SAMARITAN COUNSELING CENTER (SCC)
FEE AGREEMENT FOR PROFESSIONAL SERVICES
Client Information
Name ___________________________________________________________ DOB ______/______/_______
Social Security Number ______-_____-_______ Used for insurance purposes only
Address ___________________________________City________________________State ______ Zip_______
Phone: Home _____________________Cell:_______________________
Employer__________________________________________________________________________________
Email address_____________________________________ Can we leave a message?______Yes _____No____
Person Responsible for Payment/Insurance (if different from Client)
Name _________________________________________________________ DOB ______/________/_______
Social Security Number _______-______-______
Address _______________________________City________________________State ______ Zip______
Phone: Home:_______________________ Cell:______________________
Employer_________________________________________________________________________________
Relationship to client _____________________________________________
The standard therapy session is 45 minutes.
Please initial where indicated
INSURANCE:
_______ I wish to use my insurance and request that Samaritan Counseling Center bill my insurance
company for fees. I am aware that I will be responsible for deductibles or co-payments/co-insurance
required by my policy as well as charges not covered by my insurance plan. Co-payments are required
at the time of the services. Billing statements are sent out monthly and are expected to be paid in full
within 30 days. If my insurance company denies payment of fees for any reason, I agree to make
payment of the fees in full. SCC will submit claims to your insurance company as a courtesy to you, but
as the insured, I acknowledge that I am responsible for all fees incurred for services provided for myself
and/or my dependents.
FEE FOR SERVICE:
_______ If you do not want to use your insurance or SCC is not in your plan, you will be billed directly
for services provided to you. We accept credit, cash, or checks.
COURT ORDERED:
_______ Please note that if you are recommended to SCC by an attorney or the courts for services,
often times the insurance company will not cover those charges, so we will ask for full payment at the
time of service. No reports will be submitted to the attorneys or courts until all fees are paid in full.
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Revised 4-14-16
Fee agreement-Page 2
REQUEST FOR FINANCIAL ASSISTANCE:
_______ Samaritan Counseling Center may be able to offer reduced fees to uninsured clients because
of the financial contributions of area churches, organizations and individuals. If you have requested to
be considered for a reduced fee based on your ability to pay, a fee worksheet will be attached to this
agreement. You are required to pay this fee at the time of services.
Late Cancellation and No Show fee: If you do not keep a scheduled appointment or do not notify SCC at least
24 hours in advance to cancel a scheduled appointment, Samaritan Counseling Center has the right to charge a
$70.00 fee that must be paid prior to being seen again. This can be paid by credit card or cash in the office.
Any future appointments that are scheduled may be cancelled to allow other clients to be seen. Upon
payment of the no show charge you may again resume scheduling an appointment. There may be some
conditions based on payer types where someone might be placed on a “same day” appointment policy. A third
no show will result in termination of care.
Fees for Minors: In the case of minors, the parent that signs the fee agreement is responsible for payment. As
it relates to custody it is the parents’ responsibility to come to an agreement related to payment of any
account balance.
Address changes: You are expected to notify us immediately of changes in address, phone numbers, insurance
coverage, etc. Failure to notify Samaritan Counseling Center of changes to insurance will result in an
expectation of you paying the charges incurred. Insurance companies generally do not allow back billing.
I hereby authorize Samaritan Counseling Center to furnish the above named insurance company (ies) or other
named parties responsible for payment with information requested and necessary for payment of services
provided. I further authorize payment directly to Samaritan Counseling Center for services provided. I am
further aware that failure to pay, may result in action taken to collect my fees, and that in doing so, Samaritan
Counseling Center will be disclosing that I have received services at their agency.
___________________________________________________________
Signature of Responsible Person
________________________
Date
Who recommended you come for therapy?
__________________________________________________________________________________________
What made you choose Samaritan Counseling Center?
__________________________________________________________________________________________
2
Revised 4-14-16
SAMARITAN COUNSELING CENTER (SCC)
ORIENTATION TO OUTPATIENT COUNSELING
Client responsibilities
Appointment times are reserved especially for you. If you are unable to attend a scheduled appointment, you need to cancel or
reschedule that appointment 24 hours before your scheduled time. For your convenience, our telephones are answered 5 days per
week- during normal business hours (9am-5pm) or after hours feel free to leave a message. You are responsible to be on time for
your appointments. Failure to do so may result in your appointment being rescheduled. You may be denied further appointments or
charged a fee after having missed an appointment without proper notice. Samaritan Counseling Center may terminate you from
services for failure to attend scheduled appointments.
