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MCS Counseling Center (Montesinos Counseling Services, LLC) 7545 Centurion Parkway, Suite 106, Jacksonville, FL 32256
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
I. OUR PLEDGE REGARDING HEALTH INFORMATION: We understand that health information about you and your health care is personal. We are committed to safeguarding your protected health information (PHI). PHI constitutes the information we maintain in records of the care and services you receive from our practice that can identify you. This includes information about your past, present, or future health or condition, providing health care services to you, and the payment for such health care. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by our mental health care practice. This notice will tell you how we may use and disclose your health information. We also describe your rights to the health information we keep about you and our obligations regarding using and disclosing your health information. We are required by law to:
Ensure health information (“PHI”) that identifies you is kept private.
Give you this notice of my legal duties and privacy practices concerning health information.
Follow the terms of the notice that is currently in effect.
We can change the terms of this Notice, which will apply to all information we have about you. The new Notice will be available in our office, our website, and the client portal if a change is made.
II. HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU: The following categories describe different ways that we use and disclose health information. For each category of uses or disclosures, we will explain what I mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all the ways we are permitted to use and disclose information will fall within one of the categories. Generally, using PHI means sharing, applying, utilizing, examining, or analyzing information within our practice. The disclosure of PHI means releasing, transferring, giving, or otherwise revealing it to a third party outside our practice.
Uses and Disclosures Related to Treatment, Payment, or Healthcare Operations Do Not Require Your Prior Written Consent
Federal privacy rules (regulations) allow healthcare providers who have a direct treatment relationship with the patient/client to use or disclose the patient/client’s personal health information without the patient’s written authorization to carry out the healthcare provider’s treatment, payment, or healthcare operations.
For Treatment: We can use your PHI within our practice to provide you with mental health treatment. This includes consultation with clinical supervisors or other treatment team members. We may disclose your PHI to physicians, psychiatrists, psychologists, and licensed healthcare providers who provide you with healthcare services or are otherwise involved in your care. However, we prefer to have your authorization. For example, if a clinician were to consult with another licensed healthcare provider about your condition, we would be permitted to use and disclose your personal health information, which is otherwise confidential, to assist the clinician in diagnosing and treating your mental health condition.
Disclosures for treatment purposes are not limited to the minimum necessary standard because therapists and other health care providers need access to the full record and complete information to provide quality care. The word “treatment” includes, among other things, the coordination and management of health care providers with a third party, consultations between providers, and patient referrals for health care from one health care provider to another.
To obtain payment for treatment: We may use and disclose your PHI to bill and collect payment for our treatment and services. For example, we might send your PHI to your insurance company or health plan to get paid for the health care services that we have provided to you. We could also provide your PHI to business associates, such as billing companies, claims processing companies, and others who process health care claims for my office.
We may disclose your PHI for healthcare operations to facilitate our practice's efficient and correct operation. For example, to maintain quality control, we might use your PHI to evaluate the quality of healthcare services you have received. Other examples of healthcare operations are business-related matters such as audits, administrative tasks and services, and disclosing PHI to our attorneys or other consultants to ensure we comply with applicable laws.
Other disclosures: Your consent isn’t required if you need emergency treatment, provided we attempt to get your consent after treatment is rendered. If we try to get your consent, but you cannot communicate with me (for example, if you are unconscious or in severe pain), but we think that you would consent to such treatment if you could, we may disclose your PHI.
III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION:
Psychotherapy Notes. Some of our providers keep “psychotherapy notes,” as that term is defined in 45 CFR § 164.501. Any use or disclosure of such notes requires your authorization unless the use or disclosure is: a) For use in treating you. b) For use in training or supervising mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy. c) For use in defending ourselves in legal proceedings instituted by you. d) For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA. e) Required by law, and the use or disclosure is limited to the requirements of such law. f) Required by law for certain health oversight activities about the originator of the psychotherapy notes. g) Required by a coroner who is performing duties authorized by law, and h) Required to help avert a serious threat to the health and safety of others.
