try U-first

We welcome you to U-First Healthcare, LLC and we are pleased to be able to support your mental, medical and physical wellness. Our sincere goal is to facilitate your healing, growth, and restoration and to provide you with the maximum benefit from your treatment plan. In order for treatment to be most effective, it is crucial that you take an active role in this journey by working on things that you and your provider discuss at your visit. In addition, avoid any mind-altering substances at least eight hours before your visit. The more of yourself you are willing to invest, the greater the return. Further, it is our policy to only see clients who we believe have the capacity to resolve their own problems with our assistance. It is our intention to empower you in your growth process to the degree that you can face life’s challenges in the future without the practitioners here at U-First Healthcare.

Your provider will always keep everything you say completely confidential, following exceptions: (1) You direct your provider by signing a “Release of Information” form or “Coordination of Care” form; (2) your provider determines that you are a danger to yourself or others;(3) you report information about abuse of a child, an elderly person, or a disabled individual; or (4) your provider is ordered by a judge to disclose information. In the latter case, your provider’s license does provide with the ability to uphold what is legally termed “privileged communication” which is your right as a client to have a confidential relationship with behavioral professionals. The state of Georgia has a very good track record in respecting this legal right. If there is such an order, it can be appealed. We cannot guarantee a sustained appeal, but we use every resource to keep what you have said confidential. Please make note that in couples and family counseling, your provider does not agree to keep secrets. Therefore, information revealed in any context may be discussed with either partner.

If you choose to include personal and or clinical concerns, please know that your PHI information is at risk, does not guarantee privacy, and is not deemed confidential. Please know U-First Healthcare will maintain your confidentiality to the best of our ability, however, we cannot guarantee this with any electronic communication.

Tele-mental health services are used when our mental health providers are not physically present with you to evaluate your mental health needs and if appropriate the prescription of medications. You and your mental health provider will utilize HIPAA compliant virtual face- to-face apparatus on a computer, tablet, or cell phone. Tele-mental health services use a video camera and computer to send both voice and visual images between you and your mental health practitioner. Tele-mental health services can be just as beneficial as in person sessions. Since face-to-face treatment is relegated only in the state of Georgia so are virtual tele-mental sessions. Your provider will treat and document your session. Any prescriptions that are prescribed will be sent to the pharmacy and ready for you to pick up.

In Case of Emergency

U-First Healthcare, LLC is an outpatient practice. We are set up to accommodate individuals who are reasonably safe and resourceful. We do not carry beepers, pagers ;nor are we available at all times. If at any time this does not feel like sufficient support, please inform your provider so additional resources can be discussed or transfer your case to a provider/ clinic with 24-hour availability. Generally, your provider will return messages within 24-48 hours. If you have a mental or medical health emergency, do not wait for a call back, but proceed with one or more of the following:
GCAL 800-715-4225 Call
Ridgeview Institute at 770-434-4567 or Peachford Hospital at 770-454-5589
Call 911
24hours a day into a psychiatric hospital or emergency room for an assessment

Professional Relationship

Mental health treatment is a professional service we will provide to you. A provider’s responses to your situation are based onr tested theories and methods of change. Because of the nature of the treatment, it must be limited to only the relationship of provider and patient. Medical providers are required to keep the identity of their patients’ secret. For confidentiality, a provider will not address you in public unless you initiate a conversation first. Your provider must decline any invitation to attend gatherings as well as must decline requests on all social networking sites. In sum, it is the duty of your provider to always maintain a professional role. Please note that these guidelines are not meant to be discourteous in any way, but strictly for your long-term protection.

Statement Regarding Ethics, Client Welfare and Safety

U-First Healthcare assures that services rendered will be done in a consistent , professional manner in accordance with the governing bodies. If at any time you feel that your provider’s performance is unethical or unprofessional, we ask that you let the provider know immediately. If you are both unable to resolve the concern, please email us at info@ufirsthealthcare.org attention : Agency Director.

Health Insurance Portability and Accountability Act (HIPAA) Rights.

I acknowledge U-First Healthcare, LLC adheres to the federal mandates of the HIPAA laws. My signature bellow acknowledges receipt of this notice. I am able to receive the full disclosure in print, email or fax upon request.

Your signature indicates that you have read and understood the contents of this form. You agree to the policies of your relationship with your provider and you are authorizing your clinician to begin treatment with you. You also agree to undergo mental health treatment and understand that you can end your treatment at any time. It should be discussed with your clinician, but you always reserve the right to stop treatment.

