Client Rights, Notice to Privacy Practice,
and Authorization to Bill Insurance
I request that payment of authorized insurance benefits be made on my behalf to Andrea T. Latell, LPC. I authorize any holder of medical information about me to release to the health care financing administration and its agents any information needed to determine these benefits. If I have a co-pay, I am required to make a payment at each visit. Clients must notify Andrea T. Latell when insurance has been switched to another carrier or discontinued.
Each client will be treated with dignity and respect regardless of sex, age, race, handicap, or origin.
Each client will be treated as an individual and therapy will be based on individual needs.
Each client has a right to expect that all records and information learned will be kept confidential and only released by written permission of client or custodian if client is a minor or specifically required by law.
Confidentiality may be broken in the event of eminent danger to self or others, a subpoena from court, or a suspected child abuse complaint as defined by law.
Each client has the right to expect that he/she will be treated by a competent staff whom are free from mind altering, mood changing substances and function according to a professional code of ethics.
Each client may expect appropriate referral to meet specific needs.
I am aware that I may request a copy of Notice of Privacy Rights (NPP) copies by calling Andrea Latell at 804-435-7355 or stopping by 25 Office Park Drive Suite 2 Kilmarnock.
I agree to receive telehealth services, if I choose that option. Telehealth involves the delivery of mental health services including assessment, diagnosis and treatment using interactive audio, video and data communications. I understand that I will not be in the same room as my provider. I understand that there could be technical difficulties and that I will not hold the provider liable.
By typing my name in the box below, I am confirming that I have read all of the above statements as well as understand and agree. This serves as my electronic signature.
Electronic signature: