Consent for Service

This Notice describes how medical information about you may be used and disclosed and how you can access this information. Please review it carefully.

iCare Telecare, PLLC (is required by law to protect the privacy of your health information and to provide you with this Notice.

Informed Consent for Service

This form is an agreement between you, and me/us, when we use the words "you" and "your" below, this can mean you, your child, a relative.
The information authorized for release may include protected health information related to mental health, substance or drug use, genetic testing, and/or HIV-related information. Release of such records or psychotherapy notes requires consent of the treatment provider or a court order. THE INFORMATION AUTHORIZED FOR RELEASE MAY INCLUDE RECORDS THAT MAY INDICATE THE PRESENCE OF A COMMUNICABLE DISEASE OR NONCOMMUNICABLE DISEASE.
When we examine, test, diagnose, treat, or refer you, we will be collecting what the law calls "protected health information" (PHI) about you. We need to use this information in our office to decide on what treatment is best for you and to provide treatment to you. We may also share this information with others to arrange payment for your treatment, to help carry out certain business or government functions, or to help provide other treatment to you. By signing this form, you are also agreeing to let us use your PHI and to send it to others for the purposes described above. Your signature below acknowledges that you have read or heard our notice of privacy practices, which explains in more detail what your rights are and how we can use and share your information.
This request/authorization to release confidential information is being made in compliance with the terms of the Privacy Act of 1974 (Public Law 93-579) and the Freedom of Information Act of 1974 (Public Law 93-502); and pursuant to Federal Rule of Evidence 1158 (Inspection and Copying of Records upon Client's Written Authorization). This form is to serve as both a general authorization, and a special authorization to release information under the Drug Abuse Office and Treatment Act of 1972 (Public Law 92-255), the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act Amendments of 1974 (Public Law 93-282), the Veterans Omnibus Health Care Act of 1976 (Public Law 94-581), and the Veterans Benefit and Services Act of 1988 (Public Law 100-322). It is also in compliance with parts of 42 C.F.R. Part 2 (Public Law 93-282), federal and state law of STATE code, which prohibits further disclosure without the express written consent of the person to whom it pertains, or as otherwise permitted by such regulations. It follows the Health Insurance Portability and Accountability Act (HIPAA) of 1996, Public Law 104-191. I understand that a "treating provider relationship" exists when a client receives, agrees to receive, or is legally required to receive diagnosis, evaluation, treatment, or consultation, for any condition, from an individual or entity who undertakes or agrees to undertake that diagnosis, evaluation, treatment, or consultation. An in-person encounter is not required.
Welcome to iCare Center for Change. This document contains important information about our professional services and business policies. It also provides an overview of patient privacy and confidentiality protections under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 42 CFR Part 2 (when applicable), and relevant Idaho state laws governing healthcare records and patient confidentiality. Although these documents are long and sometimes complex, it is very important that you understand the information presented. When you sign the consent document, it will also represent an agreement between us. We can discuss any questions you have when you sign them or at any time in the future.

ABOUT THIS NOTICE

We are required to follow the terms of this document, currently in effect. We reserve the right to change our practices and the terms of this document at any time and to make the new practices and document provisions effective for all health information that we keep. Before we make such changes effective, we will make available the revisions to this document available in physical form where we deliver care. You are entitled to receive this document in writing at any time by contacting any of our office locations.

Description of Service

Medical therapy services are provided in an office setting or via telehealth services by a certified or licensed professional. iCare Center for Change, provides individual, group, and/or family counseling for adults, children, and adolescents.
The length of therapy will be agreed upon by your medical provider and the client, with consideration of the limits set by third-party payers. Be aware that, under managed care programs, termination of therapy is generally determined by the managed care provider. The duration of an intake session involving a comprehensive evaluation may range from one (1) to two (2) hours, with subsequent standard sessions running for twenty (20) to sixty (60) minutes each. It is expected that clients will arrive for their appointments on time, and no time adjustment will be made for late arrivals.
Following the initial assessment, the frequency and duration of such sessions will be based on each client's individual needs, as well as any stipulations set by the client's managed care program. A comprehensive treatment plan will be developed between you and your medical provider following the initial assessment. This treatment plan will be referenced throughout your treatment and adjusted as needed to meet your therapeutic needs.
Clients are responsible for providing iCare Center for Change with all necessary information to access services, including insurance details, medical history, and other pertinent information. It is also the client's responsibility to inform iCare Center for Change of any changes in this information that could impact their care, ensuring they receive the best possible service.
Should it be determined that a client is not benefiting from or meeting the service's requirements, iCare Center for Change will collaborate with the client to resolve or improve the situation. If a solution cannot be reached, the client may be discharged.

Contact Information

Medical providers are often not immediately available by phone. The medical providers do not answer their phones when they are with clients or otherwise unavailable. At these times, the client may leave a message on the agency's confidential voicemail, and the call will be returned as soon as possible; however, for non-urgent matters, it may take 24 to 48 hours. For confidentiality protection, the medical provider may restrict the use of email, chat, or text to engage clients (unless authorized electronic appointment reminders and/or enrollment requests are activated). If, for any number of unseen reasons, the client does not hear from the medical provider or the medical provider is unable to reach the client, and the client feels they cannot wait for a return call or if the client feels unable to keep themselves, or others, safe, 1) contact the following crisis hotline: Prevention Hotline at 988) go to your Local Hospital Emergency Room or call 911.
If the medical provider is unable to reach the client via authorized means of communication, the medical provider will use the client's emergency contact information to locate and contact the client. Provided examples: if the client cannot be contacted within 48 hours by the medical provider after a no-call, no-show appointment, the client's emergency contact information will be utilized to locate and contact the client or in the event of a medical emergency, the medical provider may contact the client's emergency contact to inform them of the client's medical emergency.