U-First Healthcare, LLC seeks to keep medical costs down by ensuring we can get reimbursed for our services on a timely basis. To help our office provide the most efficient and reasonable health care services, it is necessary for us to have a financial policy indicating our requirements for payment of services provided to our clients.

Structure and Cost of Sessions: Unless negotiated by your insurance carrier, your provider agrees to provide treatment and medication management at the following fee schedule:

The fee for each visit will be due prior to the start of the session. The receipt of payment may also be used as a statement for insurance if applicable. Please note that insurances audit and will retract payment, making you fully liable, if they find the client ineligible at time of services, i.e. your employer indicates a termination date, but services were paid to the provider after that date.

Telephone Calls: Phone contact to set or rearrange appointment times or brief phone contact to obtain relevant treatment information will not be billed. Doing treatment by telephone is an option, however it requires advance scheduling and may not be covered by your insurance. If you need to talk to your practitioner between sessions as an emergency, you may be billed for that extra support. Telephone calls that exceed 10 minutes in duration will be billed at $1.00 per minute. If this is the case, you and your clinician will need to explore adding tele-mental sessions or develop other resources to help you in-between sessions.

Ancillary Services: Time spent performing services that support your treatment, such as writing reports, paperwork, contact with outside parties by phone or letter, and supportive phone contact to the client outside of regular sessions, are not covered by insurance and will be billed directly to the client. Ancillary services such as these will be charged at $90.00 per need and due at time of request. Copy of records must be made in writing and emailed to info@ufirsthealthcare.org ATTN: Records Request and will be charged a fee of $25.88 plus $0.97 per page.

Cancellation Policy & Fees: In the event you are unable to keep an appointment, notify the office at least 24-hours in advance. If a notice is not received, you will be financially responsible for the visit you’ve missed. Insurance companies DO NOT reimburse for missed visits. To avoid a missed appt fee, a same week reschedule can be made, if availability exists. Same day appointment cancellations at a $45.00 per occurrence. Cancellations in the pre-hour of scheduled appointments and no-show appointments are charged at a $60.00 per occurrence. Payment arrangements are mandatory prior to getting back on the schedule.

, hereby consent to authorization and treatment voluntarily at UFirst Healthcare, as agreed upon in the best interest of my health.

I consent to the release and disclosure of my medical history, condition, and documentation that is necessary to process insurance claims, assist other medical professionals in continuation of care, or to another healthcare facility if admission is required. I understand that a copy of this signed release is valid as the original. I understand that I or the provider can discontinue this authorization at any time, in writing. I have read and understand this agreement and attest to all the information being provided, is true and accurate. I fully accept all terms of this agreement and will receive a copy, if requested. 

THIS INFORMATION MAY BE USED OR DISCLOSED IN CONNECTION WITH MENTAL HEALTH TREATMENT, PAYMENT, OR HEALTHCARE OPERATIONS. I UNDERSTAND THAT I HAVE THE RIGHT TO REVOKE THIS AUTHORIZATION, IN WRITING, AT ANY TIME, BY SENDING WRITTEN NOTIFICATION TO MY PROVIDER’S OFFICE. I FURTHER UNDERSTAND THAT A REVOCATION OF THE AUTHORIZATION IS NOT EFFECTIVE TO THE EXTENT THAT ACTION HAS BEEN TAKEN IN RELIANCE ON THE AUTHORIZATION.

UNLESS YOU HAVE SPECIFICALLY REQUESTED IN WRITING THAT THE DISCLOSURE BE MADE IN A CERTAIN FORMAT, WE RESERVE THE RIGHT TO DISCLOSE INFORMATION, AS PERMITTED, BY THIS AUTHORIZATION, IN A MANNER WHICH WE DEEM APPROPRIATE AND CONSISTENT WITH APPLICABLE LAW, INCLUDING BUT NOT LIMITED TO, VERBAL, IN PAPER FORMAT, OR ELECTRONICALLY.

I understand that there is the potential that the protected health information that is disclosed pursuant to this authorization may be re-disclosed by the recipient and the protected health information will no longer be protected by the HIPAA privacy regulations unless state law applies that is stricter than HIPAA and provides additional privacy protection. I will be given a copy of this authorization for my records, if requested.

