentiality.

Consent to Telemental Health Services

I consent to telemental health services provided by Wellness Grove. I understand that these services include assessment, diagnosis, and/or treatment, that is deemed necessary by my clinician’s professional judgment.

I understand that:

• I must provide verification of my identity to my clinician.
• Due to certain limitations of telemental health, my clinician will determine whether or not my presenting issue is appropriate for a telehealth encounter.
• Should my clinician determine that a telehealth encounter is not appropriate for my presenting issue, I will be provided appropriate alternatives for my care.
• I am required to have technical competence on my part to participate in telemental health services to include, but not limited to, being able to use equipment (such as a laptop, PC, or phone) and connect to the internet.
• All confidentiality protections required by law or regulation will apply to my care.
• I will have access to all medical information resulting from the telemental health services as provided by law, and that my express permission is required before my medical information may be shared with a third-party, unless otherwise allowed by law.
• I have the right to refuse, or discontinue, mental health services via telemental health at any time without affecting my right to future care or treatment, and without risking any service benefits to which I would otherwise be entitled.
• If an emergency occurs during a telemental health encounter, I should call 911 and stay on the video or phone connection (if applicable) until help arrives.

Benefits of Telemental Health

I understand that telemental health has numerous benefits to include:

• Expanding access to clients who may not otherwise be able to participate in in-person counseling sessions
• Eliminating the need for transportation and travel-related costs
• Convenience in scheduling appointments
• Being an effective alternative to in-person counseling sessions as demonstrated by research

Risks of Telemental Health

I understand that there are potential risks with any form of counseling, including telemental health. I understand that potential risks associated with the use of telehealth systems include, but are not limited to:

• Despite personal and clinician efforts, the presenting issue may not improve, and in some instances may get worse
• Interruption of the audio/visual link
• Disconnection of the audio/visual link
• Distorted or blurred video
• Electronic tampering
• In extremely rare instances, a breach of privacy of private medical information due to failed security protocols

I understand that should any of these risks occur, the telemental health session may need to be stopped.

Telemental Health Session Protection

I understand that Wellness Grove has taken the appropriate security measures to ensure that each telemental health session is secure by providing the telehealth sessions through a HIPPA compliant platform, encrypting my healthcare data, and placing safeguards on the systems used to access my data.

Confidentiality and Records

I acknowledge and understand that my clinician has certain duties and obligations that may require the disclosure of my confidential information under certain situations, including, but not limited to: harm to self or others, child abuse, or elder abuse.

I also understand that my clinician may disclose my confidential information to any other person or entity of my choice upon receipt of a valid and executed release of information from me.

I understand that the telemental health sessions shall not be recorded in any way unless agreed to in writing by mutual consent. I understand that my clinician will maintain a record of the sessions in the same ethical manner for in-person sessions.

Location for Telemental Health Sessions

I understand that different states have different regulations for the use of telehealth. I understand that in order for my clinician to participate in a telemental health session with me, I must be physically present within the state of Ohio. I understand that in order to ensure the confidentiality of my telemental health, I agree to participate in the session from a safe, private, and quiet environment and not record the session. If I am unable to meet this requirement, I understand that it is responsibility to discuss these issues with my clinician.

I understand that depending on my insurance plan, my insurance company may require a designated location that I must remain during the session for telemental health. I acknowledge and understand that I am responsible for understanding my coverage and requirements. I acknowledge and understand that it is my obligation to notify my clinician of my location at the beginning of each telemental health session. If for some reason I change locations during the session, I understand that it is my obligation to notify my clinician of the change in location.

Billing & Fees

I understand that the same fee rates and policies (including no-show and late cancellation) will apply for telemental health as they do for in-person therapy. I acknowledge and understand that while most insurance companies offer telemental health coverage, some do not. I understand that it is my obligation to understand my insurance policy before engaging in telemental health services to determine if there are applicable co-pays or fees which I am responsible for. I understand that if my insurance, HMO, third-party payor, or other managed care provider does not cover the telemental health sessions, I will be solely responsible for the entire fee of the session.

Crisis and Emergency Situations

I understand that certain situations including crises and emergency are not appropriate for telemental health services. I acknowledge and understand that if I am in a crisis or emergency, I should immediately call 9-1-1 or seek help from a hospital or crisis-oriented health care facility in my immediate area. I understand that emergency situations include having thoughts of killing or harming myself or another person, hallucinating, experiencing a life-threatening or emergency situation of any kind, having emotional reactions that are uncontrollable, or experiencing dysfunction due to abuse of alcohol or other drugs.

I acknowledge I have been told that if I feel suicidal, I am to contact one of the following resources:

1. Emergency Services (911)
2. National Suicide Prevention Lifeline (1-800-273-8255)
3. Crisis Text line (Text: HOME to 741741)

Emergency Contact

I understand that assessing and evaluating threats and other emergencies can be more difficult when conducting telemental health sessions than traditional in-person treatment. I understand that my clinician may need to call my emergency contact in the event of a crisis or emergency in order to promote my safety.