All clients are expected to communicate in a respectful manner to all Samaritan Center staff and to refrain from verbal threats,
physical harm to personnel, clients or property of Samaritan Counseling Center. Weapons of any kind are not allowed on the
premises.
You are expected to attend all sessions alcohol and/or drug free.
Please discuss any questions or concerns about your treatment with your Therapist. If this does not resolve the matter, ask to speak
to the Clinical Director at 920-866-9319.
Parents/Guardians of minors are expected to accompany the child to each appointment. For safety reasons an adult must supervise
any children in the waiting area at all times.
Client Rights
Confidentiality
Information shared by clients during sessions is confidential, and you (and/or your legal guardian if you are under 14 years) must
give written permission to share information with others, except in the following circumstances:
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There is a threat of harm to yourself or others.
You report an incident of physical, emotional or sexual abuse or neglect of a child, or you report sexual activity and you are
under the age of 18.
Parents or legal guardians of children younger than 18 years of age can request information from the client file.
You are on Samaritan Counseling Center premises and need immediate medical attention.
Your records are ordered by a Judge through a court order.
Disclosure to another health care Therapist-treatment facilities may release limited information without written consent to a
health care Therapist under certain circumstances. This information may be released without consent under DHS 51.30 (8).
You may be asked to sign releases of information. These may be revoked at any time but must be done in writing.
Emergency Services
Emergency services can be obtained after hours by contacting 911, your local county crisis intervention line, or SCC at 920-886-9319.
An emergency is one that is considered to be life or death and you feel that you need immediate assistance from a therapist.
I hereby attest that I understand the expectations written above and I agree to uphold my responsibilities. Further I attest that I
have been offered a HIPAA packet, and the Client Rights Brochure.
_______________________________________
Client signature (14 years and older)
_______________
Date
_______________________________________
Parent/Legal Guardian Signature
_______________
Date
SAMARITAN COUNSELING CENTER (SCC)
INFORMED CONSENT –Treatment Services (HSS 94.03)
SCC is sensitive to the spiritual and faith-based resources that some people want to use as they explore health and well-being. We
welcome opportunities to integrate a client’s spiritual belief and practices as a part of the therapeutic process. Therapists will not
impose their personal belief upon our clients, rather if requested, we work with the belief system of the clients and include
discussion of spirituality/religion/faith according to the expressed preference.
PROBABLE BENEFIT OF TREATMENT: If you do not think your needs are being met, you are urged to discuss this with your therapist.
This discussion will provide the opportunity to clarify goals, or consider the possibility of a referral to another therapist who may
better meet your needs.
SIDE EFFECTS OF TREATMENT/Probable consequences of not receiving treatment: The treatment process typically involves
identifying and talking about issues that are difficult or painful. It is not unusual to feel like things are getting worse before you feel
progress or improvement. Not receiving treatment will include the possibility you will continue to experience similar problems or
things may get worse.
PROVIDERS OF TREATMENT: Services are provided by Licensed Masters level Therapists or Master level Therapist-Residents holding
a training license provided by the State of Wisconsin. All Clinical Therapists and their cases are reviewed and supervised by a Clinical
Director and/or Supervisor as well as a consulting Clinical Psychologist. Alcohol and Drug services are provided by dual licensed
therapist with a specialty in AODA and supervised by an AODA Clinical Supervisor.
ALTERNATIVE TREATMENT: Alternative modes of treatment will be discussed during the assessment process, and/or during the
course of treatment planning.
RELEASE OF INFORMATION FOR BILLING PURPOSES: I agree that the organization may release to and receive from any insurers,
other payers, or other persons, necessary for billing and related purposes. This information may include my identity, diagnosis and
prognosis, treatment for mental health and/or alcohol or drug issues and all other information contained in my record to the extent
that such records are needed for billing or collection of benefits. I am aware that I have the option to pay for services at the time of
my sessions.
TIME PERIOD OF INFORMED CONSENT/RIGHT TO WITHDRAW: Your consent for treatment will last until the goals of treatment
have been satisfactorily reached, or you or your therapist elects to terminate treatment. This consent will be renewed every 12
months. You retain the right to withdraw informed consent and terminate treatment at any time. We do ask that you discuss this
with your therapist.
