Integration Station will conduct business except in the cases of severe conditions requiring businesses to close. Therapists reserve the right to cancel an appointment due to inclement weather and will contact me in the event of a change in schedule or cancellation.

If I feel travel is unsafe because of poor road conditions, I may request that my child’s session be held virtually instead of in-person without penalty.

I, the Legal Parent Or Guardian Understand:

I have initiated services and understand evaluation, treatment, and/or other service fees are due at the time of delivery.

Integration Station will bill my insurance directly at my request, only when all the proper insurance information is on record at Integration Station. It is my responsibility to contact my insurance plan to discuss benefits and the necessary requirements for coverage. At times, insurance policies require pre-certification, prior-authorization, or place visit limitations on therapy services. I understand it is my responsibility to monitor my child’s service coverage. Verification of coverage and benefits is NOT a guarantee of payment. Benefits and payment are determined by the insurance company once claims are received.

Amounts not covered by my insurance, including deductibles, coinsurance, co-payments, as well as non-reimbursable items must be paid within 30 days otherwise treatment may be discontinued. Outstanding accounts may be turned over to collections with additional fees applied for processing.

Should I make a request for a consultation; Integration Station will make every effort to coordinate, however based on availability this may not be possible. I understand that consultations will not be billed to my insurance, and I will be responsible for all customary fees as set by Integration Station, this may include travel time to and from the appointment.

I am ultimately responsible for payment of any service provided by Integration Station. If my insurance company, school system, or other source of payment decreases or discontinues payment for services for any reason, I will be responsible for assuming payment for past, current, and future services.

Payments may be made in the form of cash, check, or credit card. I also understand that should a check be returned due to insufficient funds; I will be charged $30.00 plus any additional processing fees.

I give consent for Integration Station to deliver services to my child. I acknowledge that there is some inherent risk through the engagement of therapeutic services and use of therapy equipment. I agree to assume such risk and indemnify and hold Integration Station and its staff harmless from all losses and claims for any injuries or other damage occurring to myself, my children, or our belongings.

In the event of an emergency, while under the direct care of Integration Station, I give permission to initiate emergency medical services as necessary, however Integration Station and staff will not be responsible for hospital or EMS providers designated.

Integration Station participates in various social and print media outlets such as Facebook, Instagram, Google, parent publications, etc. Through these venues we love to celebrate our clients and their families as they Maximize Their Potential, in addition to sharing staff pictures, events, company updates, contests, and other fun and helpful information.

Health Insurance Portability and Accountability Act

Notice of Privacy Practices

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review this notice carefully.

Understanding Your Therapy Health Record Information

Each time that you visit a hospital, a physician, or another health care provider, the provider makes a record of your visit. Typically, this record contains your health history, current symptoms, examination and test results, diagnoses, treatment, and plan for future care or treatment. This information often referred to as your medical record, services as the following:

• Basis for planning your care and treatment.
• Means of communication amount the many health professionals who contribute to your care.
• Legal document describing the care that you received.
• Means by which you or a third-party payer can verify that you actually received the services billed for.
• Tool in medical education.
• Source of information for public health officials charged with improving the health of the regions they serve.
• Tool to assess the appropriateness and quality of care that you received.
• Tool to improve the quality of health care and achieve better patient outcomes.

Understanding what is in your health records and how your health information is used helps you to-

• Ensure its accuracy and completeness.
• Understand who, what, where, why, and how others may access your health information.
• Make informed decisions about authorizing disclosure to others.
• Better understand the health information rights detailed below.

