Welcome to GraceMind
Behavioral Health
Please complete your confidential intake and consent forms below. It takes about 2–5 minutes. Your information is private and securely transmitted.
Please complete your confidential intake and consent forms below. It takes about 2–5 minutes. Your information is private and securely transmitted.
HIPAA compliant • GraceMind Behavioral Health Services LLC
I voluntarily consent to receive treatment and related services by GraceMind Behavioral Health Services, as advised by the attending physician, including such behavioral health and related medical services as are deemed medically necessary and appropriate. I understand that in a medical or psychiatric emergency it may become necessary for GraceMind to render emergency treatment and/or transfer me or my child to a hospital. I understand that if I do not make payment I may be refused future appointments and/or discharged from the agency, that all information about my participation is confidential and released only with my written consent, and that I have been oriented to the program's services, my rights and responsibilities, the grievance process, and the discharge/termination policy. I agree to follow my individualized treatment plan and keep scheduled appointments, to pay promptly all charges not covered by insurance, and I understand a 24-hour notice is required to cancel or I may be billed for a no-show. I may stop treatment at any time but remain responsible for outstanding balances. No promises have been made as to the results of treatment.
GraceMind will use my protected health information (PHI) for treatment, payment and health care operations, on a "minimum necessary" basis, consistent with the HIPAA Privacy Rule and Maryland law. PHI may be disclosed to me or my personal representative (except where GraceMind reasonably believes I may be subject to abuse, neglect or endangerment), and pursuant to the Notice of Privacy Practices.
Disclosures to individuals involved in my care or payment may occur if I agree, fail to object, or where GraceMind reasonably infers no objection, or in the case of incapacity or emergency where disclosure is in my best interest. GraceMind may disclose PHI for notification purposes; for providing prescriptions and medical supplies to third parties; pursuant to a specific authorization (including HIV/AIDS, mental health, substance abuse, and therapy-note information); to Business Associates under written agreement; and to law enforcement to identify or locate a suspect, fugitive, material witness or missing person (excluding Mental Health and Substance Abuse records protected by Maryland law), limited to: name and address; date and place of birth; social security number; blood type and Rh factor; type of injury; date and time of treatment; date and time of death; and distinguishing physical characteristics.
GraceMind will not sell my PHI without a valid authorization. Limited PHI may be used for marketing only with my authorization (and I may opt out), and for fundraising (and I may opt out). I acknowledge I have received and reviewed this policy.
I am ultimately responsible for my account. GraceMind is a contracting provider with most insurance carriers and will bill my insurance accordingly; any balance due is my responsibility (excluding Medicaid patients). My insurance coverage and any required Prior Authorization are my responsibility. GraceMind accepts Medical Assistance and associated MCOs. For minor patients or those with legal guardians, the parent/guardian and/or guarantor is responsible for payment at the time of treatment.
A 24-hour cancellation notice is required for all appointments. A missed appointment incurs a $50 fee, payable before additional appointments are scheduled; missing three (3) appointments results in dismissal from the program. Commercial Insurance: I assign my insurance benefits to be paid directly to GraceMind, understand I am financially responsible for non-covered services, and authorize release of information required to process my claims. Medical Assistance: I request payment of authorized benefits be made on my behalf to GraceMind and authorize release of my medical information to CMS and its agents until I revoke this authorization in writing.
I have the right to: be treated carefully, with respect and privacy; fair treatment regardless of race, religion, gender, ethnic background, disability or source of payment; privacy of my records; accessible, timely, culturally respectful care I can understand; participation in my plan of care; free interpretation services; information about GraceMind, its providers, programs and services; a second medical opinion and the right to refuse treatment; to file complaints, grievances and appeals and request a State Fair Hearing; a copy of my records and to request corrections; written information on advance directives; and information about state benefits, cost-sharing and transportation.
My responsibilities include: getting treatment from a provider; treating staff with respect; giving accurate information; asking questions; following my treatment and medication plans; attending visits and giving timely cancellation notice; telling my provider when the plan is not working or if I have trouble paying co-pays; sharing concerns about quality of care; and reporting suspected abuse, fraud, waste and abuse. I have been informed of and understand my rights and responsibilities.