NO SHOW: Be aware that if you miss an appointment SCC has the right to charge a fee and all future appointments already
scheduled will be cancelled to make time available for other client’s. If you no show or late cancel for more than two appointments
Samaritan Counseling may terminate services.
My signature below indicates that my therapist has explained this informed consent and I am satisfied with my understanding of the
treatment process and have been offered a copy of this document. I hereby voluntarily consent to be actively involved in treatment.
_______________________________
______________
____________________________ _____________
Client Signature
Date
Parent/Guardian Signature
_______________________________
Therapist Signature
Date
SAMARITAN COUNSELING CENTER OF THE FOX VALLEY
INFORMATION FORM
Parents of Children and Adolescents
Parents: Please complete this form. This information will be treated confidentially and will be helpful to your child’s counselor.
Please try to answer each question.
Child’s Name ____________________________________________
Sex M __ F __ Age ____ Birth Date ____/____/____
Mother’s Name___________________________________________ Age_____ Birth Date____/____/____ Nationality___________
Father’s Name____________________________________________ Age_____ Birth Date____/____/____ Nationality__________
Legal Guardian(s)_________________________________________ Age_____ Birth Date____/____/____
Address___________________________________________________Telephone (H)_______________(W)____________________
Step Parent’s name and address__________________________________________________________________________________
Step Parent’s name and address__________________________________________________________________________________
Parents:
Single___ Married___ Divorced ___ Widowed___
If married, please rate your marriage as . . . Very Happy ___ Happy ___ Unsure ___ or Unhappy ___
Date of marriage __________ Ages when married: Wife _____ Husband _____
Are you currently separated _____ or in the process of divorce _____?
Is spouse/family willing to come for counseling? Yes ___ No ___ Uncertain ___
If divorced, when? __________ Reason for divorce _________________________________________________________________
If widowed, when? _________ Concerns _________________________________________________________________________
Previous marriages: Dates _______________ Reason(s) for marriage ending __________________________________________
Dates _______________ Reason(s) for marriage ending __________________________________________
Education: (years) Father _____ Mother _____
Employment: Father____________________________________Mother_______________________________________
Have you changed jobs recently? Reasons for the change ___________________________________________________
Religious preference: Father _________ Mother _________
Other adults significant in my child’s life___________________________________________________________________________
Other Children
Check( ) if child is by previous marriage or stepchild. If more than four children, use the back of this form
 Name
Age
Sex (F or M)
Living (Yes or No)
Education (Years)
Married (Yes or No)
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Health
Rate your child’s physical health: Very Good ___ Good ___ Average ___ Declining ___ Poor ___
Height __________ Weight __________ Recent weight changes? Loss ___ Gain ___
Sleep: No Trouble ___ Have trouble ___ Please explain _____________________________________________________________
Date of last physical exam __________ List significant medical conditions _______________________________________________
Is your child presently taking medication? If so, what? _______________________________________________________________
Has your child ever had a “nervous breakdown” or been severely emotionally upset? Yes ___ No ___
Has your child ever been physically abused? Yes ___ No ___ Sexually abused? Yes ___ No ___
Has your child had previous counseling? Yes ___ No ___ Facility and therapist __________________________________________
When ______________________Issues addressed___________________________________________________________________
Addictions
Has alcohol, drugs, or gambling ever been a problem? You ___ Spouse ___ Children___Grandparents ___Other__________________
In a few words, describe the problem(s) ___________________________________________________________________________
Has your or your child’s social life, work life, or relationships changed due to drugs, alcohol, or gambling? (Explain)_____________
____________________________________________________________________________________________________________
Has your child or anyone in your family ever had an eating disorder? If so, please specify __________________________________
- Over Confidential: Client Information
Client:______________________________________ Date: ______________________________
Developmental History
Child’s Prenatal History:
Were there any conception or fertility problems?__________________________________________________________________
Has mother had any miscarriages, still births, or abortions?_________________________________________________________
Was this a planned pregnancy?________________________________________________________________________________
Were there any complications during the pregnancy?______________________________________________________________
Were there any stressors during the pregnancy?___________________________________________________________________
Did mother take medications, use alcohol or drugs, or smoke during the pregnancy? Please specify ________________________
_________________________________________________________________________________________________________
Any complications with labor and delivery?_____________________________________________________________________
Child’s Infancy and early childhood:
How was this child as an infant (quiet, colicky, easy, predictable, etc.)?________________________________________________
_________________________________________________________________________________________________________
When did your child walk?____________________Talk_________________________Toilet Train_________________________
How did/does you child handle separations?_____________________________________________________________________