Marketing Purposes. We WILL NOT use or disclose your PHI for marketing purposes.
Sale of PHI. We WILL NOT sell your PHI in the regular course of our business.
IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION. Subject to certain limitations in the law, we can use and disclose your PHI without your authorization for the following reasons:
When disclosure is required by state or federal law, the use or disclosure complies with and is limited to the relevant requirements of such law.
For public health activities, including reporting suspected child, elder, or dependent adult abuse or preventing or reducing a serious threat to anyone’s health or safety.
For efforts to address risks of danger to self or others, including if you are experiencing a mental or emotional condition causing you to pose a serious risk of danger to yourself or the person or property of others, and if we determine that disclosure is necessary to prevent the threatened danger.
For health oversight activities, including audits and investigations.
For judicial and administrative proceedings, including responding to a court or administrative order, although my preference is to obtain Authorization from you before doing so.
For law enforcement purposes, including reporting crimes occurring on my premises.
To coroners or medical examiners when such individuals perform duties authorized by law.
For research purposes, including studying and comparing the mental health of patients who received one form of therapy versus those who received another form of therapy for the same condition. All research projects are subject to a special review process and the confidentiality requirements of state and federal law.
Specialized government functions, including ensuring the proper execution of military missions, protecting the President of the United States, conducting intelligence or counter-intelligence operations, or helping to ensure the safety of those working within or housed in correctional institutions.
For workers' compensation purposes. Although we prefer obtaining Authorization from you, we may provide your PHI to comply with workers' compensation laws.
Disclosures to Business Associates. We may disclose PHI about you to business associates for services they may provide to assist us in providing quality health care. To ensure the privacy of your PHI, we require all business associates to apply appropriate safeguards to any PHI they receive or create.
Appointment reminders and health-related benefits or services. We may use and disclose your PHI to contact you to remind you that you have an appointment with our office. We may also use and disclose your PHI to tell you about treatment alternatives or other healthcare services or benefits that we offer.
V. CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT.
Disclosures to family, friends, or others. We may provide your PHI to a family member, friend, or another person you indicate is involved in your care or the payment for your health care unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergencies.
VI. YOU HAVE THE FOLLOWING RIGHTS CONCERNING YOUR PHI:
The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask me not to use or disclose certain PHI for treatment, payment, or health care operations purposes. I am not required to agree to your request, and I may say “no” if I believe it would affect your health care.
The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service you have paid for out-of-pocket in full.
The Right to Choose How I Send PHI to You. You have the right to ask me to contact you in a specific way (for example, by home or office phone or by an alternate method such as via e-mail instead of by regular mail) or to send mail to a different address, and I will agree to all reasonable requests.
The Right to See and Get Copies of Your PHI. Other than “psychotherapy notes,” you have the right to get an electronic or paper copy of your medical record and other information I have about you. I will provide you with a copy of your record or a summary of it (if you agree to receive a summary) within 30 days of receiving your written request, and I may charge a reasonable, cost-based fee for doing so.
The Right to Get a List of the Disclosures I Have Made. You have the right to request a list of instances in which I have disclosed your PHI for purposes other than treatment, payment, and healthcare operations for which you provided me with Authorization. I will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list I will give you will include disclosures made in the last six years unless you request a shorter time. I will provide the list to you at no charge, but if you make more than one request in the same year, I will charge you a reasonable cost-based fee for each additional request.
The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI or that a piece of important information is missing, you have the right to request that I correct the existing information or add the missing information. I may say “no” to your request, but I will tell you why in writing within 60 days of receiving your request.
The Right to Get a Paper or Electronic Copy of this Notice. You have the right to get a paper copy of this Notice, and you have the right to get a copy of this notice by e-mail. And, even if you have agreed to receive this Notice via e-mail, you also have the right to request a paper copy.
VII. COMPLAINTS.
If, in your opinion, we may have violated your privacy rights, or if you object to a decision we made about access to your PHI, you are entitled to file a complaint with the person listed in Section VIII below. You may also send a written complaint to the Department of Health and Human Services Secretary at 200 Independence Avenue S.W., Washington, D.C. 20201. If you file a complaint about our privacy practices, we will take no retaliatory action against you.
