CONSENT TO RECIEVE TEXT MESSAGE: Our staff uses text message to communicate service-related information such as, appointment reminders, intake reminders, payment due or any other service related information. You certify, warrant and represent that the telephone number you have provided us is your contact number and not someone else's. It is the client responsiblity to notify us if you have telephone number changes.

Controlled substance medications (i.e., benzodiazepines, stimulants or any other controlled drug class) are very useful, but have a high potential for misuse. Therefore, they are closely controlled by local, state, and federal governments.

Should a Brighter Life provider provide you with a prescription for a controlled substance medication, please note the following:

1. Benzodiazepines/Stimulants medications can have side effects:

a. Common side effects include drowsiness and constipation. This is more noticeable at higher doses. b. Serious side effects can include an effect on breathing.

2. Due to the high number of prescription drug related deaths, documentation and rules surrounding these prescriptions are closely monitored by Brighter Life and by state and federal agencies. In order to ensure that your Brighter Life provider is documenting the appropriate management of controlled substance use, please note the following:

a. Initial and subsequent prescriptions of controlled substance medication are at the sole discretion of each health care provider.

b. Controlled substance medication should be taken exactly as prescribed, unless otherwise discussed with your doctor.

c. Driving a motor vehicle may not be allowed while taking these medications and it is your responsibility to comply with the laws of the state while taking prescribed medications.

d. You are responsible for the medications prescribed to you. Controlled substance prescriptions will not be replaced if the medication is used too quickly, lost, stolen, or misplaced.

e. All patients on controlled substance medication must agree to urine drug testing at any time your Brighter Life provider requests it. If you decline to provide a sample, you will not be provided with further controlled substance prescriptions. Urine drug testing is a routine part of controlled substance medication management, and these requests should not be considered an accusation of drug abuse.

f. Generally only ONE provider should be providing controlled substance medications to any patient. As a result of Illinois State law, we monitor prescription refills through the Illinois Prescription Monitoring Program. This allows us to see the prescriptions you fill from all pharmacies and all providers.

g. If you have a substance abuse disorder, our providers are trained and experience to further assist you.

3. Refills of controlled substance medications:

a. Should be requested at your pharmacy. Even if your prescription has no refills remaining, you should call your pharmacy and they will notify your physician electronically.

b. Should be requested before 5pm Monday thru Friday

c. May require you to be seen by your physician in the office/video. One office visit required for initial prescribing controlled medication and for maintenance once a year office visit required.

d. Will not be made at night, on weekends, or during holidays.

e. Will not be made as an emergency, or if the medication is used too fast, lost, stolen, or misplaced.

f. May take up to three business days to be processed.

4. Brighter Life, takes the care and treatment of our patients very seriously. As a result, any violation of the above items can result in termination of your controlled substance prescription and/or discharge from our practice.

This notice describes how medical information about you may be used and disclosed, and how you can gain access to this information. Protected Health Information (PHI), about you, is maintained as a written and/or electronic record of your contacts or visits for healthcare services with Brighter Life Behavioral Services. Specifically, PHI is information about you, including demographic information (i.e., name, address, phone, etc, that may identify you and relates to your past, present or future physical or mental health condition and related healthcare services.

Brighter Life Behavioral Services is required to follow specific rules on maintaining the confidentiality of your PHI, using your information, and disclosing or sharing your information with other healthcare professionals involved in your care and treatment. This Notice describes your rights to access and control your PHI.

It also describes how we follow applicable rules and use and disclose your PHI to provide your treatment, obtain payment for services you receive, manage our healthcare operations and for other purposes that are permitted or required by law.

HIPAA Notice of Privacy Practices

Your Health Information Rights

Inspect and Copy: You have the right to inspect and copy the protected health information that we maintain about you in our designated record set for as long as we maintain that information. This designated record set includes your medical and billing records, as well as any other records we use for making any decision about you. Any psychotherapy notes that may have been included in records we received about you are not available for your inspection or copying by law. We may charge you a fee for the costs of copying, mailing, or other supplies used in fulfilling your request.

If you wish to inspect or copy your medical information, you must submit your request in writing to our practice manager. You may mail in your request, or bring it to our office. We will have 30 days to respond to your request for information that we maintain at our practice site. If the information is stored offsite, we are allowed up to 60 days to respond but must inform you of this delay.

Request Amendment: You have the right to request that we amend your medical information if you feel that it is incomplete or inaccurate. You must make this request in writing to our practice manager, stating exactly what information is incomplete or inaccurate and the reasoning that supports your request. We will respond in writing within 60 days of your request.

We are permitted to deny your request if it is not in writing or does not include a reason to support the request.

