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Call: +971 4 2513123

CLIENT INFORMATION SHEET

YesNo


Insurance Information

Authorization for services may be required prior to treatment.

YesNoNot Required

*Consumer Consent for Use/Disclosure of Health Care Information

I, understand that the consumer’s health information is private and confidential. I, understand that Nak Union Behavioral Health (NUBH) works very hard to protect the consumer’s privacy and preserve the confidentiality of the consumer’s personal health information. I, understand that NUBH may use and disclose the consumer’s personal health information to help provide health care to the consumer, to handle billing and payment, and to take care of health care of other health care operations. In general, there will be no other uses and disclosures of this information unless I permit it. I, understand that sometimes the law may require the release of this information without my permission. Examples would be if a consumer threatened to hurt someone of if child abuse is reported.

*Business Policies and Procedures and Notice of Privacy Policies.

Your signature below acknowledges that you have, understand and consent to the above authorizations and consents, policies and procedures. Your signature also signifies that you been given a copy of the Business Policies. It also acknowledges that you understand these policies.

Skipped Signature

FINANCIAL AGREEMENT AND PROMISE TO PAY ACCOUNT

For, and consideration of services rendered, and to be rendered to (client name), I, will promise to pay NAK Union Behavioral Health (NUBH). I understand the total charges are due when services are rendered.


I, agree to make available any and all insurance information to NUBH and/or billing personnel. I understand that NUBH bills from ninety dollars to one hundred and fifty dollars ($90-$150) for sessions lasting 45-90 minutes, based upon therapist and licensure. I agree to provide insurance claim forms of any insurance company and/or will complete HCFA form 1500 form. I agree to assign any and all benefits to NUBH and sign in the designated areas on the insurance claim form. I agree to pay the entire deductible amount, as well as any co-payment amount due.


I, understand that I am financially responsible for missed appointments, in which I do not give 24- hour notice and that my credit card listed below will be charged if I do not give 24 hours notice. The fee for a missed visit ( in which less than 24- hours notice is given) is ½ of my session rate or $60.00 whichever is greater.


I,addition, if my insurance company fails to pay for each date of service with four weeks, I, will be billed for the date of services. I, will be provided with a super bill so you can be reimbursed by NUBH. By signing this agreement I, completely understand that it is my responsibility to handle all insurance matters, including getting authorization and untimely payment by my insurance company (more than 4 weeks after date of service). I understand that NUBH will file each date of service one time and any rejection payment from insurance company will be taken care of by me.


I,understand that I am financially responsible for all charges not covered or denied by my insurance company. I, understand that if I should receive payment form the insurance company by mistake, which payment was /should be assigned to NUBH, I, will sign this payment over to NUBH and NUBH has the right to seek legal action to receive payment for this agreement, relative to payment fees, NUBH shall be entitled to reasonable attorney fees and cost of collection.


I,further understand that no records (written or verbal) will be released to me or on my behalf I have an outstanding balance due to NUBH.


Please provide us with your credit card information. The card will be billed if less than 24 hours notice is given:

Type of card we accept:(Visa, MC, AMEX, and Discover)



By signing below, I,am agreeing to the terms and conditions of this financial contract.


FINANCIAL AGREEMENT AND PROMISE TO PAY ACCOUNT

I have been furnished a copy of the NAK UNION, INC. Orientation Packet which explains the mission of NAK UNION, INC. and the services it offers.

I have been furnished a copy of NAK UNION, INC. ethical standards and understand that all reported violations of the ethical standards will be investigated.

I have been furnished a Notice of Privacy Practices.

I understand that, with special exceptions, information regarding my treatment is confidential and will be released to other parties only with my written consent. I have been furnished a summary of the rules and procedures Involving confidentiality.

I understand that I, and in some cases my family, will play an active role in setting my goals and planning my services. I understand that a person will be assigned to be responsible for the overall coordination of my services. I will be given the name of this person at the conclusion of the intake process. This person is referred to in the Orientation Packet as my "Service Coordinator".

