INFORMED CONSENT:
Per the Social Work Code of Ethics (Ethical Standards) and HIPPA Privacy Rule, BHCCC will provide services to clients only in the context of a professional relationship based, when appropriate, on valid informed consent. The forms below consist of the HIPPA Notice of Privacy Practices, Privacy Rule, and clients’ rights. The forms outline the purpose of the services, risks related to the services, limits to services because of the requirements of a third-party payer, relevant costs, reasonable alternatives, and the time frame covered by the consent.
INDIVIDUAL CORE FORMS
- HIPPA NOTICE OF PRIVACY PRACTICES
- Client Information Form – Adult
- Client Information Form – Minor
- Confidential Client Communication Form
- Payment Authorization-Insurance Release Form
- Service Agreement & Informed Consent Form
SUPPLEMENTAL FORMS
- Authorization for Observation Consent Form
- Collateral Service Agreement Form
- Pandemic Service Agreement (In-Person Session) Consent Form
- Release of Information Authorization Form
- Statement of Loyalty to Relationship Consent Form
- High-Conflict Parenting Custody Policy