We may also deny your request if: The information was not created by us, or the person who created it is no longer available to make the amendment; the information is not part of the record which you are permitted to inspect and copy; the information is not part of the designated record set kept by this practice; or if it is the opinion of the health care provider that the information is accurate and complete.

We will respond within 60 days, in writing, explaining if the request was accepted or denied.

Request an alternative means of confidential communication: You have the right to ask us to contact you about medical matters using an alternative method (i.e., email, telephone), and to a destination (i.e., cell phone number, alternative address, etc.) designated by you. You must inform us in writing how you wish to be contacted if other than the address/phone number that we have on file. We will follow all reasonable requests.

Request a restriction of your PHI: This means you have the right to ask us, in writing, not to use or disclose any part of your Protected Health Information for the purposes of treatment, payment or healthcare operations. If we agree to the requested restriction, we will abide by it, except in emergency circumstances when the information is needed for your treatment. In certain cases, we may deny your request for a restriction.

You will have the right to request, in writing, that we restrict communication to your health plan regarding a specific treatment or service that you, or someone on your behalf, has paid for in full, out-of-pocket. We are not permitted to deny this specific type of requested restriction.

An accounting of Disclosure: You have the right to request a list of the disclosures of your health information we have made outside of our practice that were not for treatment, payment, or health care operations.

Your request must be made in writing and must state the time period for the requested information. You may not request information for any dates greater than six years. Your first request for a list of disclosures within a 12-month period will be free.

If you request an additional list within 12 months of the first request, we may charge you a fee for the costs of providing the subsequent list. We will accommodate all reasonable requests.

A Paper copy of This Notice: You have the right to receive a paper copy of this notice upon request. You may obtain a copy by asking our receptionist at your next visit by calling and asking us to mail it to you.

File a Complaint: If you believe we have violated your medical information privacy rights, you have the right to file a complaint with us, or directly to the Secretary of Health and Human services.

U.S. Department of Health and Human Services 200 Independence Avenue, S.W. Washington, D.C. 20201 1-877-696-6775

www.hhs.gov/ocr/privacy/complaints/

Authorize other use and disclosure: You have the right to authorize any use or disclosure of PHI that is not specified within this notice.

For example, we would need your written authorization to use or disclose your PHI for marketing purposes, for most uses or disclosures of psychotherapy notes, or if we intended to sell your PHI. You may revoke an authorization, at any time, in writing, except to the extent that your healthcare provider, or our practice, has taken an action in reliance on the use or disclosure indicated in the authorization.

We may contact you to provide information about health related benefits and services offered by our office, for fundraising activities, share information in a disaster relief situation, include your information in a hospital directory, or with respect to a group health plan, to disclose information to the health plan sponsor. You will have the right to opt out of such special notices, and each such notice will include instructions for opting out.

Ways In Which We May Use and Disclose Your Protected Health Information

The following paragraphs describe different ways that we use and disclose your protected health information. We have provided an example for each category, but these examples are not meant to be exhaustive.

Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. We will also disclose your health information to other physicians who may be treating you. Additionally we may from time to time disclose your health information to another physician whom we have requested to be involved in your care.

Health care operations: We will use and disclose your protected health information to support the business activities of our practice. For example – we may use medical information about you to review and evaluate our treatment and services or to evaluate our staff’s performance while caring for you. In addition, we may disclose your health information to third-party business associates who perform billing, consulting, or transcription services for our practice.

Payment: We will use and disclose your protected health information to obtain payment for the health care services we provide you.

Public health: We will use and disclose your protected health information in certain situations to help with public health and safety issues, including preventing disease, helping with product recalls, reporting adverse reactions to medications, reporting suspected abuse, neglect, or domestic violence, and preventing or reducing a serious threat to anyone's health or safety.

Research: We will disclose your protected health information to researchers provided the 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.

As Required by Law: We will use and disclose your protected health information when required to by federal, state, or local law.

Our Responsibilities

We are required by law to maintain the privacy and security of your protected health information. We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.

We must follow the duties and privacy practices described in this notice and give you a copy of it. We will not use or share your information other than as described here unless you tell us we can in writing.

If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

By signing this form, you acknowledge you were advised of the HIPAA Notice of Privacy Practices. Our HIPAA Notice of Privacy Practices provides information about how we may use and disclose your protected information. We encourage you to read it in full. Our Notice of Privacy Practices is subject to change. You may request a copy of the Notice of Privacy.

Thank you for choosing {Brighter Life Behavioral Services/ Open Mind Counseling Services}: as your health care provider. Please carefully read and Initial under each statement and sign below. This policy has been put in place to ensure that financial payments due are recovered to allow us to continue to provide quality medical care for our patients. It is important that we work together to assure that payment for services is as simple and straightforward as possible. Our practice manager or billing department will be glad to discuss these policies with you.

1. I understand that if I do not have my insurance card, referral, and/or co-payments, that my appointment may be rescheduled until such time that I can provide the required documents or payments.

2: I understand that {Brighter Life Behavioral Services} will collect all co-payments/co-insurance before claim processed from your insurance and prior to next follow up visit. ALL PENDING BALANCE ARE DUE PRIOR TO NEXT FOLLOW UP VISIT.

Payment in full and expected coinsurance payment responsibility are determined by the anticipated billing code(s), details of your Insurance policy, and agreement between your insurance company and {Brighter Life Behavioral Services}. Any overpayment to your account will be refunded to you at your request after payment and/or remittance has been received from your insurance company. Any pending balance over due 90 days will be sent to the collection agency.

3. I understand that a $25 service fee will be added for any checks returned for any reason and I will be responsible for payment of this fee and the amount of the returned check. NSF checks must be redeemed with certified funds cashier's check, money order, or cash

4. I understand that if I am unable to make a scheduled appointment I need to contact {Brighter Life Behavioral Services} at least 24 hours before my scheduled appointment time. Due to a high demand for appointments, missed appointments prevent us from scheduling appropriately and keep others in need of urgent care from being seen.

5. A $25 FEE WILL BE ASSESSED FOR ALL MISSED APPOINTMENTS NOT CANCELED WITH AT LEAST 24-HOUR ADVANCED NOTICE.

6. I understand that if my accounts not paid in full within 90 days of a statement date, a 35% collection agency processing fee will be added to the outstanding balance and will be turned over to collections for further processing. No additional appointments/medication refills will be made for delinquent accounts until they are brought current.

7. {Brighter Life Behavioral Services} will allow 60 days from the date of filing for my Insurance company to process or pay a claim. State law allows Insurance companies operating in the state no more than 60 days to process claims. It is my responsibility to provide my Insurance company with requested Information needed to process a claim for services. It is also my responsibility to notify {Brighter Life Behavioral services} if there is any change in my insurance coverage, residence, or phone number.

8. Patients with greater than 3 late cancellations and/or no shows per calendar year will be notified in writing of the absences. Patients with continued occurrences following written notice will be subject to the Brighter Life Behavioral Services Patient Dismissal from Care Policy.

ULTIMATELY, IT IS UP TO ME TO KNOW MY INSURANCE BENEFITS.

By signing below, I acknowledge I have read and agree to all the provisions of the above financial policy. I understand that I am ultimately responsible for all professional fees incurred for professional services performed by the attending physician.

We require insured patients to complete the assignment of benefits authorizing Insurance to remit payment to the physician's office.

I hereby assign all mental health benefits to include major mental health benefits to which I am entitled, private insurance, and any other health plans to: {Brighter Life Behavioral Services/OMCS}. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original. I understand that I am financially responsible for all charges where or not paid by said insurance.

I hereby authorize said assignee to release all medical information necessary to secure the payment.

I consent to evaluation and treatment of the condition for which I, my child or dependent, have come to Brighter Life Behavioral Services, and authorize the Mental health providers and other health care providers affiliated with Brighter Life Behavioral Services, to provide such evaluation and treatment. I understand that health care providers in training may be involved in my care and treatment and consent to their involvement.

I understand that the practice of medicine is not an exact science, and acknowledge that no guarantees have been made to me regarding the likelihood of success or outcomes of any examination, treatment, diagnosis, or test performed at or by Brighter Life Behavioral Services.

I acknowledge and agree that this consent will be applicable to all visits or episodes of evaluation and treatment at Brighter Life Behavioral Services. I have had an opportunity to discuss it, and any questions I have had have been answered to my complete satisfaction.

We are partnered with Open Mind Counseling Services (OMCS). If you need Therapy or TMS services it may be provided through Open Mind Counseling Services. Financial/HIPPA/Demographic forms signed by you at Brighter Life Behavioral Services will be transferred over to OMCS in order to continue with the services without any disruption.

By providing your phone number to “Brighter Life Behavioral Services”, you hereby acknowledge and agree that we may send text messages to your wireless phone number for various purposes. Please note that message and data rates may apply. Message frequency will vary, and you retain the right to Opt-out by simply replying “STOP.” For a detailed understanding of how we handle your data, please refer to our Privacy Policy below.

Privacy Policy:

No mobile information will be shared with third parties/affiliates for marketing/promotional purposes. All the above categories exclude text messaging originator opt-in data and consent; this information will not be shared with any third parties.