Cancellation or Rescheduling Fee

We are committed to protecting your personal health information in compliance with the Federal law.
We may use or disclose your personal health information for these purposes:

For Treatment, Payment, Health Care Operations, Appointment Reminders, Health Related Services and Treatment Alternatives, Fundraising Activities, Individuals Involved in Your Care or Payment for Your Care, Research, Organ and Tissue Donation, As Required By Law, To Avert a Serious Threat to Health or Safety, Military and Veterans, Workers’ Compensation, Public Health Activities, Health Oversight Activities, Lawsuits and Disputes, Law Enforcement, Coroners, Health Examiners and Funeral Directors.,
National Security and Intelligence Activities. Protective Services for the President and Others, and Inmates.

You have certain rights with respect to your personal health information:

Right to Inspect and Request a Copy, Right to Amend, Right to Receive an Accounting of Disclosures, Right to Request Restrictions, Right to Receive Confidential Communications, Right to a Paper Copy of this Notice.

Changes to this Notice:

We reserve the right to change this notice and to make the changed notice effective for all of the health information that we maintain about you, whether it is information that we previously received about you or information we may receive about you in the future. We will have available a copy of our current notice in our facility. Our notice will indicate the effective date on the first page, in the center of page. We will also give you a copy of our current notice upon request.

Complaints:

If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the Department of Health and Human Services. You may file a complaint by mailing us a written description of your complaint or by telling us about your complaint in person or over the telephone:

Amy Karamyan, President
Pure Autism Counseling Center INC.
19981 Soledad Canyon Rd,
Santa Clarita CA
661.360.7730
I*

Patient’s FIrst Name
Patient's Last Name*

Patient’s Last Name
understand that PACC Mental Health Services has a 24-hour notice policy (Patient’s name) Patient’s Signature Date for cancellation or rescheduling of any appointments. Excluding emergencies, cancellations, rescheduling, and no shows appointments within 24-hours of the time of appointment will be subject to a $350.00 ( Three Hundred Fifty Dollar) fee.
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Date*
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