Right to Request Amendment of Medical Information You Believe Is Erroneous or Incomplete: If you examine your medical information and believe  that some of the information is wrong or incomplete, you may ask us to amend your record. To ask us to amend your medical information, call and speak to a supervisor. 

Right to Get a List of Certain Disclosures of Your Medical Information: You have the right to request a list of many of the disclosures we make of your  medical information. If you would like to receive such a list, call a Supervisor.  

We will provide the first list to you free, but we may charge you for any additional lists you request during the same year. We will tell you in advance  what this list will cost. 

Right to Request Restrictions on how the Clinic Will Use or Disclose Your Medical Information for Treatment, Payment, or Health Care Operations: You  have the right to request that the Clinic not make disclosures of your medical information to treat you, to seek payment for care, or to operate the Clinic.  

In many cases, the Clinic is not required to agree to your request for restriction, but if we do agree, we will comply with that agreement. If you want to  request a restriction, write to the Supervisor and describe your request in detail.  

However, the Clinic must agree to your request not to disclose to your health plan any medical information about items or services for which you have paid  in full, unless such disclosure is required for treatment or by law.  

If you do not want the Clinic to disclose medical information to your health plan, you must notify us at the time of your registration as well as make  immediate arrangements to pay in full for your treatment. 

Right to Request Confidential Communications: You have the right to ask us to communicate with you in a way that you feel is more  confidential. For example, you can ask us not to call your home, but to communicate only by mail. To do this, write to the Supervisor. Upon  request, you can also ask to speak with your health care providers in private outside the presence of other patients or family. 

Duties of the Clinic: The Clinic is required by law to protect the privacy of your medical information, give you this Notice of Privacy Practices, and follow  the terms of the Notice that is currently in effect. The Clinic is also required to notify you if there is a breach of your unsecured medical information. 

Which Health Care Providers are Covered: This Notice of Privacy Practices applies to the Clinic and its personnel, volunteers, students and trainees.  This Notice also applies to other health care providers when they come to the Clinic to care for patients, such as physicians, physician assistants,  therapists, other health care providers who are not employed by the Clinic. However, these other health care providers may follow different practices at  their own offices or facilities. 

Changes to this notice: From time to time, we may change our practices concerning how we use or disclose patient medical information, or how we will  implement patient rights concerning their information.  

We reserve the right to change this Notice and to make the provisions in our new Notice effective for all medical information we maintain. If we change  these practices, we will publish a revised Notice of Privacy Practices. You can get a copy of our current Notice of Privacy Practices at any time by  contacting the Clinic. 

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN  GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. 

We are committed to protecting the confidentiality of your medical information, and are required by law to do so. This notice describes how we may use  your medical information within the Clinic and how we may disclose it to others outside the Clinic. This notice also describes the rights you have  concerning your own medical information. Please review it carefully and let us know if you have questions. 

How will we use and disclose your medical information? Treatment: We may use your medical information to provide you with medical services and  supplies. We may also disclose your medical information to others who need that information to treat you, such as doctors, physician assistants, nurses,  medical and nursing students, technicians, therapists, emergency service and medical transportation providers, and others involved in your care. 

For example, we will allow your primary care physician to have access to your Clinic medical record. To assure that your other treatment providers have  quick access to your latest health information, we may participate in a community-based electronic health information exchange. We also may use and 

disclose your medical information to contact you to remind you of an upcoming appointment, to inform you about possible treatment options or  alternatives, or to tell you about health-related services available to you, or to perform follow-up calls to monitor your care experience. 

Family Members, Legal Counsel, and Others Involved in Your Care: We may disclose your medical information to a family member, legal counsel,  or friend who is involved in your medical care, or to someone who helps to pay for your care. 

Payment: We may use and disclose your medical information to get paid for the medical services and supplies we provide to you. 

For example, your health plan, Health Insurance Company, or attorney may ask to see parts of your medical record before they will pay us for your  treatment. 

Clinic Operations: We may use and disclose your medical information if it is necessary to improve the quality of care we provide to patients or to run the  Clinic. We may use your medical information to conduct quality improvement activities, to obtain audit, accounting or legal services, or to conduct  business management and planning. For example, we may look at your medical record to evaluate the care provided by clinic personnel, your doctors, or  other health care professionals. 

Required by Law: Federal, state, and local laws sometimes require us to disclose patients’ medical information.  

