INSURANCE IDENTIFICATION CARDS MUST BE PRESENTED AT TIME OF REGISTRATION

I authorize Neighborhood Counseling Center to render treatment to me and/or my dependents. I agree that Neighborhood Counseling Center staff can contact me and/or leave messages at the address, phone number(s) and/or email address(es) provided.
I authorize the release of information regarding my medical treatment and related information to my health insurance company, their authorized agents and/or intermediaries for the purpose of validating, determining benefits payable, and compliance requirements. Insurance coverage must be verified before services are rendered for assigned benefits; ID cards must be presented at registration and when there is a change of coverage.
I authorize payment of medical benefits to the Neighborhood Counseling Center for services I receive. I request payment of government benefits including Medicare and Medicaid to Neighborhood Counseling Center.
I authorize photocopies of this form to be as valid as the original.
I am responsible for insurance policy deductible and charges during a lapse in benefits. All payments are due at time of service. I am responsible to confirm my health coverage allows for two different behavioral health service visits on the same day prior to making any arrangements of this nature. If the health coverage denies a claim for this reason, it will be my responsibility to cover the cost for the service visit.
I understand Neighborhood Counseling Center has a 48-hour cancellation policy. If I give less than 48 hours cancellation notice or fail to come to a scheduled appointment, I may be charged a minimum of $50.
My signature below means I understand and agree to the policies and procedures described above.

It can be helpful to involve family members and significant others in the treatment process. Note that a significant other can be anyone who is not a relative and is considered by you to be a person that is important to you such as a friend, neighbor, partner, etc. Involving a family member or significant other in your treatment can provide an opportunity to receive additional support and to obtain assistance with the problems and concerns that you are facing. This can be helpful to your efforts to solve problems and make decisions about Important issues. This can also prove to be a useful source of information about you and your life circumstances as the people that know us can often offer information and a view about ourselves that we may not see or may overlook. If you would like to include family members and/or significant others in your treatment, please let us know. It is important to point out that whatever your choice is at present about this, you can change your mind at any time during the course of treatment and decide to either include or exclude a family member or significant other at any time. If you are a minor, your choice must be approved by your parent and/or guardian.

This is to confirm that I have received the NOTICE OF PRIVACY PRACTICES concerning Protected Health Information from the Neighborhood Counseling Center. This has provided me with information regarding how my Protected Health Information can be used and disclosed by the Neighborhood Counseling Center in accordance with the Health Insurance Portability and Accountability Act

This is to confirm that I have received the CLIENT GRIEVANCE POLICY maintained at the Neighborhood Counseling Center. I have been informed that this policy outlines the procedures available to clients to file complaints at the Neighborhood Counseling Center pertaining to any dissatisfaction with agency services or any concern related to any experience with this agency.

This is to confirm that I have received the POLICY ON CRISIS INTERVENTION maintained at the Neighborhood Counseling Center. I have been informed that this policy outlines the procedures available to clients to request after hours assistance and the opportunity to speak with a clinician seven days a week, twenty-four hours a day.

This is to provide authorization to NCC to access and view information about controlled substances that are being prescribed to me as outlined in the NYS Prescription Monitoring Program (PMP). This information will be used by NCC clinical staff for the purpose of assessment and treatment planning that can be§t serve my current treatment needs.

Only agencyb illing staff and front desk reception staff are authorizedt o acceptf unds from consumers on behalf of the agency and only f~r the purpose of fee collection for servicesprovided. A n agencyr eceipt is to be issued for all such transactionsa s this validatest hat. this is an official NCC document. If any other employee seeks funds from a consumer ~d/or the family member of a consumer, this should be reported to agency management in:un.ediately. This notice· is being circulated to protect all the individuals that receive services at the Neighborhood Counseling Center. This agency is firmly committed to providing high quality services to the people -served'by our agency and to insure that the best interests of our consumers is always a priority.

I have chosen to receive services from the Neighborhood Counseling Center by means of telehealth sessions. The potential benefits and risks of receiving services in this manner has been sufficiently explained. • It is understood that services can still be provided in person at the clinic offices at my request and that there is always an option to withdraw this consent. • It has been explained to me that there may be circumstances in which receiving services by telehealth may not be in my best interests. For example if there are any concerns for my safety and/or my condition that have been determined by clinical assessment to be best served by in-person services then it may be necessary to discontinue telehealth services. Should this become necessary it is understood that this may be a temporary measure however the length of time this will remain in effect will be determined by my clinical needs and condition. It has been explained to me that my preference will be given serious consideration. • It has been explained to me that I must be present in the New York City area in order to receive services via telehealth. There can be exceptions to this as long as any travel outside of New York City does not involve a permanent re-location and are limited to brief periods that do not exceed 30 days. It is understood that during any period of travel outside of the local area that the telehealth session will be limited to the continental United States. • It has been explained to me that telehealth services are considered more effective when conducted by means of video. The above stipulations have been carefully reviewed as my signature below provides authorization to receive telehealth services at the neighborhood Counseling center. Telehealth policies were reviewed and verbal consent was provided to intake coordinator during initial intake phone screening