I understand services begin with an intake/psychosocial assessment, after which I receive feedback and recommendations and may be referred to psychiatric evaluation, group, family, couples, substance abuse treatment, or case management. GraceMind accepts Aetna, Blue Cross Blue Shield (CareFirst), Cigna, United Health Care, and MD Medicaid (Amerigroup, Priority Partners, United Health Care, etc.), and collects copays at the start of each session. For non-accepted insurance, a $50 intake fee and copays apply, with a $90 hardship balance limit. For uninsured clients, income documentation is reviewed against Federal Poverty Guidelines, with sliding-scale fees ($10–$30 per session type) and a $25–$50 intake fee, and a $40 hardship balance limit. The DUI program ($460) is paid out of pocket. Missed sessions without 24-hour notice incur a $20 no-show fee.
My therapy records are confidential and released only with properly executed written consent, except where reporting is required by law: a threat of bodily injury to self or others or suicidality; reasonable suspicion of abuse to a child or dependent adult; or when required by law or court order. Counselors work as a team and may consult; they may request to video a session for training (which I may decline). Electronic communication (email, fax, cell calls) is not secure. I have read and understood this information and agree to disclose personal information with these exceptions in mind.
Appointments require 24-hour cancellation notice or I am subject to a full charge. Sessions last 30–50 minutes; fees are based on annual income, due at the time of service, and paid directly to the counselor (cash, check, or online). Returned checks incur a $25 penalty. Unpaid balances may suspend sessions. GraceMind does not provide childcare. I will not call upon the therapist to testify in court or any proceeding, nor request disclosure of psychotherapy records (legal limitation). I have read these policies, agree to comply, am personally responsible for all financial obligations, and consent to treatment by GraceMind.
I consent to engage in telemedicine as part of my psychotherapy, understanding it involves communication of my medical/mental information by interactive audio, video or data. I may withhold or withdraw consent at any time without affecting future care. Confidentiality protections and their legal exceptions (mandatory reporting, threats of violence, legal proceedings, court orders, and the Patriot Act) apply. I understand the technology risks — disruption, distortion, interruption or unauthorized access — and that I am responsible for the privacy of my device; I will use a safe computer, exit fully after sessions, and attempt to reconnect within 10 minutes of any breakdown. Telemedicine may be less complete than in-person care, and I may be referred elsewhere or must find a local therapist if I move out of Maryland. A "no secrets" policy applies to family/couples therapy. Disputes go first to mediation, then arbitration; the litigation limitation applies. Payment is due before each session (50 minutes), most insurance does not reimburse online counseling, returned checks incur a $25 charge, and brief between-session contact (5 minutes) is acceptable. In a crisis, I will go to the nearest hospital or call 911 (or 988). I have read, understand, discussed, and consent to telemedicine services.
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I voluntarily consent or give my consent to receive treatment and/or related services by GraceMind Behavioral Health Services which may be advised and/or recommended by the attending physician. I hereby request GraceMind Behavioral Health Services and its qualified clinicians, physicians, employees and agents to provide such patient behavioral health and related medical services as are deemed medically necessary and appropriate. I understand that in the event of a medical or psychiatric emergency which may be life threatening, it may become necessary for GraceMind to render such emergency treatment and/or transfer myself or my child to a hospital for evaluation and/or treatment. I understand if I don't make payment to GraceMind I may be refused future appointments and/or discharged from the agency. I understand that all information concerning participation of myself/my child is confidential and that no information will be given without written consent from me. I agree that I have been fully oriented to the program's services and the treatment that is being provided to me, and that I have reviewed my rights and responsibilities, the grievance process, and the discharge/termination policy. I shall assist in following the individualized treatment plan and ensure all scheduled appointments are kept. I also agree to pay promptly all charges for services, drugs and medications not covered by insurance or third party payers, and am aware that an agent of my insurance company may be given information about services such as cost, dates, and providers. I understand it is my responsibility to cancel an appointment with 24 hour notice or I may be billed for a no-show. I am aware that I may stop treatment at any time but remain responsible for the outstanding balance. No promises have been made to me as to the results of treatment or of any procedures provided by this agency.