For instance, we are required to report child abuse or neglect and must provide certain information to law enforcement officials in domestic violence cases.  We also are required to give information to the State Workers’ Compensation Program for work-related injuries. 

Public Health: We also may report certain medical information for public health purposes. For instance, we are required to report births, deaths, and  communicable diseases to the State. We also may need to report patient problems with medications or medical products to the FDA, or may notify  patients of recalls of products they are using. 

Public Safety: We may disclose medical information for public safety purposes in limited circumstances. We may disclose medical information to law  enforcement officials in response to a search warrant or a grand jury subpoena.  

We also may disclose medical information to assist law enforcement officials in identifying or locating a person, to prosecute a crime of violence, to report  deaths that may have resulted from criminal conduct at the Clinic. We also may disclose your medical information to law enforcement officials and others  to prevent a serious threat to health or safety. 

Military, Veterans, National Security and Other Government Purposes: If you are a member of the armed forces, we may release your medical  information as required by military command authorities or to the Department of Veterans Affairs. The Clinic may also disclose medical information  to federal officials for intelligence and national security purposes, or for presidential Protective Services. 

Judicial Proceedings: The Clinic may disclose medical information if the Clinic is ordered to do so by a court or if the Clinic receives a subpoena or  a search warrant. You will receive advance notice about this disclosure in most situations so that you will have a chance to object to sharing your  medical information. 

Information with Additional Protection: Certain types of medical information have additional protection under state or federal law.  

For instance, medical information about communicable disease and HIV/AIDS, and evaluation and treatment for a serious mental illness is treated  differently than other types of medical information. For those types of information, the Clinic is required to get your permission before disclosing that  information to others in many circumstances. 

When is Your Authorization Required? Uses and Disclosures for Which Your Authorization is Required: With limited exceptions, the Clinic 

must obtain your written authorization before it may disclose your medical information in the following circumstances: (1) to disclose  psychotherapy notes, (2) to conduct marketing activities, or (3) to sell your medical information to a third party. 

Other Uses and Disclosures Requiring Authorization: If the Clinic wishes to use or disclose your medical information for a purpose that is not discussed  in this Notice, the Clinic will seek your written authorization.  

If you give your authorization to the Clinic, you may take back that authorization any time, unless we have already relied on your authorization to use or  disclose the information. If you ever would like to revoke your authorization, please notify the Supervisor in writing.

U-First Healthcare offers family medical, psychiatric, medical detoxification, weight management, and  psychotherapy treatments. When meeting with the psychiatric providers the appointment will include  the assessment of your mental health condition and treatment options.  

During the visit, you and your provider will discuss:  

1. The nature of your mental condition.  
2. Your physician’s reasons for prescribing the medication, including the likelihood of your condition  improving or not improving without the medicine.  
3. The importance of medication compliance and the option to discuss with your prescribing physician  any desire to stop taking any medication.  
4. Reasonable alternative treatments that are available for your condition.  
5. There may be a need for initial or periodic medical or laboratory consultations with the use of these  medication(s).  
6. That certain antipsychotic medications may cause additional side effects for some persons, including  tardive dyskinesia. Tardive dyskinesia is defined as persistent involuntary movements of the face,  mouth, torso, hands, or feet. These symptoms are potentially irreversible, and may continue after the  antipsychotic medication has been stopped.  

I was given information about the recommended medication. I understand that the  information does not cover everything, but it includes items of clinical significance to me. I  should discuss all my medical problems and any medication that I take with my healthcare  provider or physician(s). For more information, I may refer to a pharmacist or to a standard  text such as the Physician’s Desk Reference (PDR).  

U-First Healthcare: 1479 Brockett Road Suite 101 Tucker, GA 30084 Office: 1-833-645-4653 Fax: 1-866-892-3005 www.U-First Healthcare.org

Add the score for each column

Add the score for each column

5) Suicide Intent with Specific Plan:
Thoughts of killing oneself with details of plan fully or partially worked out and person has some intent to carry it out.

6) Suicide Behavior Question:

Examples: Collected pills, obtained a gun, gave away valuables, wrote a will or suicide note, took out pills but didn’t swallow any, held a gun but changed your mind or it was grabbed from your hand, went to the roof but didn’t jump; or actually took pills, tried to shoot yourself, cut yourself, tried to hang yourself, etc