I understand that I have specific rights as a consumer and that a procedure exists to process any complaints I may have. I have been furnished a list of my rights and the name of the persons I should contact if I have a complaint. I understand that, when necessary, behavior management procedures may be used to prevent injury to myself or others or the destruction of property. I understand I can review these procedures with the person responsible for the overall coordination of my services.

Any fees that I will incur from receiving services at NAK UNION, INC. and the payment expectations for these fees have been explained to me.

I understand that while I am receiving services, periodic confidential surveys may be conducted by mail, face-to-face, and/or by phone, inquiring as to my satisfaction with services. Also, I understand that after completing services, confidential follow-up may be conducted by mail and/or by phone. I understand that my records may be reviewed by representatives from licensing and accreditation agencies and organizations.

My signature below indicates I understand all of the points listed above and have been furnished a copy of all of the documents referenced.

Signature...

Consumer Rights
Consumer’s Copy
  • The right to agree to and approve of your treatment.
  • The right to be involved in planning your treatment.
  • The right to a written Individualized Service Plan (ISP) and be promptly and fully informed of any changes in the plan.
  • The right to have services provided in a way that fits your individual characteristics, needs, and abilities.
  • The right to review and obtain copies of your service record unless the physician or other determines it authorized staff not to be in your best interest.
  • The right to understand how to give permission to release or obtain information about your treatment, as well as how to revoke the permission.
  • The right to be free of physical abuse, sexual abuse, harassment or physical punishment.
  • The right to be treated with respect, dignity and kindness, free of mental abuse, such as humiliation, being threatened or taken advantage of.
  • The right to know funds are used for providing treatment instead of financial gain.
  • The rights to be informed of how to get other help you may need through referral to a) guardians or conservators, b) self-help groups, c) advocacy services, and d) legal services.
  • The right to be provided with information to help you make the best decisions.
  • The right to express who you want for a case manager, therapist, or other service provider.
  • The right to know how to use services when you are in a crisis.
  • The right to be free of any physical restraint or time-out procedure except for the purpose of providing
  • effective treatment and protecting your safety and other persons.

  • The right to have and retain personal property, which does not jeopardize your safety or the safety of
  • other consumers and have such property treated with respect.

  • The rights to written information that explains when the use of treatment interventions and restriction of rights would occur.
  • The right to know the limitations of confidentiality.
  • The right to privacy with respect to your past, present, and future mental health and medical information.
  • The right to receive treatment in the least restrictive environment available.
  • The right to refuse service, unless it is determined by a physician, licensed clinician or licensed psychologist that you are unable to care for self, is dangerous to yourself or others or is mandated by a court.
  • The right to receive clinically appropriate treatment even if it is determined you are unable to pay.
  • The right to be fully informed of the charges for treatment.
  • The right to obtain a copy of the program’s most recently completed report of licensing inspections forms.
  • The right to request clarification if you have any questions regarding these rights.
  • The right of referral to legal entities for appropriate representation, and to self-help and advocacy support services.
  • The right to exercise all civil, political, personal, privacy and property rights to which you are entitled to as a citizen.
  • The right to remain free of psychological abuse, including humiliating, threatening, and exploiting actions.
  • The right to file a complaint if you think any of these rights have been restricted or denied. Information on how to file a complaint or contact your Consumer's Rights Representatives is presented on a poster near the reception desk at every service site.

Call or Write to: 404-657-5557. Office of Regulatory Services, ORS, Complaint Intake Unit, 2 Peachtree Street, Atlanta,
GA 30303
404-657-7857. Division of MHDDAD, 2 Peachtree Street, Atlanta, GA 30303 I have reviewed these rights. I have received a copy of these rights and understand that a copy will be placed in my medical record.

