Protecting your confidentiality is of the utmost importance to DePaul Community Resources. All client information is kept confidential. Written permission is required by law to facilitate the release of client-related information to outside parties, except in the following situations:
1. Mandated reporting of suspected or confirmed abuse, neglect, self-harm, harm to others, duty to warn of threats to harm others, or inability to care for self.
2. Medical emergencies, for the purpose of preventing injury to, or death of, client or other persons.
3. Subpoena for records, legal counsel, hearings, reviews, appeals, or investigation under the regulations of Licensing, Human Rights, or certification or accreditation (12 VAC 35-115-80).
I authorize the release of any information, to include protected health/medical/substance abuse information, that is deemed necessary to process claims to third-party payors (i.e. Medicaid, HMO’s, CSA, etc.) as needed. I also authorize payment of any medical benefits to be made to DePaul Community Resources (DCR) on my behalf. If any payments are made directly to me as reimbursement for services that I have not yet paid to DCR, I will immediately notify DCR of such payments and arrange payment to DCR.
I agree to pay all co-payments and deductibles, if applicable, and understand that if fees are not paid when due, services may be delayed or discontinued. I agree to notify DePaul Community Resources of any changes to my healthcare benefits, as needed, and will provide up-to-date benefit information, as necessary. I understand that my insurance may require me to supply certain information directly to ensure payment, and it is my responsibility to comply with their request. I understand the balance of my claim is my responsibility, whether or not the insurance company pays my claim, as my insurance benefit is a contract between myself and my insurance company, and DePaul is not party to that contract.