Confidentiality Statement
I/We understand that information regarding services provided to the above-mentioned individual/s is private and confidential with the exception of cases involving suspected child abuse, neglect, and/or imminent danger to a child in accordance to Public Law 99-401. Confidentiality may also be broken in cases of threatened danger to self and/or others to include homicide and/or suicide.
Patient records will not be released without written permission of the client, parent and/or guardian depending on the client age except in cases of a court ordered subpoena.

if payment for services is received from local, state or federal sources, these sources have the right to review the patient files on a periodic basis to verity services have been delivered appropriately.
Furthermore, insurance companies may need to review parts or all of the file to verify diagnosis and ensure treatment is rendered to process payment.

Billing Statement

In cases of receiving Employee Assistance Program (EAP) benefits, I/We understand EAP will cover

In cases of payments received from insurance companies, I/We understand that upon billing, Pathway to Hope LLC/ Rue La Shelle Tennyson will receive direct payment from my insurance company for services rendered. All co- payments are due at the time services are rendered.

*Please initial to acknowledge the following*

I understand Pathway to Hope LLC has a $50 late cancellation/no-show fee for appointments not cancelled within 24 hours of scheduled appointment time and rescheduling will not take place until fee is paid.