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For general questions, contact our main office:
Please fill in every answer to the best of your ability. For those utilizing private insurance (or Minnesota students), please be sure to email pictures of your insurance card (front and back) to firstname.lastname@example.org. Those utilizing UCSHIP (California students), please contact your on campus student health services to receive your referral (if applicable).
Questions? Email email@example.com or call/text 323.284.6801!
Please fill in every answer to the best of your ability. For University of California students utilizing their student UCSHIP insurance, be sure to have a mental health referral from campus before finalizing this form. For those utilizing private insurance, please be sure to email pictures of your insurance card (front and back) to firstname.lastname@example.org.
Questions? Email email@example.com or call/text 530.206.9996!
Please fill in every answer to the best of your ability. For University of California students utilizing their student UCSHIP insurance, be sure to have a mental health referral from campus before finalizing this form. For those utilizing private insurance, please be sure to email pictures of your insurance card (front and back) to firstname.lastname@example.org.
Questions? Email email@example.com or call/text 949.502.0736!
Please fill in every answer to the best of your ability. For University of California students utilizing their student UCSHIP insurance, be sure to have a mental health referral from campus before finalizing this form. For those utilizing private insurance, please be sure to email pictures of your insurance card (front and back) to firstname.lastname@example.org.
Questions? Email email@example.com or call/text 805.699.6668!
Please fill in every answer to the best of your ability. For University of California students utilizing their student UCSHIP insurance, be sure to have a mental health referral from campus before finalizing this form. For those utilizing private insurance, please be sure to email pictures of your insurance card (front and back) to firstname.lastname@example.org.
Questions? Email email@example.com or call/text 858.768.0028!
Please fill in every answer to the best of your ability. For those utilizing insurance, private and university, please be sure to email pictures of your insurance card (front and back) to firstname.lastname@example.org.
Questions? Email email@example.com or call/text 612.299.1090!
Please fill in every answer to the best of your ability. For University of California students utilizing their student UCSHIP insurance, be sure to have a mental health referral from campus before finalizing this form. For those utilizing private insurance, please be sure to email pictures of your insurance card (front and back) to firstname.lastname@example.org.
Questions? Email email@example.com or call/text 831.999.3524!
Please fill in every answer to the best of your ability. For University of California students utilizing their student UCSHIP insurance, be sure to have a mental health referral from campus before finalizing this form. For those utilizing private insurance, please be sure to email pictures of your insurance card (front and back) to firstname.lastname@example.org.
Questions? Email email@example.com or call/text 424.273.8900!
We understand the expense involved with psychotherapy and the need for many to utilize insurance to help cover the cost of treatment. We strive to make this process as easy as possible and to enable you to effectively utilize your insurance benefits. Due to the number of different insurance companies and the differences in policies, it is difficult to generalize insurance company coverage and practices. Your insurance carrier is your best source of information on your specific benefits.
We are currently a contracted provider with Anthem Blue Cross, Aetna, and Optum/HealthNet (California) and Blue Cross Blue Shield of MN, Aetna, Optum/Medica/United Healthcare, Health Partners, Preferred One, and UCare (Minnesota). If you have a policy through one of these carriers, we accept reimbursement as in-network providers. Depending on what your insurance policy states, you may either have a deductible to meet before services are fully or partially covered, or you may only be responsible for the copay or coinsurance associated with your policy. Please verify with your insurance whether or not you have a deductible for an in-network provider.
With all other providers we are considered an out-of-network provider and you may pay higher costs than you would with an in-network provider. With these policies, you will be responsible for payment of our discounted upfront fee of $150 at the time of treatment. Your insurance company will then process your claim and provide any reimbursement to you. We can assist you in submitting your claim either by submitting an electronic claim at the time of treatment or providing you with a “Superbill” that you can submit to your insurance carrier. You are strongly encouraged to contact your insurance company at the number on your insurance card prior to receiving any services in order to understand your benefits and your responsibility of any incurred charges.
We are happy to answer any questions about this policy so please feel free to ask.
Thank you, Acacia Counseling & Wellness
Clients have the right to:
Clients have a responsibility to:
If you have a complaint about your protected health information under the Health Insurance Portability and Accountability Act (HIPAA), call FBHP at (303)432-5950.
Or write to: United States Department of Health and Human Services, Office for Civil Rights, 200 Independence Ave. S.W., Room 515F, Washington, D.C. 20201.
Please read this carefully. It notifies you of many of your rights and responsibilities and will represent an agreement between you and Acacia Counseling & Wellness (hereafter referred to as “Acacia”) unless it is amended or terminated in writing.
While many problems can be well addressed in psychotherapy, therapy does not always accomplish everything expected or hoped for and may at times bring up uncomfortable feelings. Working through these feelings is a typical part of the therapeutic process. Successful treatment is greatly enhanced by attending treatment at the suggested frequency, arriving on time, and discussing any concerns you have with your therapist. For select clients, a therapist may determine that it is clinically appropriate to offer to go outdoors for a portion of your session. In this situation, you will sign a separate consent form. If you believe your therapist has mismanaged your treatment or your privacy, you are encouraged to discuss this with him/her directly. You may also report any concerns to the Clinical Director, the Department Of Consumer Affairs’ Board of Psychology (https://mn.gov/boards/psychology/), or the Board of Behavioral Health (https://mn.gov/boards/behavioral-health/).