Your Rights under the Federal Privacy Standard

 Although your health records are the physical property of the health care provider who completed the records, you have the following rights regarding the information contained therein:

• Request restriction on uses and disclosures of your health information for treatment, payment, and health care options. “Health care operations” consist of activities that are necessary to carry out the operations of the provider, such as quality assurance and peer review. The right to request restriction does not extend to uses or disclosures permitted or required under the following sections of the federal privacy regulations: §164.502(a)(2)(i) (disclosures to you), §164.510(a) for facility directories, but note that you have the right to object to such uses), or §164.512 (uses and disclosures not requiring consent or an authorization). The latter uses and disclosures include, for example, those required by law, such as mandatory communicable disease reporting. In those cases, you do not have a right to request restriction. The consent to use and disclose your individually identifiable health information provides the ability to request restriction. We do not, however, have to agree to the restriction, except in the situation explained below. If we do, we will adhere to it unless you request otherwise, or we give you advance notice. You may also ask us to communicate with you by alternate means, and if the method of communication is reasonable, we must grant the alternate communication request. You may request restriction or alternate communications on the consent form for treatment, payment, and health care operations. If, however, you request restriction on a disclosure to a health plan for purposes of payment or health care operations (not for treatment), we must grant the request if the health information pertains solely to an item or services for which we have been paid in full.
• Obtain a copy of this notice of information practices. Although we have readily available copies at our facility, you have the right to a hard copy upon request.
• Inspect and copy your health information upon request. Again, this right is not absolute. In certain situations, such as if access would cause harm, we can deny access. You do not have a right of access to the following:
  • Psychotherapy notes. Such notes consist of those notes that are recorded in any medium by a health care provider who is a mental health professional documenting or analyzing a conversation during a private, group, joint, or family counseling session and that are separated from the rest of your medical record.
  • Information compiled in reasonable anticipation of or for use in civil, criminal, or administrative actions or proceedings.
  • Protected health information (”PHI”) that is subject to the Clinical Laboratory Improvement Amendments of 1988 (“CLIA”), 42 U.S.C. §263a, to the extent that giving you access would be prohibited by law.
  • Information that was obtained from someone other than a health care provider under a promise of confidentiality and the requested access would be reasonable likely to reveal the source of the information.

In other situations, we may deny you access, but if we do, we must provide you a review of our decision denying access. These “reviewable” grounds for denial include the following:

• A licensed health care professional, such as your attending physician, has determined, in the exercise of professional judgment, that the access is reasonably likely to endanger the life or physical safety of yourself or another person.
• PHI makes reference to another person (other than a health care provider) and a licensed health care provider has determined, in the exercise of professional judgment, that the access is reasonably likely to cause substantial harm to such other person.
• The request is made by your personal representative and a licensed healthcare professional has determined, in the exercise of professional judgment, that giving access to such personal representative is reasonable likely to cause substantial harm to you or another person.

For these reviewable grounds, another licensed professional must review the decision of the provider denying access within 60 days. If we deny you access, we will explain why and what your rights are, including how to seek review. If we grant access, we will tell you what, if          anything, you have to do to get access. We reserve the right to charge a reasonable, cost-based fee for making copies.

• Request amendment/correction of your health information. We do not have to grant the request if the following conditions exist:
  • We did not create the record. If, as in the case of a consultation report from another provider, we did not create the record, we cannot know whether it is accurate or not. Thus, in such cases, you must seek amendment/correction from the party creating the record. If the party amends or corrects the record, we will put the corrected record into our records.
  • The records are not available to you as discussed immediately above.
  • The record is accurate and complete.
• If we deny your request for amendment/correction, we will notify you why, how you can attach a statement of disagreement to your records (which we may rebut), and how you can complain. If we grant the request, we will make the correction and distribute the correction to those who need it and those whom you identify to use that you want to receive the corrected information.

• Obtain an accounting of nonroutine uses and disclosures, those other than for treatment, payment, and health care operations until a date that the federal Department of Health and Human Services will set after January1, 2011. After that date we will have to provide an accounting to you upon request for uses and disclosures for treatment, payment, and health care operations. We do not need to provide an accounting for the following disclosures:
  • To you for disclosures of protected health information to you.
  • For the facility directory or to persons involved in your care or for other notification purposes as provided in §164.510 of the federal privacy regulations (uses and disclosures requiring an opportunity for the individual to agree or to object, including notification to family members, personal representatives, or other persons responsible for your care, of your location, general condition, or death).
  • For national security or intelligence purposes under §164.512(k)(2) of the federal privacy regulations (disclosures not requiring consent, authorization, or an opportunity to object).
  • To correctional institutions or law enforcement officials under §164.512(k)(5) of the federal privacy regulations (disclosures not requiring consent, authorization, or an opportunity to object). That occurred before April 14, 2003.