Consumer Rights
  • The right to agree to and approve of your treatment.
  • The right to be involved in planning your treatment.
  • The right to a written Individualized Service Plan (ISP) and be promptly and fully informed of any changes in the plan.
  • The right to have services provided in a way that fits your individual characteristics, needs, and abilities.
  • The right to review and obtain copies of your service record unless the physician or other determines itauthorized staff not to be in your best interest.
  • The right to understand how to give permission to release or obtain information about your treatment, as well as how to revoke the permission.
  • The right to be free of physical abuse, sexual abuse, harassment or physical punishment.
  • The right to be treated with respect, dignity and kindness, free of mental abuse, such as humiliation, being threatened or taken advantage of.
  • The right to know funds are used for providing treatment instead of financial gain.
  • The rights to be informed of how to get other help you may need through referral to; a) guardians or conservators, b) self-help groups, c) advocacy services, and d) legal services.
  • The right to be provided with information to help you make the best decisions.
  • The right to express who you want for a case manager, therapist, or other service provider.
  • The right to know how to use services when you are in a crisis.
  • The right to be free of any physical restraint or time-out procedure except for the purpose of providing effective treatment and protecting your safety and other persons.
  • The right to have and retain personal property, which does not jeopardize your safety or the safety of other consumers and have such property treated with respect.
  • The rights to written information that explains when the use of treatment interventions and restriction of
    rights would occur.
  • The right to know the limitations of confidentiality.
  • The right to privacy with respect to your past, present, and future mental health and medical information.
  • The right to receive treatment in the least restrictive environment available.
  • The right to refuse service, unless it is determined by a physician, licensed clinician or licensed psychologist that you are unable to care for self, is dangerous to yourself or others or is mandated by a court.
  • The right to receive clinically appropriate treatment even if it is determined you are unable to pay.
  • The right to be fully informed of the charges for treatment.
  • The right to obtain a copy of the program’s most recently completed report of licensing inspections forms.
  • The right to request clarification if you have any questions regarding these rights.
  • The right of referral to legal entities for appropriate representation, and to self-help and advocacy support services.
  • The right to exercise all civil, political, personal, privacy and property rights to which you are entitled to as a citizen.
  • The right to remain free of psychological abuse, including humiliating, threatening, and exploiting actions.
  • The right to file a complaint if you think any of these rights have been restricted or denied. Information on how to file acomplaint or contact your Consumer's Rights Representatives is presented on a poster near the reception desk at every service site.

Call or Write to: 404-657-5557. Office of Regulatory Services, ORS, Complaint Intake Unit, 2 Peachtree Street, Atlanta, GA 30303 404-657-7857. Division of MHDDAD, 2 Peachtree Street, Atlanta, GA 30303

I have reviewed these rights. I have received a copy of these rights and understand that a copy will be placed in my medical record.

Signature...

NOTICE OF PRIVACY PRACTICES
(HIPAA)

Health Insurance Portability and Accountability Act of 1996
Consumer’s Copy

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

You are receiving this Notice from NAK UNION, INC. and certain affiliated health professionals and providers (collectively “Nak Union” providers). A federal regulation, known as the “HIPAA Privacy rule”, requires that certain health care providers deliver detailed notice in writing of their privacy practices. The “We” and “Our” refer to Nak Union Providers collectively, and the term “you” refer to you as a specific Nak Union, Inc. Client.

The services NAK UNION, INC. provides include certain aspects of basic health care, mental health counseling services, therapeutic residential care and treatment for chemical dependency care services. Nak Union, Inc. submits claims for these services electronically, making it a health plan covered by the HIPAA Privacy Rule. In addition to the licensed health professionals whom it employs, NAK UNION, INC. contracts with psychiatrists and social workers whom provide individual and group services at their private offices. NAK UNION, INC. also maintains affiliations with pharmacies to provide access to prescription drug and supplies. These relationships are integral part of the services NAK UNION, INC. provides and are considered an Organized Health Care Arrangement as defined by the HIPAA Privacy Rule.

I. CONFIDENTIALITY OF ALCOHOL AND DRUG ABUSE PATIENT RECORDS

Federal law and regulations protect the confidentiality of alcohol and drug abuse patient records maintained by this program. Generally, the program may not say to a person outside the program that a patient attends the program, or disclose any information identifying a patient as an alcohol or drug abuser, unless:

  • The patient consents in writing
  • The disclosure is allowed by a court order or
  • The disclosure is made to medical personnel in a medical emergency, or to qualified personnel for research, audit, or program evaluation.