VIII. CONTACT INFORMATION FOR QUESTIONS ABOUT THIS NOTICE TO ISSUE A COMPLAINT ABOUT THESE PRIVACY PRACTICES.
If you have any questions about this notice or any complaints about these privacy practices or would like to know how to file a complaint with the Secretary of the DHHS, don't hesitate to get in touch with Steven Montesinos, LMHC, Privacy Officer, Owner, MCS Counseling Center (Montesinos Counseling Services, LLC) 7545 Centurion Parkway, Suite 106, Jacksonville, FL 32256, steven@mcsjax.com
EFFECTIVE DATE OF THIS NOTICE
This notice went into effect on May 6, 2018
Acknowledgment of Receipt of Privacy Notice
Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights to use and disclose your protected health information. By checking the box below, you acknowledge that you have received a copy of the HIPAA Notice of Privacy Practices.
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As a current or prospective client, you understand that you can text us STOP at any time to opt out of receiving SMS text messages from us. You can text us HELP at any time to receive help.
You understand that the messaging frequency may vary.
Your mobile information will not be shared with any third parties/affiliates for marketing/promotional purposes. All policies are followed as per CTIA guidelines 5.2.1. At any time if you want your information to be removed, you can contact us via our email address or regular mail.
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MCS Counseling Center (Montesinos Counseling Services, LLC) 7545 Centurion Parkway, Suite 106, Jacksonville, FL 32256
INFORMED CONSENT FOR PSYCHOTHERAPY & PRACTICE POLICIES
You or a member of your family is about to become involved in counseling or psychotherapy with a mental health provider at our practice. We wish to take this opportunity to welcome you and to review some key principles and policies that are essential in establishing a good counseling relationship. Please read through this information, asking questions as needed.
GENERAL INFORMATION
The therapeutic relationship is characterized by its deeply personal nature as well as being a professional agreement. It is essential that we establish a clear understanding of how the therapeutic relationship will function and what each party can expect. This consent document aims to provide a comprehensive framework for engagement in the therapeutic process. We invite open dialogue regarding any aspect of this document and welcome your questions anytime.
THE THERAPEUTIC PROCESS
Pursuing therapy is a significant step toward personal growth and well-being. The success of therapy is largely dependent on active involvement and commitment to the process. Engaging in therapy can sometimes be challenging and uncomfortable, as it may involve recalling distressing events and confronting associated emotions. While we can not offer guaranteed outcomes regarding the therapeutic process, our providers pledge to offer you support and assistance in clarifying and achieving your personal goals.
CONFIDENTIALITY
Confidentiality is a fundamental aspect of the therapeutic relationship. All information discussed in sessions, as well as relevant materials related to your treatment, will be held in strict confidence by our providers, except under the following circumstances:
If there is a direct threat of harm to yourself or others, including suicide or violence.
If there is reasonable suspicion of abuse or neglect involving minors, the elderly, or disabled individuals.
If a court orders the release of information through a legitimate subpoena.
When consulting with other healthcare professionals to enhance your treatment, anonymity will be preserved.
If you use insurance or a third-party payer, limited information must be shared for billing, payment, and coverage determination purposes, as required.
APPOINTMENTS AND CANCELLATIONS
To help us provide consistent and timely care to all our clients, we kindly request that you provide at least 24 hours’ notice if you need to cancel or reschedule an appointment. This allows us the opportunity to offer your appointment slot to someone else who may be in need of our services. In the event that an appointment is missed or canceled without a 24-hour notice, a fee of $50 will be applied. This fee helps us maintain the quality and accessibility of our services. Should such a situation occur, the fee will be processed using the payment method we have on file for you. Insurance does not cover missed appointments or late cancellation fees.
Our standard individual psychotherapy sessions are 53–55 minutes in duration. If you arrive late, we may not be able to extend your session time, and late arrival will likely result in a shorter session.