In general, law protects the confidentiality of all communications between a patient and a mental health professional and the provider can only release information about your treatment to others with your written permission. However, there are some situations in which the provider is legally entitled or even required to release patients’ information without their authorization. Your provider may release information to your insurance company to obtain authorization for treatment, payment or other purposes, such as for quality improvement programs. Information may also be disclosed without notification for the purposes of professional consultation, in lawsuits against the therapist or Acacia, in Worker’s Compensation claims, and in health oversight activities of government agencies. In all such cases, disclosed information is limited to only that which is necessary or required. If the provider believes that a child, an elderly person, or a dependent adult is being abused, he/she is mandated to file a report with the appropriate agency. As providers, we are also required by law to report to authorities any client that discloses developing, duplicating, printing, downloading, streaming, or accessing any images of persons, under the age of 18, engaged in an act of obscene sexual conduct. If the provider believes that a patient is imminently dangerous to himself/herself/themselves or to another, he/she/they is required to take protective actions, which may include contacting authorities, family members, or others who can help prevent harm.
Please note that for the safety of our clients, staff, and facilities, you are subject to video surveillance in all public areas (i.e., lobbies, hallways, entrances, etc.) located on any of our Acacia office locations. Such surveillance is conducted by Acacia in a manner consistent with the standards of other confidential information.
Laws and professional standards require that treatment records be created and maintained. A complete copy of our Health Insurance Portability and Accountability Act (HIPAA) Notice of Privacy Practices describing the protection and use of your health information will be provided to you.
By signing this form, you are agreeing to pay the agreed-to fee or insurance copay for each session at the beginning of each session. You are strongly urged to read your insurance policy concerning deductibles, co-payment, annual limits, and the process for appeal of denied services. You are responsible for services not covered by your insurance policy. It is up to you to ascertain with your insurer the particular coverage to which you may be entitled.
If an appointment is missed or canceled with less than 24 hours notice, by signing this form you are agreeing to pay the late cancellation fee of $50 for non-psychiatric appointments and $100 for psychiatric appointments. “Twenty-four hours notice” is inclusive of weekends and holidays, so if your appointment falls on a Monday and/or after a holiday, a notice of cancellation must be given the day prior to that appointment, not the weekend or holiday. Most insurers do not pay for missed sessions, therefore your credit card will be kept on file, and an automatic fee of $50 will be charged to your card. You will not be charged this fee for late cancellations when you and your therapist agree it was due to unavoidable circumstances such as being in an accident or being too sick to attend your session.
If your account has not been paid for more than 60 days and arrangements for payment have not been mutually agreed upon by you and Acacia, Acacia has the option of using legal means to secure payment from you. This may involve hiring a collection agency or going through small claims court. If such legal action is necessary, the costs for doing so will be included as your responsibility in the claim.
FREQUENT CANCELLATION POLICY
By signing this form, you are acknowledging that there is a late cancellation/no-show fee for sessions and that it requires 24 hours notice to avoid the fee. Additionally, after two consecutive late cancellation/no-shows (within 2 weeks), you will be informed that one more such late cancellation/no-show will result in a removal from your scheduled recurring appointment. After three consecutive late cancellation/no-shows (within 3 weeks), you are removed from the calendar and notified that you will have a limited window to reclaim that appointment time. No response results in the allotted time being scheduled with a new or existing client.
Please read this carefully. This notice describes how mental health information about you may be used and disclosed and how you may obtain access to this information.
This Notice of Privacy Practices is being provided to you as a requirement of the Health Insurance Portability and Accountability Act (HIPAA). This Notice describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations and for other purposes permitted or required by law. It also describes your right to access and control your health information in some cases. Your PHI means any of your written and oral health information which can be used to identify you. This is health information that is created or received by your healthcare provider, and relates to your past, present, or future physical or mental health. We are committed to protecting the privacy of the personal and mental health information you disclose to us. We are required by law to maintain the confidentiality of information that identifies you and the care you receive. When we disclose information to other persons and companies to perform services for us, we require them to protect your privacy, too. We must also provide certain protections for information related to your medical diagnosis and treatment, including HIV/AIDS, and information about alcohol and other substance abuse. We are required to give you this Notice about our privacy practices, your rights and our legal responsibilities.
We may use and disclose your mental health information:
For TREATMENT: We will use and disclose your PHI to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, your PHI may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.
For PAYMENT: Your PHI will be used, as needed, to obtain payment for your health care services. For example, we may contact your insurer to verify what benefits you are eligible for, to obtain prior authorization, and to receive payment from your insurance carrier.
