IMPACT STATEMENT OF UNDERSTANDING AND AGREEMENT ON CONFIDENTIALITY:
- Confidentiality
Information you provide to IMPACT is confidential and will not be disclosed without your written consent except as set forth below: - abuse or neglect of a child, dependent adult, or person with a disability,
- threat of bodily harm to yourself or someone else,
- as mandated by a court order or law, or
- with your signed consent.
- Fees
- Please consult with your insurance or benefits representative before you access services outside of the IMPACT provider network.
- There is no charge to you for initial IMPACT counseling visits up to the number of visits indicated in your benefit plan description. Your organization pays for these services. If you need longer-term counseling or a specialized service, if appropriate, you can continue with your current provider or IMPACT will assist in locating additional resources or services. It will be your responsibility to determine whether or not those services are covered under your medical benefit plan and to pay any charges for services not covered by your medical benefit plan.
- Some services, such as psychological testing, are not covered under IMPACT. Fees for such non-covered services will be discussed with you in advance. If you consent to non-covered services, you are responsible for any and all fees.
- Complaints of Harassment and/or Discrimination
Discussion of concerns about potential workplace/school harassment, violations of organizational policy and/or discrimination with your counselor are not considered official notification to your employer/school. To do so you will need to follow your organization’s policy.
By accepting below I acknowledge that I have read and understand the above statement and that I agree to proceed pursuant to the terms set forth above.