The full self-pay rate for each session is $155. This rate applies when services are paid out-of-pocket without the use of insurance or a third-party payer. Fees may differ if you use insurance or another third-party payer, or if you are approved for a discounted self-pay rate. Payment is processed after each session using the payment method on file.
Should any payment be returned or declined due to insufficient funds, chargebacks, or other banking or payment processing issues, a $10.00 service charge may be applied.
INSURANCE AND BILLING
Our practice accepts several insurance plans; however, not every provider at our practice accepts each of these plans. Please contact our office or visit the provider’s profile page on our website, www.mcsjax.com, to ensure that the provider you are scheduled with accepts your specific insurance. You agree to cooperate with all efforts to file claims on your behalf and to notify us immediately of any changes in insurance coverage. You are responsible for providing accurate and current insurance information. Failure to provide or update insurance information in a timely manner may result in claim denials or delays. In such cases, you may be responsible for charges at the self-pay rate for services rendered. You agree to be responsible for all charges not covered by your health plan, including claim denials.
If you have a TRICARE plan, some providers at our practice are TRICARE-certified but are not in-network. In these cases, you may be responsible for a deductible and/or cost-share before your plan covers a portion of the cost of services.
Headway is a third-party billing and credentialing partner that manages insurance claims and payment processing for some services at our practice. If your insurance plan is billed through Headway, you will receive a registration email and additional communication from Headway to manage your insurance and payment details. While we do not control Headway’s reimbursement rates or billing determinations, we are happy to help clarify the process and direct you to the appropriate resources if billing questions arise. If you have a concern related to Headway billing, please notify our office, and you may also contact Headway directly by visiting their website at https://headway.co/.
To help ensure uninterrupted access to care, you agree to maintain a valid payment method on file with our billing partner, Headway, or directly with our office, as applicable. If your payment method becomes invalid or is not kept up to date, appointments may be paused, canceled, or rescheduled until payment information is updated. Repeated failure to maintain a valid payment method may result in discharge from care, in accordance with our non-payment policy.
If you do not have one of the health insurance plans we accept, we can provide documentation (often referred to as a superbill) for filing out-of-network insurance claims, should you wish to submit services toward your annual out-of-network deductible or seek possible reimbursement through your insurance policy. We cannot guarantee reimbursement for out-of-network services, and we encourage you to contact your insurance provider directly to review your specific benefits. Some providers at our practice offer discounted self-pay rates. Clients may inquire with their provider or our office to request an eligibility form to determine whether they qualify for a discounted self-pay rate.
For self-pay and uninsured clients, we will provide a Good Faith Estimate of the expected costs of mental health services as required by law prior to the start of services. This estimate outlines anticipated fees but may be subject to change based on clinical needs or service frequency.
STAFF INTERNS AND SUPERVISION
Some providers at our practice are Registered Interns in the State of Florida who are working toward full licensure. These clinicians have completed graduate-level education and are gaining the supervised clinical experience required for licensure. Registered Interns are supervised by a State of Florida–approved Registered Supervisor and receive additional oversight within our practice to support high-quality care.
If you have any questions or concerns about your care while working with a Registered Intern, please contact our office. We are committed to providing high-quality services while also supporting the training and development of future mental health professionals.
COMMUNICATION & ELECTRONIC MESSAGING
For routine communication, clients are encouraged to contact our office by phone at 904-701-4662 or through the secure online client portal. Each provider has a direct phone extension, which can be accessed through the provider directory from the main menu when calling our office number, or by asking your provider directly.
If we are unavailable to take your call, please leave a voicemail. We make reasonable efforts to return calls within 48 business hours, excluding weekends and holidays. Messages received outside of normal business hours will be addressed on the next business day.
Please note that our practice is not equipped to provide immediate crisis response. In the event of an emergency, call 911 or go to the nearest emergency room.
The confidentiality of electronic communications, including email and text messaging, cannot be guaranteed. These methods should not be used to share sensitive or time-sensitive therapeutic information. For matters related to your care or treatment, clients should use secure communication methods such as the client portal or phone.