Violation of the Federal Law and regulations by a program is a crime. Suspected violations may be reported to appropriate authorities in accordance with Federal regulations.

Federal law and regulations do not protect any information about a crime committed by a patient, either at the program or against any person who works for the program. Threats to commit a crime also are not protected.

II. OUR COMMITMENT TO PROTECTING HEALTH INFORMATION ABOUT YOU

The HIPAA Privacy Rule requires that we protect the privacy of health information that identifies a participant, or where there is a reasonable basis to believe the information can be used to identify a participant. The information is called “protected health information” or “PHI”. This Notice describes your rights as a health plan participant and our obligations regarding the use and disclosure of PHI. We are required by law to:

  • Maintain the privacy of PHI about you;
  • Give you this Notice of our legal duties and privacy practices with respect to PHI;
  • Comply with the terms of our Notice of Privacy Practices that is currently in effect.

POLICY: The filing is the protocol to ensure adherence to the standards set forth in the Notice of Privacy practices. This notice relates only to health information. Nak Union, Inc. in complies with applicable federal and state laws including HIPPA Privacy rules to secure confidential information.

PURPOSE: According to Federal laws and current consumer covenants, Nak Union, Inc. will collect, use and disclose protected health information only in conformance with Georgia, and/or authorizations, as appropriate.

PROCEDURE

  • Notice of Privacy Practices will be posted in each facility. (The consumer will be given an opportunity to receive a written copy.) In keeping with the Notice of Privacy, Nak Union, Inc. will:
  • Not use or disclose protected health information for uses outside of the practices treatment, payment or operations without a written authorization from the consumer (or his or her authorized representative).
  • Implement reasonable measures to protect the integrity of all protected health information maintained about consumers including, but not limited to:
    • Education of staff
    • Disciplinary action for violations
    • Confidentiality agreements
    • Procedures for complaints and appeals

Treat all protected health information data as confidential in accordance with professional ethics, accreditation standards, and legal requirements.

Each consumer will acknowledge his or her right to review or receive a copy of the Notice of Privacy Practices.

Each consumer has the right to request limitations and/ or restrictions of disclosures.(These requests must be in writing)

A signed Release of Information for will be obtained when protected health information is disclosed to third parties. Certain non-treatment, payment, and operational disclosures do not require and authorization, however; a log will be maintained of these disclosures.

Each consumer has the right to request an inspection of his/her protected health information. Nak Union, Inc. will act on this request within thirty (30) days.) The consumer may request correction/amendments of his/her protected information.

  • Request must be made in writing
  • Nak Union, Inc. may or may not be required to honor these requests.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint on us. You may file a complaint directly with the Secretary of the United Stated Department of Health and Human Services. We will not retaliate or take action against you for filing a complaint.

Note: Our practice may change this notice in the future. Any changes will be effective upon the release of a revised policy and will be made available to consumers upon request. All previous copies of this policy and the Notice of Privacy Practices will be retained for six (6) years,

The HIPPA Policy is provided to each consumer upon the intake process.

NOTICE OF PRIVACY PRACTICES
(HIPAA)

Health Insurance Portability and Accountability Act of 1996

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

You are receiving this Notice from NAK UNION, INC. and certain affiliated health professionals and providers (collectively “Nak Union” providers). A federal regulation, known as the “HIPAA Privacy rule”, requires that certain health care providers deliver detailed notice in writing of their privacy practices. The “We” and “Our” refer to Nak Union Providers collectively, and the term “you” refer to you as a specific Nak Union, Inc. Client.