Cancellations and No-Show Policy

To be successful, clients must participate in their therapy program by attending all appointments on time. We do, however, understand that 'life happens' and unforeseen situations do arise. As a result, we do request the following:
We ask that standard cancellations be made at least 48 hours (2 days) before the scheduled appointment. This will allow us to schedule other clients who are waiting for an appointment. Any appointment cancelled less than 48 hours (2 days) in advance will be subject to a late cancellation fee of $35, unless such cancellation fees are null and void based on the client's managed care program regulations, or such cancellation was deemed medically necessary/emergency based. iCare Center for Change, reserves the right to request medical documentation to prove that such a medical emergency took place on the stated date/time to justify the appointment cancellation.
iCare Center for Change will ensure you are seen if you arrive at your appointment within 15 minutes of the scheduled appointment (barring emergency or extenuating circumstances). If you are more than 15 minutes late, your appointment may be cancelled.
Late cancellations and no-shows are disruptive to the care of all our clients and providers. If an appointment is canceled three (3) hours or less before the appointment date/time and the cancellation is not due to a medical emergency, this appointment will be considered a no-show.
If the client has two (2) no-call, no-show appointments during the course of their treatment (these do not have to be consecutive) for any/all iCare Center for Change services, the client may be limited to same-day scheduling and may face restrictions on future appointments. If the client has three (3) no-call, no-show appointments throughout the course of their treatment (these do not have to be consecutive) throughout any/all iCare Center for Change services, the medical provider will determine the client's ability to participate in services and may consider an automatic treatment discharge and/or a referral to another service if deemed necessary. If these situations should occur, iCare Center for Change will send the client written notice of these decisions.
Forgetting that the client had an appointment, lack of receiving an appointment reminder, transportation issues (non-emergent), and/or lack of coordination/communication between the client and the client's treatment facilities/transportation, will still constitute a no-show. Ultimately, it is the client's responsibility to be aware and to follow through with their scheduled appointments.

Digital Communications

As a courtesy to clients, phone calls, text messages, and/or e-mail appointment reminders are available 24 to 48 hours before your scheduled appointment. Clients can also access their appointment dates/times through the Client Portal. By providing these automated services, clients can also confirm or cancel appointments.
Digital communication, while convenient, carries certain risks. These include the risk that messages may be intercepted or sent to the wrong party. However, digital communication also offers benefits such as the ability to send messages at any time and maintain a record of communication. Clients should weigh these risks and benefits when consenting to digital communication. Clients are encouraged to consider alternatives to digital communication, such as face-to-face meetings or telephone calls, especially when discussing sensitive information. These alternatives may provide a higher level of confidentiality and security.
To protect client confidentiality, iCare Center for Change will implement security measures, including the use of encrypted messaging services and secure email platforms. Clients are encouraged to use password-protected devices and secure networks when engaging in digital communication.
Clients must provide consent for the use of digital communication. Clients can also outline any specific limitations or preferences regarding digital communication. Clients have the right to revoke their consent for digital communication at any time. To do so, please inform your medical provider in writing. Revocation of consent will not affect your access to other services provided by iCare Center for Change.
iCare Center for Change is not held responsible if such automatic reminders and/or digital communications do not reach the client due to changes in the client's contact information that were not disclosed to iCare Center for Change, technical difficulties, lack of coordination/communication between the client and the client's treatment facilities, lack of protective measures by the client and/or their electronic devices and/or other unforeseen circumstances.

Interruptions in Therapy

Interruptions may occur due to family or medical emergencies, death, hospitalization, vacations, or professional training. When such interruptions occur, clients will be informed. Please provide your medical provider with your preferred contact information upon enrollment. As well, if such interruptions occur, such as the incapacitation or death of your provider, other providers and the administration within iCare Center for Change will be granted access to your PHI to assist you in obtaining copies of your PHI.

Self-Pay and Charges

The fee for self-pay counseling services is as follows: Initial assessment: $250; 15 to 30-minute session: $100; 31 to 45-minute session: $150; 45 to 60+-minute session: $175. Payment is due upon the client's attendance at their appointment. There will be no bartering of services, and gratuity gifts will not be accepted. Payments may be made by cash, check, or credit card. Any returned checks are subject to an additional fee of up to $40 to cover the bank's returned check fee. Credit card charges will read the following title on the bank statement: "iCare". If the client files a chargeback claim against iCare Center for Change, iCare Center for Change 's legal department will dispute the chargeback by preparing a chargeback rebuttal letter, gathering relevant information and supporting evidence, and producing records and invoices to rebut the charge. In addition to the payment of the chargeback processing fee, the cost of going to arbitration if applicable, and various other administrative tasks associated with the chargeback representation process. THE CLIENT AGREES TO REIMBURSE iCare Center for Change for the cost incurred in disputing the client's chargeback (invoice to be provided). The client understands that this charge does not include reasonable attorneys' fees ($300 /hr), which will be charged to the client separately. Lastly, if the investigation reveals the chargeback was fraudulent, the client may be subject to civil or criminal legal proceedings.
Upon request, a Sliding Fee Scale Application and/or a Payment Plan Request form can be completed and returned to iCare Center for Change for consideration. iCare Center for Change reserves the right to halt all services rendered until either the outstanding balance is paid in full, or a Payment Plan Request form is completed and approved by iCare Center for Change.
Before your first appointment, our office must confirm your payment method. Either by confirming your insurance coverage with a valid medical card, completing and submitting a completed and approved sliding fee scale application to our office, or obtaining approval from another payment source. If such financial payment is not validated/approved by our office prior to your first appointment, full payment of $250 for your first evaluation will be due before services are rendered. Any subsequent appointments will also be billed at our self-pay rate until another form of payment can be secured. If an individual is court-ordered to mental health services, such individuals fall under these same financial payment requirements. A court order does not guarantee payment for our services by the court system; the patient remains financially responsible for them.

