(1) Go to the nearest emergency room OR (2) Call 911 or local police OR (3) Call Netcare Access 24 hr mental health services __________________________________________________ at: 614.276.2273 PRINTED FULL NAME Communications __________________________________________________ The Restore Counseling, LLC phone number allows for SIGNATURE communication to be received via phone, voicemail and text. Clients are asked to restrict text communication to issues concerning scheduling, directions, and billing due to the risks __________________________________________________ inherent in this form of communication. DATE Notice of Privacy Information and Disclosure Without your expressed consent for the release, no information shall be released to any other provider, with the exception provided by Ohio Revised Code 4757-5-02 (D1): Expressed imminent danger to yourself or another person or the report of abuse of a minor or incapacitated adult person. And with the exceptions as provided by HIPAA which may include electronic transmission of information deemed necessary to process remittance of payment, requested clinical or billing information you have given consent to be released by signing this document and the HIPAA acknowledgement document. This practice is a HIPAA covered entity according to the guidelines set forth at: Downloads/CoveredEntitycharts.pdf You should have received a copy of your HIPAA privacy rights either digitally or on paper. If you need help understanding this document or the document explaining your privacy rights please inform this provider. PLEASE SIGN BELOW INDICATING YOU HAVE RECEIVED, UNDERSTAND, and AGREE WITH THE INFORMATION IN THIS DOCUMENT:
(1) Go to the nearest emergency room OR (2) Call 911 or local police OR (3) Call Netcare Access 24 hr mental health services at: 614.276.2273 Communications The Restore Counseling, LLC phone number allows for communication to be received via phone, voicemail and text. Clients are asked to restrict text communication to issues concerning scheduling, directions, and billing due to the risks inherent in this form of communication. Notice of Privacy Information and Disclosure Without your expressed consent for the release, no information shall be released to any other provider, with the exception provided by Ohio Revised Code 4757-5-02 (D1): Expressed imminent danger to yourself or another person or the report of abuse of a minor or incapacitated adult person. And with the exceptions as provided by HIPAA which may include electronic transmission of information deemed necessary to process remittance of payment, requested clinical or billing information you have given consent to be released by signing this document and the HIPAA acknowledgement document. This practice is a HIPAA covered entity according to the guidelines set forth at: Downloads/CoveredEntitycharts.pdf You should have received a copy of your HIPAA privacy rights either digitally or on paper. If you need help understanding this document or the document explaining your privacy rights please inform this provider. PLEASE SIGN BELOW INDICATING YOU HAVE RECEIVED, UNDERSTAND, and AGREE WITH THE INFORMATION IN THIS DOCUMENT: __________________________________________________ PRINTED FULL NAME __________________________________________________ SIGNATURE __________________________________________________ DATE
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