Acknowledge & Sign Telemental Health Consent

I have read and understand the information provided within this Telemental Health Consent Form. I understand that I will have an opportunity to discuss the terms of this consent with my clinician at the start of my telehealth session. I acknowledge and agree to present all of my questions to my clinician, if any, and to not proceed with my telemental health session until all of my questions have been answered to my satisfaction. I understand that by continuing my participation in the telemental health session I am asserting my understanding and agreement to the information provided in this consent form.

I hereby give my informed consent to participate in the use of telemental health services for treatment under the terms described herein with Wellness Grove. I give my clinician permission to speak with my emergency contact if necessary.

Notice of Privacy Practices (NPP)

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.

If you have any questions about this notice please contact our Chief Information Officer or any staff member at Wellness Grove.

Our Chief Information Officer is:
Shaun Swiger

This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out your treatment, collect payment for your care, and manage the operations of the organization. It also describes our policies concerning the use and disclosure of this information for other purposes that are permitted or required by law. It describes your rights to access and control of your protected health information. “Protected Health Information” (PHI) is information about you, including demographic information that may identify you, that relates to your past, present, or future physical/mental health/condition and related healthcare services. We are required by federal law to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice at any time. The new notice will be effective for all Protected Health Information that we maintain at that time. You may obtain revisions to our Notice of Privacy Practices by accessing our website https://www.wellnessgrove.com/notice-of-privacy-practices-npp, calling the office and requesting that a revised copy be sent to you in the mail or asking for one at the time of your next appointment.

A. Uses and Disclosures of Protected Health Information

By applying to be treated by Wellness Grove, you are implying consent to the use and disclosure of your protected health information by your provider, Wellness Grove staff and others outside of Wellness Grove that are involved in your care and treatment for the purpose of providing healthcare services to you. Your protected health information may also be used and disclosed to bill for your healthcare and to support the operations of the organization.

Uses and Disclosures of Protected Health Information Based Upon Your Implied Consent

Following are examples of the types of uses and disclosures of your protected healthcare information we will make, based on this implied consent. These examples are not meant to be exhaustive but to describe the types of uses and disclosures that may be made by Wellness Grove.

Treatment:

We will use and disclose your protected health information to provide, coordinate, or manage your healthcare and any related services. This includes the coordination or management of your healthcare with a third party that has already obtained your permission to have access to your protected health information. For example, we would disclose your protected health information, as necessary, to another healthcare provider who may be treating you. Your protected health information may be provided to a healthcare provider to whom you have been referred to ensure that healthcare provider has the necessary information to diagnose or treat you.

In addition, we may disclose your protected health information from time-to-time to another healthcare provider (e.g., a specialist) who, at the request of your treating provider, becomes involved in your care by providing assistance with your healthcare diagnosis or treatment.

Payment:

Your protected health information will be used, as needed, to obtain payment for your healthcare services. This may include certain activities that your health insurance plan may undertake before it approves or pays for the healthcare services we recommend for you, such as making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities.

Healthcare Operations:

We may use or disclose, as needed, your protected health information in order to support the business activities of Wellness Grove. These activities may include, but are not limited to, quality assessment activities, and staff review activities.

For example, we may disclose your protected health information to interns that see clients at our office. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your provider. Communications between you and your provider or assistants may be recorded to assist us in accurately capturing your responses; we may also call you by name in the reception area when your provider is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment.

We will share your protected health information with third party “business associates” that perform various activities (e.g., billing, transcription services for the organization). Whenever an arrangement between Wellness Grove and a business associate involves the use or disclosure of your protected health information, we will have a written contract with that business associate that contains terms that will protect the privacy of your protected health information.

We may use or disclose your protected health information, as necessary, to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you. We may also use and disclose your protected health information for other internal marketing activities. For example, your name and address may be used to send you a newsletter about our practice and the services we offer. We may also send you information about products or services that we believe may be beneficial to you. You may contact our Chief Information Officer to request that these materials not be sent to you.

Uses and Disclosures of Protected Health Information That May Be Made Only With Your Written Authorization

Other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law as described below.

• Disclosures of psychotherapy notes;
• Uses and disclosures of Protected Health Information for external marketing purposes;
• Disclosures that constitute a sale of Protected Health Information; and
• Other uses and disclosures not described in the Notice of Privacy Practices.

You may revoke any of these authorizations, at any time, in writing, except to the extent that your provider or Wellness Grove has already taken an action in reliance on the use or disclosure indicated in the authorization.

Other Permitted and Required Uses and Disclosures That May Be Made With Your Authorization or Opportunity to Object

In the following instance where we may use and disclose your protected health information, you have the opportunity to agree or object to the use or disclosure of all or part of your protected health information. If you are not present or able to agree or object to the use or disclosure of the protected health information, then your provider may, using his or her professional judgment, determine whether the disclosure is in your best interest. In this case, only the protected health information that is relevant to your healthcare will be disclosed.

Others Involved in Your Healthcare:

Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your protected health information that directly relates to that person’s involvement in your healthcare. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose protected health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location or general condition. Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your healthcare.

Other Permitted and Required Uses and, Disclosures That May Be Made Without Your Consent, Authorization or Opportunity to Object

We may use or disclose your protected health information in the following situations without your consent or authorization. These situations include:

Required by Law:

We may use or disclose your protected health information to the extent that the use or disclosure is required by law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, as required by law, of any such uses or disclosures.

Public Health:

We may disclose your protected health information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. The disclosure will be made for the purpose of controlling disease, injury or disability. We may also disclose your protected health information, if directed by the public health authority, to a foreign government agency that is collaborating with the public health authority.

Communicable Diseases:

We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.

Health Oversight:

We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws.

Abuse or Neglect:

We may disclose your protected health information to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, we may disclose your protected health information if we believe that you have been a victim of abuse, neglect or domestic violence to the governmental entity or agency authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.

Legal Proceedings:

We may disclose protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), in certain conditions in response to a subpoena, discovery request or other lawful process.

Law Enforcement:

We may also disclose protected health information, so long as applicable legal requirements are met, for law enforcement purposes. These law enforcement purposes include (I) legal process and otherwise required by law, (2) limited information requests for identification and location purposes, (3) pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) in the event that a crime occurs on the premises of Wellness Grove, and (6) medical emergency (not on Wellness Grove's premises) and it is likely that a crime has occurred.

Workers’ Compensation:

We may disclose your protected health information, as authorized, to comply with workers’ compensation laws and other similar legally-established programs.

Required Uses and Disclosures:

Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500 et. seq.

 

B. Your Rights

Following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these rights.

You have the right to inspect and copy your protected health information.

This means you may inspect and obtain a copy of protected health information about you that is contained in a designated record set for as long as we maintain the protected health information. A “designated record set” contains medical and billing records and any other records that your provider and Wellness Grove uses for making decisions about you.

Under federal law, however, you may not inspect or copy the following records; psychotherapy notes; information complied in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding; and protected health information that is subject to law that prohibits access to protected health information. Depending on the circumstances, a decision to deny access may be reviewed. In some circumstances, you may have a right to have this decision reviewed. Please contact our Chief Information Officer, if you have questions about access to your medical record.

You have the right to request a restriction of your protected health information.

This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You have the right to restrict certain disclosures of protected health information to a health plan when you pay out of pocket in full for the healthcare delivered by Wellness Grove. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must be in writing and state the specific restriction requested and to whom you want the restriction to apply.

Your provider is not required to agree to a restriction that you may request. If the clinician believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. If your clinician does agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment. With this in mind, please discuss any restriction you wish to request with your provider.

You have the right to request to receive confidential communications from us by alternative means or at an alternative location.

We will accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not request an explanation from you as to the basis for the request. Please make this request in writing.

You may have the right to have your clinician amend your protected health information.

This means you may request an amendment of protected health information about you in a designated record set for as long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Please contact our Chief Information Officer if you have questions about amending your medical record.

You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information.

This right applies to disclosures for purposes other than treatment, payment or healthcare operations as described in this Notice of Privacy Practices. It excludes disclosures we may have made to you, to family members or friends involved in your care, pursuant to a duly executed authorization or for notification purposes. The right to receive this information is subject to certain exceptions, restrictions, and limits.

You have the right to be notified by Wellness Grove of any breach of privacy of your protected health information.

You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice electronically.

C. Complaints

You may complain to Wellness Grove, or the Secretary of Health and Human Services, if you believe your privacy rights have been violated by Wellness Grove. For information regarding how to file a complaint, please visit the following website:

https://www.hhs.gov/hipaa/filing-a-complaint/complaint-process/index.html

Alternatively, Wellness Grove can provide you with an electronic form in which to file your complaint. You may also file a complaint with us by notifying our Chief Information Officer of your complaint. We will not retaliate against you for filing a complaint.

Our Vice President of Operations is Xavier Swiger. You may contact our VP of Operations directly at xavier.swiger@wellnessgrove.com.

You may also contact Wellness Grove at (330) 915-2907.

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If you have Medicaid, you will NEVER be charged for sessions.

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If you are experiencing current suicidal thoughts while waiting for your appointment, please take steps to ensure your safety to include using the Suicide and Crisis Lifeline (Call or Text: 988) or the National Suicide Prevention Lifeline (1-800-273-8255). If you are in immediate danger, please contact 9-1-1 or go to the nearest emergency room.

For crises that are serious but not life-threatening, please contact your local crisis agency or other area providers. Ohio residents can also use the Ohio Careline: 1-800-720-9616.

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