For HEALTHCARE OPERATIONS: We may use or disclose, as needed, your PHI in order to support the business activities of your provider’s practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of students, licensing, and conducting or arranging for other business activities. We may also call you by name in the waiting room when your provider is ready to see you. You may revoke this authorization at any time, in writing, except to the extent that your provider or the provider’s practice has taken action in reliance on the user or disclosure indicated in the authorization. Under the law, we must make disclosures to you upon request and when requested by the Secretary of the Department of Health and Human Services to investigate or determine our compliance.
For APPOINTMENTS AND SERVICES: We may use or disclose your PHI, as necessary, to contact you to remind you of an appointment, or tell you about treatment alternatives or health related benefits or services.
To INDIVIDUALS INVOLVED IN YOUR CARE, such as your parents, if you are a minor, or your conservator.
WITH YOUR WRITTEN AUTHORIZATION: We may use or disclose mental health information for purposes not described in this Notice only with your written authorization
We may use your mental health information for other purposes without your written authorization:
As REQUIRED BY LAW when required or authorized by other laws, such as the reporting of child abuse, elder abuse or dependent adult abuse. Additionally, we are required by law to report to authorities any client that discloses developing, duplicating, printing, downloading, streaming, or accessing any images of persons, under the age of 18, engaged in an act of obscene sexual conduct.
For HEALTH OVERSIGHT ACTIVITIES to governmental, licensing, auditing, and accrediting agencies as authorized or required by law including audits; civil, administrative or criminal investigations; licensure or disciplinary actions; and monitoring of compliance with law.
In JUDICIAL PROCEEDINGS in response to court/administrative orders, subpoenas, discovery requests or other legal process.
To PUBLIC HEALTH AUTHORITIES to prevent or control communicable disease, injury or disability, or ensure the safety of drugs and medical devices. Health Oversight; Food or Drug Administration requirements; Coroners, Funeral Directors and Organ Donation Programs
To LAW ENFORCEMENT for, example, to assist in an involuntary hospitalization process, or military activity and national security
To THE STATE LEGISLATIVE SENATE OR ASSEMBLY RULES COMMITTEES for legislative investigations.
For RESEARCH PURPOSES subject to a special review process, and the confidentiality requirements of state and federal law.
To PREVENT A SERIOUS THREAT TO HEALTH OR SAFETY of an individual. We may notify the person, tell someone who could prevent the harm, or tell law enforcement officials.
To PROTECT CERTAIN ELECTIVE OFFICERS including the President, by notifying law enforcement officers of potential harm.
For WORKER’S COMPENSATION: If you file a worker’s compensation claim, we must furnish a report to your employer, incorporating our findings about your injury and treatment in order to determine your eligibility for compensation.
You have the following rights:
To Receive a Copy of this Notice, upon request, when you obtain care from Acacia Counseling & Wellness.
To Request Restrictions. You have the right to request a restriction or limitation on the mental health information we disclose about you for treatment, payment or health care operations. You must put your request in writing. Your request must state the specific restriction and to whom you want the restriction applied. We are not required to agree with your request. If we do agree with the request, we will comply with your request except to the extent that disclosure has already occurred or if you are in need of emergency treatment and the information is needed to provide the emergency treatment.
To Inspect and Request a Copy of your Mental Health Record except in limited circumstances. Under federal law, you may not inspect or copy the following records: Psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding; and PHI that is subject to law that prohibits access to such PHI. A fee will be charged to copy your record.
You must put your request for a copy of your records in writing. You may request to receive in an electronic format any of your records that are stored and readily producible in an electronic format. If you are denied access to your mental health record for certain reasons, we will tell you why and what your rights are to challenge that denial.
To Request an Amendment and/or Addendum to your Mental Health Record. If you believe that information is incorrect or incomplete, you may ask us to amend the information or add an addendum (addition to the record). Your request for amendment and/or addendum must be in writing and give a reason for the request. We may deny your request for an amendment if the information was not created by us, is not a part of the information which you would be permitted to inspect and copy, or if the information is already accurate and complete. Even if we accept your request, we do not delete any information already in your records. 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.
To Receive An Accounting of Certain Disclosures we have made of your mental health information. You must put your request for an accounting in writing.
To Request That We Contact You By Alternate Means (e.g., fax versus mail) or at alternate locations.
Your request must be in writing, and we must honor reasonable requests.
Changes to this notice:
We reserve the right to change this Notice. We reserve the right to make the revised or changed Notice effective for information we already have about you as well as any information we receive in the future. We will post a copy of the current Notice on the Acacia Counseling & Wellness website: www.acaciacw.com
If you have any questions about this Notice, please contact Acacia Counseling & Wellness at 888-699-4873.
If you believe your privacy rights have been violated, you may file a complaint with Acacia’s Privacy Officer: Dr. Keith Higginbotham 805-864-2686 extension 8 or firstname.lastname@example.org. If you are not satisfied with how this complaint has been addressed, you may contact the Secretary of Health and Human Services. Or, you may file a complaint against us by notifying:
U.S. Department of Health and Human Services Office for Civil Rights
200 Independence Ave, S.W.
Washington, D.C. 20201
We will not retaliate against you for filing a complaint.
You will receive notification in the event of a breach that affects your unsecured PHI.