Client Rights and Responsibilities

 

Mental health services are a cooperative venture for clients and health care providers. You and your treatment provider have specific rights and responsibilities in relationship to each other.

 

As a client, you have the following rights:

 

      1. The right to humane care and treatment. You will be treated with respect and consideration.

 

      2. The right to accurate information, to the extent known, about your assessment, diagnosis and treatment. You will be informed about any decisions which affect your treatment or services.

      3. The right to be informed of any research aspect of the services provided to you, and to refuse to participate. Such refusal will not affect your access to services at NCS.

 

      4. The right to know the name and professional qualifications of any treatment providers from whom you receive services at NCS.

 

      5. The right to information regarding the scope and availability of services, including information on after hours and emergency care.

 

      6. The right to information regarding fees for service and payment plans, and advice on the cost and benefits of any outside services that are recommended.

 

      7. The right to confidentiality of your evaluation and treatment records. You have a right to not have your problem discussed anyplace where it might be overheard by anyone who is not a staff person at NCS, except as required by law (see exceptions to confidentiality below).


As a client, you have responsibilities:

 

      1. Provide full information about your problems and concerns to allow proper evaluation and treatment.

 

      2. Ask questions to ensure that you have a satisfactory understanding of the evaluation or treatment services which you are being provided.

 

      3. Show courtesy and respect to all staff treatment providers and other clients that you may meet at NCS.

 

      4. Respect the privacy of all other clients and their families. This includes anyone that you see in or around the waiting room.                                                          

                                                                                                                                                                                 

      5. Observe rules and policies of NCS posted in the waiting room. This includes not leaving any children unattended in the waiting room at any time.

 

      6. Pay for services billed to your account in a timely manner.

 

We keep a record of the evaluation and treatment services provided to you:

 

You may ask to see your healthcare information. You may also request a copy of your healthcare record, at a reasonable copying fee. You may ask us to correct that record. We will not disclose your record to others unless you direct us to do so or the law authorizes or compels us to do so. You may request information about your record from your treatment provider.

 

The confidentiality of your health care information is protected by state and federal laws. Your personal information will not be communicated to others without your written authorization, except in the following instances:

 

     ●    Internal Administrative Use: Your therapist may communicate your healthcare information to NCS staff and other NCS therapists for quality assurance and billing purposes. This includes case review at confidential NCS staff meetings and reports on treatment services.

 

    ●    Mandated Reporting: All healthcare providers are mandated to report to relevant state agencies any information about the abuse or harmful neglect of children, or adults who are elderly or disabled. This information is provided to governing agencies (e.g., Departments of Children & Families, Mental Retardation, or Protection Services for the Elderly). We may also disclose information to prevent individuals from physically hurting themselves or others.


If you sign an authorization to release your healthcare information to another individual or agency, you may later stop any further disclosures by revoking the authorization, in writing. Revoking an authorization will not affect any disclosures made when the authorization was in effect.

 

If you have any complaints about policies or practices at NCS, you should discuss them with your treatment provider. If you wish, you may also bring them to the attention of Dr. Ronald Anderson, who is the Clinical Director of NCS.


Attestation: By signing below, you acknowledge that you have read this form and have had an opportunity to ask any questions that you may have. Your signature indicates that your questions have been answered to your satisfaction. You will be given a blank copy of this form upon request.








__________________________________ __________________________________ _________

Client Signature (or Parent if client is a minor) Printed Name                                                   Date 





__________________________________ __________________________________ _________

Child Signature (if client is age 14 or older)             Printed Name                                        Date 

 

 

ncs rev. 12/04