Is or was your child in daycare or sittercare?_____________________________________________________________________
Child’s Temperament:
Rate your child’s activity level: Extremely Active Very Active
Active Quiet Inactive
Have there been any significant changes in your child’s activity level?________________________________________________
_________________________________________________________________________________________________________
Rate your child’s attention span: Engrossed Long 10 ----- 5 ----- 1 Short Not able to engage
How does your child respond to new people and situations?_________________________________________________________
_________________________________________________________________________________________________________
How sensitive is your child to noise, visual stimuli, rough clothing, and other sensation?__________________________________
_________________________________________________________________________________________________________
How does your child express happiness?___________________________________Sadness?______________________________
Anger?___________________________________________________________________________________________________
Who in the family is your child most like?_______________________________________________________________________
What are your child’s strengths?_______________________________________________________________________________
What are your child’s weaknesses?_____________________________________________________________________________
Child’s Educational, Vocational, and Legal History:
Grade Completed: (circle) P K 1 2 3 4 5 6 7 8 9 10 11 12 +
School _______________________ Teacher _________________________ School Counselor______________________________
Does your child receive special education services?__________ Why?___________________________________________________
Family Military History: if none ___ Branch and Years of Service _____________________________________________________
Briefly describe family involvement, at any time, with the legal system, including dates, reasons, and results)____________________
____________________________________________________________________________________________________________
Probation Officer __________________________ Telephone_______________________
Family Religious Background:
Church ______________________________ Denomination ________________________ Location _________________________
Church attendance per month (circle) 0 1 2 3 4 5+
Explain any recent changes in your religious life and/or past remarkable religious experiences ________________________________
____________________________________________________________________________________________________________
I am concerned about my child right now because _________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Confidential: Client Information
Revised 04/06
Samaritan Counseling Center of the Fox Valley
Client Information Form
Pre-Adolescents and Adolescents
Parents, please have your child answer these questions. Your answers will help your counselor get to know you.
My name _______________________________________________________________
My parents names. Mother _______________________________
My age _________
Father ____________________________
How do you get along with your parents? _______________________________________________________
__________________________________________________________________________________________
My brother(s) names __________________________
My sister(s) names ____________________________
How do you get along with your brother(s) and sister(s) ____________________________________________
__________________________________________________________________________________________
Who else lives in your home? _________________________________________________________________
What is the name of your school? ________________________________
What is your grade? ___________
How are you doing in school? _________________________________________________________________
Do you have a job? _____
Where and what do you do? __________________________________________
Does anyone in your family have problems with alcohol or drugs? ____________________________________
__________________________________________________________________________________________
Have you been to a counselor before? _____
Did it help you? How did it help you? ___________________
__________________________________________________________________________________________
Has anyone ever hurt you? ___________________________________________________________________
Do you think you are in trouble? _______________________________________________________________
Why are you coming to counseling? ____________________________________________________________
__________________________________________________________________________________________
If you had three wishes, what would they be?
1) _______________________________________________________________________________________
2) _______________________________________________________________________________________
3) _______________________________________________________________________________________
Confidential: Client Information
Revised 04/06
Right to Inspect and Copy Your Health Information
You have the right to inspect and obtain a copy of your health
care information. You have the right to request that the copy
be provided in an electronic form, e.g. PDF saved to a CD.
This right of access does not apply to psychotherapy notes,
which are maintained for the personal use of a mental health
professional. Your request for inspection or access must be
submitted in writing to Samaritan Center Privacy Official, 1478
Kenwood Dr., Suite 1, Menasha, WI 54952. We may charge you
a reasonable fee to cover our expenses for copying your health
information.
Right to Request an Amendment of Your Health Information
If you believe your health information is incorrect, you may ask
us to amend the information. You will be asked to make such
a request in writing and to give a reason as to why your health
information should be changed. However, if we did not create
the health information that you believe is incorrect, or if we
disagree with you and believe your health information is correct,
we may deny your request.