Purpose & Internal Uses. GraceMind will use patients' protected health information (PHI) for treatment, payment and health care operations, on a "minimum necessary" basis, consistent with the HIPAA Privacy Rule and Maryland law.
External Disclosures. GraceMind may disclose PHI to the client or, where the client lacks capacity (a minor or incapacitating impairment), to the client's personal representative — except where GraceMind reasonably believes the client may be subject to domestic violence, abuse or neglect by that person, that treating the person as representative could endanger the client, or that it is not in the client's best interest. PHI may be disclosed pursuant to the Notice of Privacy Practices for treatment, payment and operations; HIV/AIDS, mental health, substance abuse, and therapy-note information requires a specific written authorization.
Disclosures to individuals involved in the patient's care or payment may occur if the client agrees, fails to object, where GraceMind reasonably infers no objection, or in cases of incapacity or emergency where disclosure is in the client's best interest. GraceMind may also disclose PHI: for notification purposes (3.5); to provide prescriptions and medical supplies to third parties (3.6); pursuant to authorization, including to employers (3.7); to Business Associates under written agreement (3.8); and to a law enforcement official to identify or locate a suspect, fugitive, material witness or missing person (excluding Mental Health and Substance Abuse records protected by Maryland law) (3.9), limited to: name and address; date and place of birth; social security number; blood type and Rh factor; type of injury; date and time of treatment; date and time of death; and a description of distinguishing physical characteristics. GraceMind may also disclose information about a deceased client to law enforcement if it suspects the death resulted from criminal activity.
Prohibition against selling PHI (4). GraceMind will not directly or indirectly receive payment in exchange for PHI without a valid authorization, except for permitted purposes such as providing a copy of the record, public health activities, research (at cost), treatment, health care operations associated with a sale/merger, payment to a Business Associate, or any purpose approved by the Secretary of HHS. Marketing (5) requires my authorization (and I may opt out). Fundraising (6) may use limited PHI and I may opt out. I acknowledge I have received and reviewed this policy.
I am ultimately responsible for my account. GraceMind is a contracting provider with most insurance carriers and will bill my insurance accordingly; any balance due is my responsibility (excluding Medicaid patients). My insurance coverage and any required Prior Authorization are my responsibility, and failure to obtain Prior Authorization may make me responsible for the full amount. GraceMind accepts Medical Assistance and associated MCOs. For minor patients or those with legal guardians, the parent/guardian and/or guarantor is responsible for payment at the time of treatment, and statements are sent only to the Responsible Party. Credit balances are refunded promptly.
A 24-HOUR CANCELLATION NOTICE IS REQUIRED FOR ALL APPOINTMENTS. A missed appointment incurs a $50 fee, payable before additional appointments are scheduled; missing three (3) appointments results in dismissal from the program. Commercial Insurance: I assign my insurance benefits to be paid directly to GraceMind, understand I am financially responsible for non-covered services, and authorize release of information required to process my claims. Medical Assistance: I request payment of authorized Medical Assistance benefits be made on my behalf to GraceMind and its affiliate providers, and authorize release of my medical information to the Centers for Medicare and Medicaid Services (CMS) and its agents until I revoke this authorization in writing.
Rights. Each patient has the right to be treated carefully, with respect and privacy; to fair treatment regardless of race, religion, gender, ethnic background, disability or source of payment; to privacy of treatment records; to easy, timely care; to learn about treatment in a way that respects your culture, that you can understand, and that fits your needs; to take part in your plan of care; to free interpretation services; to information about GraceMind, its providers, programs, services and role; to information about clinical rules and providers' training; to not be kept alone or forced to do something against your will; to give feedback on this policy; to ask for a certain type of provider; to a second medical opinion and to refuse treatment (unless a court orders otherwise); to file complaints, grievances and appeals and request a State Fair Hearing; to a copy of your records and to request corrections; to written information on advance directives; and to information about state benefits, cost-sharing and transportation.
Responsibilities. Each patient is responsible for getting treatment from a provider; treating staff with respect; giving accurate information; asking questions; following the agreed treatment and medication plans; attending visits and giving timely cancellation notice; telling the provider when the plan is not working or when there is trouble paying co-pays; sharing concerns about quality of care; and reporting suspected abuse, fraud, waste and abuse. I have been informed of and understand my rights and responsibilities.