The services NAK UNION, INC. provides include certain aspects of basic health care, mental health counseling services, therapeutic residential care and treatment for chemical dependency care services. Nak Union, Inc. submits claims for these services electronically, making it a health plan covered by the HIPAA Privacy Rule. In addition to the licensed health professionals whom it employs, NAK UNION, INC. contracts with psychiatrists and social workers whom provide individual and group services at their private offices. NAK UNION, INC. also maintains affiliations with pharmacies to provide access to prescription drug and supplies. These relationships are integral part of the services NAK UNION, INC. provides and are considered an Organized Health Care Arrangement as defined by the HIPAA Privacy Rule.

CONFIDENTIALITY OF ALCOHOL AND DRUG ABUSE PATIENT RECORDS

Federal law and regulations protect the confidentiality of alcohol and drug abuse patient records maintained by this program. Generally, the program may not say to a person outside the program that a patient attends the program, or disclose any information identifying a patient as an alcohol or drug abuser, unless:

  • The patient consents in writing
  • The disclosure is allowed by a court order or
  • The disclosure is made to medical personnel in a medical emergency, or to qualified personnel for research, audit, or program evaluation.

Violation of the Federal Law and regulations by a program is a crime. Suspected violations may be reported to appropriate authorities in accordance with Federal regulations.

Federal law and regulations do not protect any information about a crime committed by a patient, either at the program or against any person who works for the program. Threats to commit a crime also are not protected.

OUR COMMITMENT TO PROTECTING HEALTH INFORMATION ABOUT YOU

The HIPAA Privacy Rule requires that we protect the privacy of health information that identifies a participant, or where there is a reasonable basis to believe the information can be used to identify a participant. The information is called “protected health information” or “PHI”. This Notice describes your rights as a health plan participant and our obligations regarding the use and disclosure of PHI. We are required by law to:

  • Maintain the privacy of PHI about you;
  • Give you this Notice of our legal duties and privacy practices with respect to PHI;
  • Comply with the terms of our Notice of Privacy Practices that is currently in effect.

POLICY:The filing is the protocol to ensure adherence to the standards set forth in the Notice of Privacy practices. This notice relates only to health information. Nak Union, Inc. complies with applicable federal and state laws including HIPPA Privacy rules to secure confidential information.

PURPOSE:To ensure that Nak Union, Inc. will collect, use and disclose protected health information only in conformance with Georgia, federal laws, and current consumer covenants and/or authorizations, as appropriate.

PROCEDURE:

  • Notice of Privacy Practices will be posted in each facility. (The consumer will be given an opportunity to receive a written copy.) In keeping with the Notice of Privacy, Nak Union, Inc. will:
  • Not use or disclose protected health information for uses outside of the practices treatment, payment or operations without a written authorization from the consumer (or his or her authorized representative).
  • Implement reasonable measures to protect the integrity of all protected health information maintained about consumers including, but not limited to:
    • Education of staff
    • Disciplinary action for violations
    • Confidentiality agreements
    • Procedures for complaints and appeals

Treat all protected health information data as confidential in accordance with professional ethics, accreditation standards, and legal requirements.

Each consumer will acknowledge his or her right to review or receive a copy of the Notice of Privacy Practices.

Each consumer has the right to request limitations and/ or restrictions of disclosures.(These requests must be in writing)

A signed Release of Information for will be obtained when protected health information is disclosed to third parties. Certain non-treatment, payment, and operational disclosures do not require and authorization, however; a log will be maintained of these disclosures.

Each consumer has the right to request an inspection of his/her protected health information. Nak Union, Inc. will act on this request within thirty (30) days.) The consumer may request correction/amendments of his/her protected information.

  • Request must be made in writing
  • Nak Union, Inc. may or may not be required to honor these requests.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint on us. You may file a complaint directly with the Secretary of the United Stated Department of Health and Human Services. We will not retaliate or take action against you for filing a complaint.

Note: Our practice may change this notice in the future. Any changes will be effective upon the release of a revised policy and will be made available to consumers upon request. All previous copies of this policy and the Notice of Privacy Practices will be retained for six (6) years,

The HIPPA Policy is provided to each consumer upon the intake process.

