Treatment Consent Form (Treatment Consent)

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Consent for Purposes of Treatment, Payment & Healthcare Operations

I consent to the use or disclosure of my/my child’s Protected Health Information (PHI) by Advanced Counseling and Testing Solutions, LLC (ACTS) for the purposes of (1) diagnosing and/or providing treatment to me/my minor child; (2) obtaining payment for my health care bills; and/or (3) to conduct routine health care operations. PHI may include demographic information, collected from me and created or received by ACTS, another health care provider, a health plan, my employer or a health care clearinghouse. This PHI relates to my/my child’s past, present and/or future physical or mental health/condition and may identify me/my child.

I understand that diagnosis or treatment of me/my child by Advanced Counseling and Testing Solutions may be conditioned upon my consent, as evidenced by my signature on this document. I further understand that I have the right to request a restriction as to how my/my child’s PHI is used/disclosed to carry out evaluation, treatment, intervention, payment or the healthcare operations of the practice. Advanced Counseling and Testing Solutions are not required to agree to the restrictions that I may request, however, if they do agree, the restriction is binding. I also have the right to revoke this consent, in writing, at any time, except to the extent that Advanced Counseling and Testing Solutions have taken action in reliance upon this consent

Advanced Counseling and Testing Solutions have taken action in reliance upon this consent. I understand that I have a right to review Advanced Counseling and Testing Solutions’s Notice of Privacy Practices (NPP) prior to signing this document and acknowledge that a written copy of Advanced Counseling and Testing Solution’s NPP has been provided to me. The NPP describes the types of uses and disclosures of my (PHI) that will occur in treatment, payment of my bills and/or in the performance of health care operations at the office of ACTS. This NPP also describes my rights and Advanced Counseling and Testing Solutions duties with respect to my PHI. Advanced Counseling and Testing Solutions reserve the right to change the privacy practices that are described in the NPP, and I may obtain a revised NPP by accessing their website (, calling the office and requesting that a revised copy be sent in the mail and/or asking for a copy at the time of my/my child’s next appointment.

After you have signed this consent, you have the right to revoke it by writing a letter telling us you no longer consent. We will comply with your request about using or sharing your PHI from that time on, but we may have already used/shared some of the PHI and cannot retrieve what has already been shared. Please read this before you sign this Consent form. If you do not sign this consent form agreeing to our NPP, we cannot complete an evaluation for you/ your child or provide any psychological services to you.

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