Insurance Reimbursement

When requested, the medical provider will file insurance forms for reimbursement and pre-authorization. The client is expected to pay their co-payment at the time the service is being rendered. The client must be billed their co-payment amount which will be due at the beginning of the appointment. Medical sessions are often limited with most insurance plans. If deemed necessary, the medical provider will seek approval for additional sessions prior to the last approved session. If the request is denied, clients have the option to pay out of pocket for services. Some managed-care plans will not allow the medical provider to provide services to you once your benefits end or you may not be able to afford the fee for service. If this is the case, the medical provider will do their best to find another provider who will help the client continue psychotherapy.

Responsibility for Payment

The client is responsible for all charges unless otherwise stipulated by the client's managed care program. Any outstanding balance over $50 will be charged to the client's credit card on file. The client will be asked to provide credit card information when they are present for medical services. Any outstanding unpaid accounts will become delinquent after 90 days and will then be turned over to an attorney, small claims court, or a collection agency. If the client has outstanding debts, counseling services may be terminated.
Payment Plan Options
- We understand that paying for mental health services can be challenging. We offer flexible payment plans to help make services affordable.
- Interest-Free Payment Plans:
- For balances over $400, you may request an interest-free payment plan with the following terms:
- Minimum monthly payment: $100 or 10% of the balance, whichever is greater
- Payment plan term: Up to 12 months for balances under $1200; up to 24 months for balances over $1201.
- No interest or fees if payments are made on time according to the payment plan agreement
- Automatic monthly payments via credit card or bank account (required for payment plans)
How to Request a Payment Plan:
- Complete a Payment Plan Request form (available at our office or on our website)
- Provide information about your income and expenses to help us determine an affordable amount
- Submit the form to our billing department for review
- You will receive a written payment plan agreement within 5 business days
- Sign and return the agreement to activate your payment plan
Payment Plan Terms:
- Payments are due on the same day each month; 5th of the month.
- Payments will be automatically charged to your credit card or bank account on file
- You will receive email confirmation of each payment
- You may pay off your balance early at any time without penalty
- If you miss two consecutive payments, your payment plan may be cancelled, and the full balance will become due immediately
Questions: Contact our billing department at (208) 918-2473 or admin@icarecfc.com to discuss payment plan options.

Collections Process and Timeline

We understand that financial difficulties can arise. We are committed to working with you to resolve outstanding balances before taking collection action.

Our Collection Process Timeline:

Day 1-30: First Statement
- You will receive a statement showing the balance due
- Payment is due within 30 days of the statement date
- You may pay online, by phone, by mail, or in person
Day 31-45: Second Statement and Phone Contact
- You will receive a second statement marked "Past Due"
- We will attempt to contact you by phone to discuss the balance
- We will offer to set up a payment plan and/or a Sliding Fee Scale if you are unable to pay in full
Day 46-60: Final Notice and Payment Plan Offer
- You will receive a final notice marked "Final Notice Before Collections or Small Claims."
- We will make a final attempt to contact you by phone
- We will offer a payment plan with terms based on your financial situation and/or a Sliding Fee Scale option
- Payment plans are interest-free if paid within the agreed timeframe
Day 61-90: Pre-Collection Review
- Your account will be reviewed by our billing manager
- We will make a final attempt to reach you by phone and certified mail
- We will consider any extenuating circumstances or hardship situations
- You may still request a payment plan or apply for our Sliding Fee Scale program
Day 91+: Collection Action
- If no payment or payment arrangement has been made, your account may be:
- Turned over to a collection agency, OR
- Filed in small claims court, OR
- Referred to our attorney for legal action
You will be notified in writing before collection action is taken
You will be responsible for all collection costs, including:
- Collection agency fees (typically 25-40% of the balance)
- Court costs and filing fees
- Reasonable attorney fees ($300 per hour)
Impact on Credit:
- Unpaid balances sent to collections may be reported to credit bureaus
- This may negatively impact your credit score
- Collection accounts may remain on your credit report for up to 7 years
Impact on Services:
- Outstanding balances over $500 may result in suspension of services until the balance is paid or a payment plan is established
- Accounts in collections may result in termination of services
- You may be referred to another provider if services are terminated due to non-payment
How to Avoid Collections:
- Pay your balance in full within 30 days of receiving a statement
- Contact our billing department immediately if you cannot pay - we will work with you
- Request a payment plan before your account becomes delinquent
- Apply for our Sliding Fee Scale program if you are experiencing financial hardship
- Keep us informed of any changes to your contact information or financial situation

Your Right to Dispute Charges:

If you believe a charge is incorrect, you have the right to dispute it. Contact our billing department at (208) 918-2473 or by emailing admin@icarecfc.com within 30 days of receiving the statement. We will investigate and respond within 10 business days.

Questions: Contact our billing department at (208) 918-2473 or admin@icarecfc.com if you have questions about your balance or need to arrange payment.

