Our relationship is, and will always remain, professional. We will treat each other with respect at all times. You acknowledge that you have received information about me, including my qualifications and credentials and that you may ask about my qualifications and credentials either during our sessions, or by contacting ThriveFocus, PLLC. If, at any time, you have concerns or complaints about your treatment, you may direct
them to me or ThriveFocus, PLLC
Our interactions will be confidential. There may be situations, however, where I am required by law to disclose certain information to certain parties, such as state agencies or law enforcement agencies. For example, I may be required by law to report abuse or neglect of a child. Further, in the event that you are a danger to yourself or others, I may be required by law to take action to protect you and those around you, which may result in you being hospitalized. I may also have a duty to warn anyone who
may be in imminent danger as a result of your threats or frame of mind. Please ask me if you have any questions about mandatory reporting situations. Additionally, I respect your privacy with regards to abortion care and reproductive care and will endeavor to protect your privacy regarding the same to the fullest extent possible. I encourage you to use discretion when disclosing specific and identifiable information about other providers to me as it relates to these services.
Your records will be stored securely for a minimum of seven years. Should you ever need access to your records, please contact Ashley Whitley. You acknowledge that you have received SonderMind's Notice of Privacy Practices, which outlines our recordkeeping and confidentiality procedures.
You have received information on the fees that I charge for my services. You understand that you are ˆfinancially responsible for charges that are not covered or paid by your insurance, and that there is no guarantee of reimbursement or payment by an insurance company or other payor. You hereby consent to the release of information to third-party payors or their representatives as deemed necessary by Ashley Whitley to
determine benefits entitlement and to process payment claims for services provided. You authorize and direct that payment of any health insurance or healthcare benefits otherwise payable to you for health care services will be paid directly to Ashley Whitley for the charges for which Ashley Whitley is authorized to bill in connection with the services provided to you. You certify that the information given by you in applying for
payment is correct. You acknowledge full responsibility for, and agree to pay, all charges not otherwise paid by your insurance company or other payor. Charges are due and payable upon receipt of the bill.
If you have questions, you are encouraged and expected to ask them before you sign this form. Your signature on this form indicates that you have read and understand this document and that you have had the opportunity to ask questions about anything in this form. By signing below, you authorize and consent to the performance of the treatment.