Services begin with an intake/psychosocial assessment, after which I receive feedback and recommendations and may be referred to psychiatric evaluation and treatment, group, family, couples therapy, substance abuse treatment, or case management. GraceMind accepts Aetna, Blue Cross Blue Shield (CareFirst), Cigna, United Health Care (Community and Private), and MD Medicaid (Amerigroup, Priority Partners, United Health Care, etc.), and collects copays at the start of each individual or group session. For insurance GraceMind does not accept, a $50 intake fee and per-session copays apply, with up to a $90 hardship balance. For uninsured clients, 30 days of income documentation is reviewed against Federal Poverty Guidelines, with sliding-scale fees ($10 individual / $15 group / $20 medication management if below guidelines; $20 / $25 / $30 if not) and a $25–$50 intake fee, with up to a $40 hardship balance. The DUI program ($460 total) is paid out of pocket. Missed sessions without 24-hour notice incur a $20 no-show fee. By agreeing, I confirm I have read and understand this agreement and will adhere to it while receiving services.
My therapy records are the property of my counselor and are confidential; they will not be released without properly executed written consent, except where reporting is required by law: when a client communicates a threat of bodily injury to self or another or is suicidal; when there is reasonable suspicion of abuse to a child or dependent adult; or when required by law or court order. If I choose to have my counselor keep a third party informed, a Release of Information Form must be completed. Counselors work as a team and may consult; on rare occasions they may request to video a session for training, which I may decline. Electronic communication (e-mail, fax, cell phone) is not secure. I have read and understood this information and agree to disclose personal information with these exceptions in mind.
Appointments require a minimum of 24 hours' notice to cancel or I am subject to a full charge. Sessions last 30–50 minutes; fees are based on annual income, due at the time of service, and paid directly to the counselor (cash, check, or online — online before the session). GraceMind does bill insurance and requires complete insurance information prior to intake. Returned checks incur a $25 penalty (repayable by cash, cashier's check or money order). Unpaid balances may suspend sessions. GraceMind does not provide childcare and asks that children not be brought unless they are receiving counseling. Under the legal limitation, neither I nor anyone acting on my behalf will call upon the therapist to testify in court or any proceeding, nor request disclosure of psychotherapy records. By signing I confirm I have read these policies, understand and agree to comply, am personally responsible for all financial obligations, and consent to receive treatment by GraceMind.
I consent to engage in telemedicine with my GraceMind counselor as part of my psychotherapy, understanding "telemedicine" includes health care delivery, diagnosis, consultation, treatment, transfer of medical data and education by interactive audio, video or data, including communication to practitioners located in or outside Maryland. I may withhold or withdraw consent at any time without affecting future care or program benefits. The confidentiality of my information and its legal exceptions apply — mandatory and permissive reporting under Maryland law (child, elder and dependent adult abuse; threats of violence toward an ascertainable victim; making my mental/emotional state an issue in a legal proceeding) and court-ordered release; I also understand the Patriot Act of 2001 may require disclosure to the FBI without notice to me.
I understand the technology risks — that transmission could be disrupted, distorted, interrupted by unauthorized persons, or that electronic storage could be accessed by unauthorized persons — and that I am responsible for the privacy of my device. I will communicate through a safe computer, fully exit after each session, and attempt to reconnect within 10 minutes of any technological breakdown (otherwise another session will be scheduled). I understand telemedicine may be less complete than face-to-face care, that I may be referred elsewhere, and that if I move out of Maryland I must inform my therapist as it may affect their ability to provide services. A "no secrets" policy applies to family/couples therapy. Disputes are referred first to mediation and then arbitration; the litigation limitation applies. Payment is due before each 50-minute session, most insurance does not reimburse online counseling, returned checks incur a $25 charge, and brief between-session contact (5 minutes or less) is acceptable. I am advised to obtain a physical exam before commencing therapy. In a crisis I will visit the nearest hospital or call 911 (or 988 / 1-800-SUICIDE). I have read, understand, discussed this with my psychotherapist, and consent to telemedicine services.