Client Conduct and Infractions

iCare Center for Change is committed to providing a safe environment for its personnel, person(s) served, visitors and stakeholder(s). Note that iCare Center for Change prohibits all mistreatment, neglect and/or abuse of any person and/or animal. The following security concerns are grounds for immediate termination of any and all iCare Center for Change services:

Any person who makes any type of threat, exhibits threatening behavior, or engages in violent acts towards iCare Center for Change providers, staff, service animals, volunteers and/or clients will be asked to leave the premises on their own accord or will be escorted by law enforcement. Such threatening behavior also includes, but not limited to, the use of profanity and/or verbal threats through the forms of text messages, social networking, online reviews/comments, written communication, phone calls and/or voicemails.
The unlawful manufacturing, distribution, dispensation, possession or use of alcohol, tobacco, and/or controlled substances is prohibited in all iCare Center for Change facilities.
Firearms and other types of weapons are prohibited on iCare Center for Change property.
A client and/or client's guardian/parent breaches the confidentiality of another iCare Center for Change client.

Note that any of the above-listed infractions could also lead to formal legal charges. If these situations should occur, iCare Center for Change will send the client written notice of these decisions.

Financial Responsibilities

It is the policy of iCare Center for Change that co-payments and deductible amounts relating to payment for services shall be collected to the full extent required by Federal and state laws and private payor agreements. iCare Center for Change does not allow routine waiver of insurance co-payments or deductibles under any circumstances.

Provider Credentials

Kelly Graff MSN, APRN-CNS, ACCNS-P, PMHNP
Lisa Leazenby DNP, APRN-CNP, FNP, PMHNP
Jennifer Benally DNP, APRN-CNP, FNP, PMHNP

A detailed description of licensure requirements for medical providers in the State of Idaho can be found at the following website: https://dopl.idaho.gov/bon/. A detailed description of ethical guidelines set for professional medical providers nationwide (United States) can be found at the following website: https://codeofethics.ana.org.

Consent to Treatment

I do hereby voluntarily seek and consent, I, or my child, to take part in the treatment by the medical provider named below. I understand that developing a treatment plan with this medical provider and regularly reviewing our work toward meeting the treatment goals are in my best interest. I agree to play an active role in this process.
I understand that no guarantee can be made to me as to the results of treatment or of any procedures provided by this medical provider. Therapy outcome is largely influenced by the clients' characteristics such as motivation, severity of symptoms and acceptance of personal responsibility for change.
I understand that there are many benefits to the therapy process, such as I may experience reduction in feelings of distress in the family or greater awareness of self and issues causing disruption in the marriage/family. However, during the counseling process I may also experience disruptions in life or discomfort due to anxiety or pain related to issues discussed or discovered during the counseling process. Risks may also include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness, and helplessness, because the process of psychotherapy often requires discussing the unpleasant aspects of my life.
I understand I acknowledge that diagnosis depends on information, and treatment depends on diagnosis, so if I withhold information, I assume the risk that a diagnosis might not be made or might be made incorrectly. Were that to happen, my treatment might be less successful than it otherwise would be, or it could fail entirely.
I understand that the services I receive at iCare Center for Change may be provided by a staff member not credentialed with my health insurance. If so, I understand that I will be informed of this information upon enrollment/admission.
I understand that I may stop my treatment with this medical provider at any time. The only thing I will still be responsible for is paying for the services I have already received. I understand that I may lose other services or may have to deal with other problems if I stop treatment. (For example, if my treatment has been court-ordered, I will have to answer the court, and my provider will have the report such termination to the proper authorities.) In the event that therapy is terminated before the time agreed upon, a referral would be given if needed. Some alternatives to traditional therapy are self-help books, pastoral counseling, support groups, and medication.
I understand that confidentiality of records of information collected regarding my treatment will be held or released in accordance with state and federal laws regarding confidentiality of such records and information as stated in the Private Notice provided to me. Such state and federal laws include mandatory reporting of all cases related to abuse or neglect of a minor or dependent adult, all cases where there exists a danger to self or others and in which the law requires my medical provider to disclose confidential information. Such specifics to confidentiality are outlined in the Privacy Notice provided to me.
I understand that information related to my medical care, mental health treatment, substance use disorder treatment, and genetic testing is protected under applicable federal and Idaho privacy laws, including the Health Insurance Portability and Accountability Act (HIPAA), the Genetic Information Nondiscrimination Act (GINA), 42 CFR Part 2 when applicable, and relevant Idaho laws governing the confidentiality of healthcare information.
I understand that additional confidentiality protections may apply to certain substance use disorder treatment records and genetic information. These protections, including how my information may be used or disclosed, are further explained in the Notice of Privacy Practices provided to me by iCare Center for Change.
I understand that if I feel my privacy rights have been violated, I have the right to file a complaint. Such procedure to file a complaint is outlined in the Privacy Notice that has been provided. Filing a complaint will not change the healthcare provided to me by iCare Center for Change in any way.
I understand that if I am court ordered to services at iCare Center for Change, such agency will file periodic updates with the courts regarding my treatment progress.
I understand that I have the right to look at my health information (PHI), in person, under the supervision of my medical provider. I also have a right to a copy of my PHI which such request information can be found in this document.
I understand that client's records, clinical notes, counseling contracts, and all financial records will be maintained for a period of seven years. In the case of minors, such records will be kept until the age of 25 or seven years after the last date of services (whichever is longer). Any release of the sessions will be done with the written approval of the clients (parent/legal guardian of minor(s) must first give permission). These documents will be kept in a secure area and on a HIPAA compliant cloud-based data system. After such a timeline has lapsed, client records will be permanently destroyed.
I understand that an agent of my insurance company or other third-party payer may be given information about the type(s), cost(s), date(s), diagnosis, and providers of any services or treatments I receive. I understand that if payment for the services I receive here is not made, the medical provider may stop my treatment, and I will be financially responsible for any unpaid services.
I understand that iCare Center for Change charges $150 per hour per compensation for my medical provider's prep time, travel, legal consultation, and court appearance if my medical provider is to appear in court and/or is subpoenaed to appear in court in reference to my medical treatment. I understand that iCare Center for Change will contact the subpoenaing party first and request prepayment. If the subpoenaing party is unwilling to pay (prepayment and/or post-payment), I understand that iCare Center for Change may hold me (the client) responsible to pay the full rate. I am encouraged to speak with my medical provider before waiving my right to confidentiality for any legal court cases.
I understand that iCare Center for Change medical providers cannot be hired for medical testimony/expert witness within legal proceedings.
I understand that if disputes/complaints arise, I should feel free to address my concerns with my medical provider. In the event their dispute(s) or complaint(s) are not resolved I have the right at any time to seek the assistance of the: Secretary of the U.S. Department of Health and Human Services, the Idaho Board of Behavioral Science and/or the Idaho Board of Certification:

