Service Forms

Before your first appointment at Excelsior Wellness Center, we ask that you fill out and bring the Informed Consent form and as many Authorization to Release Information forms as needed. As part of the Informed Consent, you will be asked to initial on the Form that you have reviewed, understand, and agree to our policies and procedures.


AUTHORIZATION TO RELEASE INFORMATION

DIRECTIONS: In order for us to share information regarding your treatment with anyone, other than you, we need your permission in writing that you want us to share your information. A form must be filled out for EACH person, examples include mother, father, other family members, doctor, probation officer, a social worker. Print as many as you want, we will also have copies available for you at your first appointment.

RELEASE OF INFORMATION FORM


INFORMED CONSENT FORM

DIRECTIONS:  Download, fill out the Informed Consent Form and bring to your first appointment. You will be asked to initial on the Informed Consent Form that you have reviewed, understand, and agree to the following policies and procedures, please open and read each document below.

INFORMED CONSENT FORM

INDIVIDUAL RIGHTS POLICY  We believe that if you understand and participate in your evaluation, care and treatment, you achieve better results. The staff has a responsibility to give you the best care and services possible and available and to ensure that each individual is treated in a manner that respects individual identity, human dignity, and fosters constructive self-esteem by ensuring that Excelsior respects the following rights. No staff person at Excelsior shall violate any of the stated rights, contribute to such violation, or tacitly approve such violation by another person.

GRIEVANCE PROCEDURE  It is the standard of Excelsior that all individuals have the right to make a grievance. A grievance is any expression of dissatisfaction. A grievance may be a concern over the quality of care or services, failure to respect the individual’s rights or an aspect of interpersonal relationships. It is also our standard that all grievances will be reviewed in a timely manner and that they all shall come to a resolution, whenever possible, at the lowest possible level of authority.

NOTICE OF PRIVACY PRACTICES  Excelsior is required by law to maintain the privacy of your health information and to provide you with this notice of our legal duties and privacy practices with respect to your health information. Excelsior is required to comply with all terms described in this Notice of Privacy Practice and is required by law to provide you with a copy. This Notice of Privacy Practices describes how we may use and disclose your “protected health information” (PHI) to carry out treatment, payment, or health care operations and for the purposes that are permitted or required by law. This notice also describes your rights to control and access protected health information.

ASSIGNMENT OF BENEFITS  Excelsior accepts most insurance carriers. We encourage all clients to review the benefits and requirements of their specific insurance plan. Your health plan may require you to be responsible for co-pays, co-insurance, deductibles, and non-covered services. Excelsior will review your insurance eligibility and benefits to ensure we have the most accurate information to support you in your services and coverage.


Referral Forms

WISe+ REFERRAL