Right to an Accounting
You or your representative has the right to request an accounting
of disclosures of your health information made by SCC for
certain purposes authorized by law and certain research.
The request for an accounting must be made in writing to
the Privacy Official, HIPAA Officer, Samaritan Counseling
Center,1478 Kenwood Dr., Suite 1, Menasha, WI 54952. The
request should specify the time periods for the accounting,
starting April 14, 2003. Accounting requests may not be made
for periods in excess of six (6) years. SCC will provide the first
accounting you request of any 12-month period without charge.
Subsequent accounting requests may be subject to a reasonable
cost-based fee. We must comply with your request within 60
days unless you agree to a 30-day extension.
reserves the right to change the terms of our Notice and to
make new Notice provisions effective for all health information
that it maintains. If SCC makes a material change to this
Notice, SCC will make the new notice available to you at your
request and will post the new notice at the location of service.
You or your representative has the right to express complaint to
SCC and the Secretary of Health and Human Services if you or
your representative believes that your privacy rights have been
violated. Any complaints to SCC should be made in writing
to the Privacy Official, HIPAA Officer, Samaritan Counseling
Center, 1478 Kenwood Dr., Suite 1, Menasha, WI 54952.
SCC encourages you to express any concerns you may have
regarding the PRIVACY of your information. You will not be
retaliated against in any way for filing a complaint.
CONTACT PERSON
SCC has designated the Privacy Official as our contact person
for all issues regarding client privacy and your rights under
the Federal Privacy Standards. You may contact this person at
Samaritan Counseling Center, 1478 Kenwood Dr., Suite 1,
Menasha, WI 54952 or at (920) 886-9319.
EFFECTIVE DATE
This revised Notice is effective September 23, 2013. If you have
any questions, please contact Privacy Official, HIPAA Officer,
Samaritan Counseling Center. 1478 Kenwood Dr., Suite 1,
Menasha, WI 54952 or (920) 886-9319.
Resources from the HIPAA Collaborative of Wisconsin were used in the creation
of this notice.
Right to a Paper Copy of Notice
You or your representative has the right to a separate paper copy
of this Notice at any time even if you or your representative has
received this notice previously. To obtain a separate paper copy,
please contact our office at (920) 886-9319.
Duties of Provider
SCC is required by law to maintain the privacy of your health
information and to provide you and your representative with
this Notice of our duties and privacy practices. SCC is required
by law to notify you following a breach of unsecured protected
health information. SCC is required to abide by the terms of
this Notice, which may be amended from time to time. SCC
Rev. 9/13
The Samaritan
Counseling Center
of the Fox Valley, Inc.
HEALING MIND, BODY, SPIRIT AND COMMUNITY
NOTICE OF UPDATED PRIVACY PRACTICES
This notice tells you how we make use of your health information
at our Center, how we might disclose your health information to
others, and how you can get access to the same information.
Please review this notice carefully.
Samaritan Counseling Center of the Fox Valley (SCC) is required
by law to maintain the privacy of your health information. SCC is
also required to provide you with a notice that describes SCC’s legal
duties and privacy practices and your privacy rights with respect
to your health information. We will follow the privacy practices
described in this notice. If you have any questions about any part
of this notice or if you want more information about SCC’s privacy
practices, please contact Samaritan Center Privacy Official, 1478
Kenwood Dr., Suite 1, Menasha, WI 54952.
HOW SCC MAY USE OR DISCLOSE YOUR HEALTH
CARE INFORMATION FOR TREATMENT, PAYMENT OR
HEALTH CARE OPERATIONS
To Provide Treatment
We may use or disclose your health care information in the
provision, coordination or management of your health care. Our
communications to you may be by telephone, cell phone, e-mail
or by mail, according to your preferences. For example, we may
use your information to call and remind you of an appointment
or to refer your care to another health care provider. If another
provider requests your health information and they are
not providing care and treatment to you we will request an
authorization from you before providing your information.
To Obtain Payment
SCC may include your health information in invoices to collect
payment from third parties for the care you may receive here. For
example, SCC may be required by your health insurer to provide
information regarding your health care status so that the insurer
will reimburse you or SCC. By signing the “Fee Agreement for
Professional Services” form, you are giving your permission to do
this. We also may need to obtain prior approval from your insurer
and may need to explain to the insurer your need for health care
and the services that will be provided to you.