US Department of Health and Human Services

Office of Inspector General

ATTN: OIG HOTLINE OPERATIONS

PO Box 23489

Washington, DC 20026

Idaho Board of Nursing

Division of Occupational and Professional Licenses

11341 W. Chinden Blvd., Building 4

Boise, ID 83714

Phone: (208) 334-3233

Website: https://dopl.idaho.gov/bon/bon-file-a-complaint/

Data Breach Notification

You have the right to be notified if your unsecured protected health information (PHI) is breached. In the event of a breach, we will notify you within 60 days of discovering the breach, as required by federal law.

Our notification will include:

A description of what happened and when the breach occurred
The types of information that were involved in the breach
Steps we are taking to investigate, mitigate harm, and prevent future breaches
Steps you can take to protect yourself from potential harm
Contact information for you to ask questions or learn more

You will be notified by first-class mail to your address on file, or by email if you have agreed to electronic communications. In cases involving a large number of individuals or when we lack sufficient contact information, we may also provide notice through media outlets or by posting it prominently on our website.

If the breach involves fewer than 500 individuals, we will notify you individually and will notify the Department of Health and Human Services annually. If the breach involves 500 or more individuals, we will also notify HHS and prominent media outlets without unreasonable delay.

Interoperability and Your Right to Electronic Access

Under the 21st Century Cures Act, you have the right to access your electronic health information without delay, and we are prohibited from engaging in information blocking practices.

Your Electronic Access Rights:

Immediate Access: You have the right to access, inspect, and obtain a copy of your health information without unreasonable delay.
Electronic Format: You have the right to receive your health information in electronic format. The first electronic copy is provided at no charge.
imely Delivery: We will provide electronic copies of your health information within 15 calendar days of your request.
Format Choice: You may request your information in the electronic format of your choice, if it is readily producible. If not, we will provide it in a readable electronic format as agreed upon with you.
Direct Transmission: You may direct us to send your electronic health information directly to another person or entity you designate.

How to Access Your Information Electronically:

Patient Portal: You can access your health information 24/7 through our secure patient portal. Contact our office to set up your portal account.
Written Request: You may submit a written request using our Release of Information form.
In-Person: You may review your records in person under staff supervision.

No Information Blocking: We will not engage in practices that interfere with, prevent, or materially discourage access, exchange, or use of electronic health information, except as required by law to protect privacy and security.

Exceptions: Psychotherapy notes, information compiled for legal proceedings, and certain other information may have additional access restrictions as permitted by law.

Consent to Treatment of a Minor

Idaho Law Regarding Minor Consent to Healthcare and Mental Health Treatment
In Idaho, the age of majority is 18 years. Under Idaho Code § 32-1015, parents and legally authorized guardians generally have the right and responsibility to make healthcare decisions for their unemancipated minor children.

Parental Consent Requirements

iCare Center for Change requires informed consent from a parent or legally authorized guardian before providing routine medical, psychiatric, or mental health treatment to an unemancipated minor, except as otherwise permitted by applicable law or court order.

Exceptions to Parental Consent

Certain exceptions may apply under Idaho law, including emergency medical circumstances, applicable court orders, and other specifically authorized situations.
When a minor seeks treatment without parental consent, iCare Center for Change will evaluate the circumstances and applicable legal requirements before providing nonemergency services.

Emancipated Minors

Minors who are legally emancipated may generally consent to their own healthcare treatment. Appropriate documentation of emancipation may be required.

Parental Access to Minor's Records:

Under Idaho Code § 32-1015, parents and legally authorized guardians generally have the right to access the healthcare information and treatment records of their unemancipated minor children under the age of 18.

Exceptions to parental access may apply under state or federal law, including:

When access is restricted by a court order.
When records involve suspected parental abuse, abandonment, or neglect and applicable legal protections restrict disclosure.
When a parent is the subject of a criminal investigation involving the child and law enforcement has requested that information not be released.
When federal privacy laws, including HIPAA or applicable substance use disorder confidentiality regulations, restrict disclosure.

iCare Center for Change will evaluate requests for minor patient records in accordance with applicable Idaho and federal laws. Any decision to restrict parental access will be based on applicable legal requirements and documented appropriately.