We must provide the accounting within 60 days. The accounting must include the following information:

• Date of each disclosure.
• Name and address of the organization or person who received the protected health information.
• Brief description of the information disclosed.
• Brief statement of the purpose of the disclosure that reasonably informs you of the basis for the disclosure or, in lieu of such statement, a copy of your written authorization or a copy of the written request for disclosure.

The first accounting in any 12-month period is free. Thereafter, we reserve the right to charge a reasonable, cost-based fee.

• Revoke your consent or authorization to use or disclose health information except to the extent that we have taken action in reliance on the consent or authorization.

Maintain the privacy of your health information, including implementing reasonable and appropriate physical, administrative, and technical safeguards to protect the information.

• Provide you this notice as to our legal duties and privacy practices with respect to individually identifiable health information that we collect and maintain about you.
• Abide by the terms of this notice.
• Train our personnel concerning privacy and confidentiality.
• Implement a sanction policy to disciple those who breach privacy/confidentiality or our policies with regard thereto.
• Mitigate (lessen then harm of) any breach of privacy/confidentiality.

Our Responsibilities under the Federal Privacy Standard

In addition to providing, you your rights, as detailed above, the federal privacy standard requires us to take the following measures:

• Maintain the privacy of your health information, including implementing reasonable and appropriate physical, administrative, and technical safeguards to protect the information.
• Provide you this notice as to our legal duties and privacy practices with respect to individually identifiable health information that we collect and maintain about you.
• Abide by the terms of this notice.
• Train our personnel concerning privacy and confidentiality.
• Implement a sanction policy to disciple those who breach privacy/confidentiality or our policies with regard thereto.
• Mitigate (lessen then harm of) any breach of privacy/confidentiality.

We will not use of disclose your health information without your consent or authorization, expect as described in this notice or otherwise required by law.

How to Get More Information or to Report a Problem

 If you have questions and/or would like additional information, you may contact the Privacy Officer or Director at 704-595-9363.

Examples of Disclosures for Treatment, Payment, and Health Care Operations

• If you give us consent, we will use your health information for treatment.
• If you give us consent, we will use your health information for payment.
• If you give use consent, we will use your health information for health care operations.
• Business Associates: We provide some services through contracts with business associates.
• Notification: We may use or disclose information to notify or assist in notifying a family member, a personal representative, or another person responsible for your care, location, and general condition.
• Communication with family: Unless you object, health professionals, using their best judgment, may disclose to a family member, another relative, a close personal friend, or any other person that you identify health information relevant to that person’s involvement in your care or payment related to your care.
• Research: We may disclose information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information.
• Marketing/Continuity of Care: We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.
• Fundraising: We may contact you as part of a fundraising effort. You have the right to request not to receive subsequent fundraising materials.
• Food and Drug Administration (“FDA”): We may disclose to the FDA health information relative to adverse effects/events with respect to food, drugs, supplements, product or product defects, or post marketing surveillance information to enable product recalls, repairs, or replacement.
• Workers Compensation: We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law.
• Public Health: As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.
• Correctional institutions: If you are an inmate of a correctional institution, we may disclose to the institution or agents thereof health information necessary for your health and the health and safety of other individuals.
• Law enforcement: We may disclose health information for law enforcement purposes as required by law or in response to valid subpoena.
• Health oversight agencies and public health authorities: If members of our work force or business associates believe in food faith that we have engaged in unlawful conduct or otherwise violated professional or clinical standards and are potentially endangering one or more patients, workers, or the public, they may disclose your health information to health oversight agencies and/or public health authorities, such as the department of health.
• The federal Department of Health and Human Services (“DHHS”): Under the privacy standards, we must disclose your health information to DHHS as necessary to determine our compliance with those standards.

 Effective: Sept. 23, 2013