Email and text message communication is optional and limited to administrative purposes (such as scheduling or appointment reminders). Clients who wish to use email or text messaging must complete and sign a separate Email and Text Communication Consent Form following intake. Until this consent is completed, communication will be limited to phone calls or secure client portal messaging. Clients may revoke consent for email or text communication at any time by notifying the office in writing.
TECHNOLOGY USE
Our practice utilizes a HIPAA-compliant Electronic Health Record (EHR) system for the secure management of client records and to conduct telehealth sessions. Some providers use HIPAA-compliant audio transcription software, including medical-grade artificial intelligence (AI) tools, to support accurate and timely clinical documentation. With your consent, therapy sessions may be temporarily recorded solely for the purpose of transcription. Any audio recording is deleted immediately after transcription is complete and is not retained as part of your medical record.
These transcription and AI tools are designed to comply with HIPAA standards and are used only for treatment and documentation purposes. Information processed through these tools is limited to what is necessary for clinical care and is not used for any other purpose.
By signing this consent, you acknowledge and agree to the limited use of audio recording and AI-assisted transcription as described above. Consent may be withdrawn at any time by notifying your provider or the office in writing.
SOCIAL MEDIA
Our practice and its providers maintain professional boundaries with clients on social media platforms. We do not accept friend, follower, or contact requests from current or former clients on personal social networking sites. This policy exists to protect confidentiality, privacy, and the integrity of the therapeutic relationship.
Clients are welcome to view or follow the practice’s professional social media accounts; however, we encourage doing so thoughtfully and with discretion to protect your privacy.
If there is a therapeutic reason to review social media content as part of your treatment (such as exploring digital behavior patterns or the impact of social media on your well-being), you may bring this content into session for discussion. Providers will review client social media activity without the client’s explicit consent and direction.
Please be aware that social media platforms may use algorithms that suggest connections to our practice or other users based on your interactions. We do not control these features and recommend reviewing and adjusting your privacy settings to help minimize unintended disclosures.
MINORS
If you are a minor, your parent(s) or legal guardian(s) may have a legal right to access certain information related to your therapy. We will discuss with you and your parent(s) or guardian(s) the types of information that may be shared and which issues are more appropriate to keep private, to the extent permitted by law. Our goal is to support your privacy and the therapeutic relationship while also complying with legal requirements and respecting the rights of parent(s) or guardian(s).
HEALTH AND SAFETY
Our practice is committed to maintaining a safe and healthy environment for clients and staff. We follow applicable public health guidelines and best practices to help reduce the spread of communicable illnesses. Clients are asked to use discretion and consider the well-being of others when deciding to attend in-office sessions.
If you are experiencing symptoms of illness, have been exposed to someone who is ill, or are not feeling well, we encourage you to reschedule your in-office appointment or request to change to a telehealth session when available. This helps protect our community and allows us to continue providing care as safely as possible.
DISCHARGE PROCESS
There are several reasons why the professional relationship may come to an end, including lack of therapeutic benefit, preference for another provider, or the need for specialized services. If we initiate discharge, we will discuss the reasons with you and, upon request, provide referrals to other qualified providers. When clinically appropriate, we may offer a time-limited transition period to support continuity of care following notice of discharge.
Discharge may also occur due to non-payment, repeated non-attendance, or disrespectful or inappropriate communication. In such cases, reasonable efforts will be made to provide referral resources.
The professional relationship will be considered inactive and discontinued if no appointments are scheduled for eight (8) consecutive weeks without prior agreement. Requests to resume services after this period are subject to provider availability and may require placement on a waitlist.
ACKNOWLEDGEMENT OF POLICIES AND CONSENT
By clicking below, you are acknowledging this document and confirming that you have read, fully understood, and agree to the terms of this informed consent and the practice policies outlined above. Your understanding and cooperation are essential in helping us provide a respectful and effective therapeutic environment. Please discuss any questions or require further explanation with your provider and/or our office administrator.
Thank you for your attention to these policies. We are here to support you and look forward to embarking on a journey together towards your goals.