For substance use treatment records under 42 CFR Part 2, special consent rules apply
I understand that the parent(s) and/or legal guardian(s) shall have the legal right to information in most cases concerning or relating to the minor child, unless otherwise listed above, as ordered by a custody decree or court order. This information may include, but is not limited to, educational, law enforcement, and medical records. It is requested that a copy of court orders and/or custody decrees be provided to iCare Center for Change, for documentation purposes.
I understand that the parent(s) and/or legal guardian(s) shall have the legal right to information concerning or relating to the minor child, except for substance use/use information, in most circumstances. Exclusions to this right to information include the limitation of information to a parent or legal guardian if such information may cause harm to the minor child, and such restriction of information would be in the best interest of the minor child's safety.
I understand that the parent(s) and/or legal guardian(s) and the minor child, if both parties are involved in the minor child's care, will discuss with the medical provider the definition of confidentiality versus privacy. Note that if the minor child reports high-risk intentions or behaviors to the medical provider, such information will also be discussed with the minor child's parent(s) and/or legal guardian(s) or with proper legal and/or medical authorities. Exclusions to this right to information include the limitation of information to a parent or legal guardian if such information may cause harm to the minor child, and such restriction of information from the child's parent(s) and/or legal guardian(s) would be in the best interest of the minor child's safety.
I understand that if a minor child is receiving services, iCare Center for Change is not accountable to notify non-custodial and/or legal guardians who were not present at the time of enrollment and/or not present at succeeding sessions in reference to current or following services, unless specifically requested by the custodial parent(s) or legal guardian(s) who is authorizing the enrollment of the minor child with iCare Center for Change.
I understand that if the minor client becomes involved in a divorce, visitation, and/or custody dispute, iCare Center for Change will not engage in custody determinations, give opinions on visitation or custody arrangements, or provide evaluations or expert testimony in court. A different medical professional for any evaluations or testimony should be acquired for these purposes.
I understand that any amount due after the third-party payment is received will be billed to the person signing the enrollment agreement. I understand that it is my obligation, as the consenting adult to services, to collect payment for any amount owed by the other parent.

Consent to Treatment of Family or Couple

I understand that the medical provider will not provide any services to an individual family member or couple while providing services to the couple and family. If the couple or entire family cannot make it to session, the session needs to be cancelled and rescheduled. The medical provider has a "No Secrets" policy and that while working with a couple or family, anything disclosed individually, whether by phone or in passing, will not be held in confidence. The medical provider will work with the member for a short period and support the disclosure to the other partner or family members. If not, the medical provider will disclose after the agreed time has passed.