To Conduct Health Care Operations
We may use or disclose your health care information for
activities relating to the evaluation of patient care, evaluating
the performance of health care providers, business planning
and compliance with the law. For example, we may use your
information to determine the quality of care you received. If the
activities require disclosure outside of our health care organization
we will request your authorization before disclosing that
information.
HOW SCC MAY USE OR DISCLOSE YOUR HEALTH
CARE INFORMATION WITHOUT YOUR WRITTEN
AUTHORIZATION
When Legally Required
SCC will disclose your health information when it is required to
do so by any federal or local law.
To Protect Public Health
We may release your health information to local, state or federal
public health agencies subject to the provisions of applicable
state and federal law for reporting communicable diseases, aiding
in the prevention or control of certain diseases and reporting
problems with products and reactions to medications to the
Food and Drug Administration.
For Worker’s Compensation SCC may re­lease your health
information for Worker’s Compensation or similar programs.
PLEASE NOTE: Licensing requirements may mandate
additional reporting based upon their standards such as to
prevent or control body/head lice, etc.
WHEN SCC IS REQUIRED TO OBTAIN AN
AUTHORIZATION TO USE OR DISCLOSE YOUR
HEALTH INFORMATION
To Report Abuse, Neglect or Violence Against a Child
SCC is allowed to notify government authorities if SCC believes
a child is the victim of abuse, neglect or domestic violence. SCC
will make this disclosure when specifically required or authorized
by law or, when you agree to the disclosure, if you are 18 or older.
Except as described in this Notice of Privacy Practices, we will
not use or disclose your health information without written
authorization from you. For example, uses and disclosures made
for the purpose of treatment referrals/alternatives and marketing
require your authorization. Your written authorization is also
required to contact you for fundraising purposes, and you have
the right to opt out of receiving such communications. If you
do authorize us to use or disclose your health information for
another purpose, you may revoke your authorization in writing
at any time. If you revoke your authorization, we will no longer
be able to use or disclose health information about you for the
reasons covered by your written authorization, though we will be
unable to take back any disclosures we have already made with
your permission.
To Conduct Health Oversight Activities
SCC may disclose your health information to a health oversight
agency for activities including audits, civil administration or
criminal investigations; inspections; licensure or disciplinary
action. SCC, however, may not disclose your health information
if you are the subject of an investigation and the investigation
does not arise out of and is not directly related to your receipt of
health care or public benefits, i.e. Social Security.
For Law Enforcement Purposes
As permitted or required by state law, SCC may disclose your
health information to a law enforcement official for certain
law enforcement purposes, including, under certain limited
circumstances, if you are a victim of a crime or in order to report
a crime.
To Coroners and Medical Examiners
SCC may disclose your health information to coroners and
medical examiners for purposes of determining cause of death or
for other duties, as authorized by law.
In the Event of a Serious Threat to Health or Safety
SCC may, consistent with applicable law and ethical standards
of conduct, disclose your health information if SCC, in good
faith, believes that such disclosure is necessary to prevent or
lessen a serious and imminent threat to your health and safety or
to the health and safety of the public.
For Specified Government Functions
In certain circumstances, Federal regulations authorize SCC to
use or disclose your health information to facilitate specified
government functions relating to the military and veterans,
national security and intelligence activities, protective services
for the President and others, medical suitability determinations
and inmates and law enforcement custody.
YOUR RIGHTS WITH RESPECT TO YOUR HEALTH
INFORMATION
You have the following rights regarding your health Information
that SCC maintains:
Right to Request Restrictions
You may request restrictions on certain uses and disclosures of
your health information. You have the right to request a limit
on our disclosure of your health information to someone who is
involved in your care or the payment of your care. If you would
like to make a request for restrictions, you must submit your
request in writing to Samaritan Center Privacy Official, 1478
Kenwood Dr., Suite 1, Menasha, WI 54952.
Right to Receive Confidential Communications
You have the right to request that SCC communicate with
you in a certain way. For example, you may ask that SCC only
conduct communications pertaining to your health information
with you privately and with no other family members present.
SCC will not request that you provide any reasons for your
request and will attempt to honor your reasonable requests for
confidential communications. For example, records of minor
children may be released to parents without a minor child’s
permission. Exceptions include Alcohol and Other Drug Abuse
records; and developmentally disabled persons.