Consent to Treatment via Telehealth Services

I understand that my medical provider may recommend engaging through telehealth communication. My medical provider has explained to me how the video conferencing technology will be used to affect such a session will not be the same as a direct patient/medical provider visit since I will not be in the same room as my medical provider.
I understand that telehealth allows me to receive counseling from virtually anywhere, if I have a secure internet connection and the necessary hardware.
I understand that I may find telehealth more comfortable than in-person therapy, as it allows me to share personal or "deep" issues more freely from the comfort of my own environment.
I understand the alternatives to the telehealth services have been explained to me, including their risks and benefits, as well as the risks and benefits of doing without treatment. I understand that I can still pursue in-person consultations. I understand that the telehealth services do not necessarily eliminate my need to see a specialist in person, and I have received no guarantee as to the telehealth services effectiveness.
I understand that telehealth is the delivery of behavioral health services using interactive technologies (use of audio, video or other electronic communications) between a practitioner and a client/patient who are not in the same physical location. This service is provided by technology (including but not limited to video, phone, text, apps and email) and may not involve direct face-to-face communication. There are benefits and limitations to this service.
I understand that regardless of the sophistication of today's technology, some information my practitioner would ordinarily get in in-person consultation may not be available in teleconsultation. I understand that such missing information could in some situations make it more difficult for my practitioner to understand my problems and to help me get better. My practitioner will be unable to physically touch me or to render any emergency assistance if I experience a crisis.
I understand that telehealth is a new delivery method for professional services, in an area not yet fully validated by research, and may have potential risks, possibly including some that are not yet recognized.
I understand electronic systems used will incorporate network and software security protocols to protect the privacy and security of health information and imaging data and will include measures to safeguard the data to ensure its integrity against intentional or unintentional corruption.
I understand these services rely on technology, which allows for greater convenience in service delivery. Though there are potential risks to this technology, including interruptions, unauthorized access, breaches in confidentiality, theft of personal information, and technical difficulties and that my provider or I can discontinue the telehealth session if it is felt that the video-conferencing connections are not adequate for the situation.
I understand I will need access to, and familiarity with, the appropriate technology to participate in the service provided.
I understand that there are potential issues related to technology, such as poor internet connection, which can disrupt sessions and affect the quality of communication.
I understand it is my responsibility to maintain privacy on the client end of communication. Insurance companies, those authorized by the client, and those permitted by law may also have access to records or communications.
I understand that I need to share my current location at the beginning of each telehealth session, especially if it differs from my usual location, to ensure that help can be directed to me if needed.
I understand and agree that I will prepare for telehealth sessions by ensuring a stable internet connection and a private, quiet environment to minimize disruptions and maintain confidentiality. I will also consider turning off electronic notifications and having tissues available to minimize interruptions.
I understand that I am to use my own equipment to communicate and not equipment owned by another, and specifically not using my employer's computer or network. I am aware that any information I enter into an employer's computer can be considered by the courts to belong to my employer and my privacy may thus be compromised.
I understand that it is my duty to inform my practitioner of electronic interactions regarding my care that I may have with other health care providers.
I understand the exchange of information will not be direct and any paperwork exchanged will likely be provided through electronic means or through postal delivery.
I understand that, under state and federal law, and regardless of what form of communication I use in working with my practitioner, my practitioner may be required to report to the authority's information suggesting that I have engaged in behaviors that endanger others.
I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. Others may also be present during the session, other than my medical provider and consulting a health care provider to operate the video equipment. All iCare Center for Change, providers and staff will maintain the confidentiality of the information obtained. I further understand that I will be informed of their presence in the session and thus will have the right to request the following: (1) omit specific details of my medical history/physical examination that are personally sensitive to me; (2) ask non-medical personnel to leave the telehealth session room: and or (3) terminate the consultation at any time.
I understand there is no permanent video or voice recording kept of the Telehealth service's session. All existing confidentiality protections apply. All existing laws regarding confidentiality, client access to mental health information and copies of mental health records apply. Dissemination of client identifiable images or information from the Telehealth interaction to provider or other entities shall not occur without the consent of the client.
I understand that if a need for direct, in-person services arises and my current practitioner is not available for in-person services, it is my responsibility to contact practitioners in my area to contact my behavioral practitioner's office for an in-person appointment or my primary care physician if my behavioral practitioner is unavailable. I understand that an opening may not be immediately available in either office.
I understand and agree that I have been provided with contact information for my practitioner and that it is my responsibility to contact practitioners in my area if further services are required, which my iCare Center for Change practitioner cannot provide.
I understand that billing will occur from both my practitioner and as a facility fee from the site from which I am presented.
I understand my practitioner and I will regularly reassess the appropriateness of continuing to deliver services to me through the use of the technologies we have agreed upon today, and modify our plan as needed.
I understand that in emergencies, in the event of disruption of service, or for routine or administrative reasons, it may be necessary to communicate by other means. I agree that my practitioner or iCare Center for Change staff may contact me at my telephone number(s) provided, or in emergency situations, may contact my emergency contact.
I understand that telehealth may not be suitable for all situations, particularly in cases of crisis, suicidal or homicidal thoughts, where in-person treatment might be more appropriate.
I understand and acknowledge that if I am facing or if I think I may be facing an emergency that could result in harm to me or to another person; I am not to seek telehealth services. Instead, I agree to seek care immediately through my own local health care practitioner or at the nearest hospital emergency department or by calling 911.
I understand I may withhold or withdraw my consent to telehealth services at any time before and/or during the session without affecting my right to future care or treatment or risking the loss or withdrawal of any program benefits to which I would otherwise be entitled.
I understand and agree that I have had a direct conversation with my practitioner or iCare Center for Change staff during which I had the opportunity to ask questions regarding this procedure. My questions have been answered, and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand.

Use of Artificial Intelligence and Automated Technology in Your Care

iCare Center for Change utilizes artificial intelligence (AI) and automated technology to enhance the quality, accuracy, and efficiency of your care. We want you to understand how these technologies are used and your rights regarding them.

AI Technologies We Use:

AI-Powered Clinical Documentation: We may use ambient listening technology and AI-powered transcription services to create accurate clinical notes during your sessions. This allows your provider to focus fully on you rather than on notetaking.
How It Works:

With your consent, your session may be recorded using secure, HIPAA-compliant technology
The recording is processed by AI to create a written transcript and clinical note
Your provider reviews, edits, and approves all AI-generated content
The original audio recording is permanently and automatically deleted within seconds to minutes after transcription
Only the provider-approved written notes remain in your medical record
Clinical Decision Support: We may use AI-powered tools to assist with treatment planning, identifying evidence-based interventions, and tracking your progress. These tools provide recommendations that your provider considers alongside their clinical expertise.
Administrative Functions: AI is used for appointment reminders, scheduling optimization, and billing processes.

Important Protections and Limitations:

AI Assists, Does Not Replace: All AI tools assist your licensed provider. AI does not make clinical decisions, diagnoses, or treatment determinations. Your provider remains responsible for your care.
HIPAA Compliance: All AI vendors operate under Business Associate Agreements and must comply with HIPAA privacy and security requirements.
Data Security: AI-processed information is encrypted during transmission and storage. AI vendors cannot use your data for their own purposes or to train their models without explicit consent.
Accuracy Review: Your provider reviews all AI-generated content for accuracy and completeness before it becomes part of your medical record.
Your Right to Opt-Out: You may decline the use of AI-assisted documentation. If you opt out, your provider will take manual notes. This will not affect the quality of care you receive, though it may affect your provider's availability or session capacity.
Your Right to Revoke: You may change your decision about AI use at any time, including during a session, by informing your provider.

Consumer Rights

I have read and had explained to me the basic rights of individuals who undergo services at iCare Center for Change. These rights include:

The right to receive quality of care, free from discrimination based on race, color, creed, sex, age, sexual orientation, gender identity, national origin, social or economic status, political belief, disability or religion.
The right to receive therapy services regardless of inability to pay. Discounts for essential services are offered based on family size and income.
The right to have a safe treatment setting, free from sexual, physical, and emotional abuse.
The right to have a respectful and dignified treatment.
The right to obtain information about the medical provider's qualifications, including his or her license, education, training, experience, membership in professional groups, special areas of practice, and limits on practice.
The right to confidential treatment under state and federal laws which is outlined in the Privacy Notice provided to me.
The right to receive comprehensible information pertaining to my services, diagnosis and expected results of my overall treatment through iCare Center for Change.
The right to participate and make decisions in the formation of my evaluation, treatment plan and services provided through iCare Center for Change.
The right to refuse any form of treatment or service.
The right to file a complaint if I believe my privacy rights have been violated. Such procedures are outlined in the Privacy Notice provided to me.
The right to have an Advanced Psychiatric Directives which will be followed with reasonable care by iCare Center for Change. Such directives should be provided to iCare Center for Change for record purposes.

More information regarding Advanced Psychiatric Directives can be found at www.nrc-pad.org.

Consumer Responsibility

As a consumer of such services, I accept the responsibility for the following:

To be an honest and active participate in my evaluation, treatment and care while engaged in services with iCare Center for Change and to ask questions if I do not understand the services that are being provided.
To inform iCare Center for Change of my past and current medical and medical issues in addition to a comprehensive listing of current medications being taken. It is also my responsibility to inform iCare Center for Change of any changes to these medications.
To provide iCare Center for Change of current insurance card(s), if such insurance will be billed for services. I am to also notify iCare Center for Change of any alterations to this insurance coverage. I will be held financially responsible at the full rate of service until such insurance information is provided.
To be accountable for my decisions and for the attainment of my treatment plan. Which also includes such results if I refuse to follow my treatment plan or its recommendations and directives.
To understand my insurance coverage and agree to all financial obligations to iCare Center for Change. I also acknowledge and agree that payment or co-payment is due at the time of the service.
To contact or communicate with my insurance company if any limitations or necessities are required for service. If such contact is not rendered, I will be financially responsible for unpaid services.
To contact or communicate with the insurance card holder that the stated insurance will be billed for such services provided by iCare Center for Change.

Provider Responsibility

The medical provider of such services accepts the responsibility for the following:

The medical provider will endeavor to be present, honest, and emphatic throughout the counseling sessions. The medical provider will engage the clients verbally and help the clients work toward the agreed upon therapy goals. Progress of therapy will be monitored with the aid of a treatment plan.
The medical provider will handle the client's personal information and information shared in the counseling sessions as confidential as stipulated by federal and state laws.
The medical provider and staff will be trained and assist in safety procedures and risk management for each office location.
The medical provider will uphold the following exceptions to confidential and privileged information:
- When mandated by law, in cases of suspected or proven physical or psychological child abuse, incest, child neglect or abuse of a dependent adult.
- When clients have provided a written waiver of right and confidentiality.
- When clients pose a danger to themselves or others.
- When clients disclose an intention to commit a crime.
- When a judge orders a medical provider to make records available.
- When the medical provider is working under supervision.
- When the medical provider consults with experts or peers.
- When the medical provider is involved in a lawsuit.
- When reimbursement requires disclosure. Third parties may review client records prior to reimbursement of fees.
- When the medical provider is a defendant in a civil, criminal, or disciplinary action arising from the therapy.
- When family members take confidential information outside the therapy sessions.
- When the medical provider is trying to collect a debt owed by the client for services.
- The medical provider may require frequent consultation with other medical professionals to ensure quality care for clients. Such consultation is standard practice. Every effort will be made to protect the identity of clients.

The medical professional will work to maintain the integrity of the counseling process, the medical professional will refrain from entering into dual and multiple relationships with the client. The medical provider will maintain a professional relationship with the client at all times. There will be no socializing between the medical provider and client outside of the counseling setting. The client is not allowed to visit or contact the medical provider at the medical provider's primary residential residence. The medical provider does not engage in any physical contact with clients. In the event that the medical provider sees the client in a public place, to maintain confidentiality the medical provider will only acknowledge the client if it is first initiated by the client. The medical provider will not engage in any conversation with the client. Please consider that if the client speaks to the medical provider in public, the client may be self-disclosing you are in session.
The medical provider will focus on the client's protection, confidentiality, and to maintain professional boundaries, the medical provider will not accept any social media requests or communicate with clients via social media. The medical provider also does not use email, chat or text to engage clients directly unless it is approved through our automated appointment reminder system, HIPAA-compliant email system or through the HIPAA-compliant EMR system. If the client shares any information about counseling services on a rating site of business or about their medical professionals, please be mindful that the client is self-disclosing whether they are or have received treatment.

In the future, we may change how we use and share your information, and so we may change our notice of privacy practices and informed consent for service. If we do change it, you can get a copy from our website, www.icarecfc.com or by calling us at (208) 918-2473 if you are concerned about your PHI, you have the right to ask us not to use or share some of it for treatment, payment, or administrative purposes. You will have to tell us what you want in writing. Although we will try to respect your wishes, we are not required to accept these limitations. However, if we do agree, we promise to do as you asked. After you have signed this consent, you have the right to revoke it by writing. We will then stop using or sharing your PHI, but we may already have used or shared some of it, and we cannot change that.

I acknowledge that iCare Center for Change is obligated by state and local regulations to report any instances of abuse or neglect involving minors or vulnerable adults. Additionally, iCare Center for Change must report situations with a risk of harm to oneself or others. I am aware that other legal circumstances may require iCare Center for Change to disclose confidential information. Furthermore, iCare Center for Change may contact me to maintain the quality and continuity of my services and possibly after services have been concluded to evaluate the outcomes of rendered services. Lastly, I understand that iCare Center for Change may review my case to ensure the quality of services provided.

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