Notice of Privacy Practices
(HIPAA)

Receipt and Acknowledgment of Notice

I hereby acknowledge that I have received and have been given an opportunity to read a copy of Nak Union, Inc. Notice of Privacy Practices. I understand that if I have any questions regarding the Notice of Privacy Practices; I can contact Nak Union, Inc. at 678-466-6458.

Signature of Client

Consumer Grievances Complaint Process
Consumer’s Copy

POLICY:It is the policy of Nak Union, Inc. to provide an immediate and fair method of resolving consumer grievance complaints. Nak Union, Inc. will not tolerate nay retaliation or barriers to services as a result of a consumer’s filing a complaint/grievance. The grievance policy for consumers is designed to facilitate effective service delivery.

PURPOSE:It is the policy of Nak Union, Inc. that all services provided to consumers will be carried out in an environment that is supportive, confidential, and respect for of the individual. Nak Union, Inc. will be accessible and will maximize the individual’s ability to make informed choices in relation to their lives.

PROCEDURES
Step 1

If any person believes that a member of Nak Union, Inc.’s staff as violating any one or more of the Consumer Rights misinterpreted or misapply the terms of the service agreement, he/she may bring forward the grievance to the Quality Assurance Officer.

Terms and Conditions:

Terms: The terms contained herein shall be defined as follows:

Grievance: A complaint by one or more consumers of an alleged violation, this interpretation or misapplication of the terms of the service agreement with Nak Union’s Program, and its consumers.

Representative: Person(s) of the consumer’s choice to represent them.

Quality Assurance Officer: The Team Leader of Nak Union, Inc.

Grievant: An employee or consumer of Nak Union, Inc.

Conditions:

If a grievance not filed within twenty (20) working days of the date the Grievant knew or should have known of the occurrence-giving rise to the grievance, it shall no longer exist.

Nothing contained herein shall interfere with the rights to meet voluntary with the Quality Assurance Officer.

The Nak Union, Inc. Quality Assurance Officer shall be available to assist the complainant in the filing of the grievance.

  • The parties may, upon mutual agreement in writing, extend time limits of the grievance procedure.
  • Nak Union, Inc. staff member who is being grieved against shall not be involved in assisting the complainant to complete the grievance, shall not be involved in the investigation of the process, and shall not be involved in the resolution of the grievance.
  • In the event that a grievance directed at the Nak Union, Inc. Quality Assurance Officer, the Chief Executive Officer shall assume the responsibility to investigate the allegation.

Step 2
Information Level

The person who believes he/she has valid basis for consumer inquiry or grievance may discuss the matter informally and on a verbal basis with Nak Union, Inc. Quality Assurance Officer, who shall in turn, investigate the complaint and rely with an answer to the complainant within seven (7) working days.

Step 3
Formal Level

If a consumer is not satisfied with the discussion and /or resolution at the formal level, the consumer may request in writing, a review of the complaint/grievance with Nak Union’s Chief Executive Officer. This must be filed within fifteen (15) working days after receiving the disposition notice.

The consumer may discuss the complaint directly with the CEO/ or designee. This review will be completed within ten (10) working days from the date of the request. The consumer will be informed of the outcome.

Step 4
Appeal Level

If the consumer is not satisfied with the resolution at the previous level, he/she may appeal the decision to the State of Georgia Department of Human Resources in accordance with their policy and procedures.

Note: Time limits designated in this process may be extended by the decision maker at each step for good cause only.

The consumer has the right to file a complaint with:

Department of Human Resources
Division of MH/DD/AD
Personal Advocacy Unit
Peachtree Street, N.W.
Atlanta, Georgia 30303-3171

Nak Union, Inc.
Nak Union Behavioral Health
5530 Old National Hwy Bldg. C, Suite B
College Park, GA 30349

Consumer Grievances Complaint Process

POLICY: It is the policy of Nak Union, Inc. to provide an immediate and fair method of resolving consumer grievance complaints. Nak Union, Inc. will not tolerate nay retaliation or barriers to services as a result of a consumer’s filing a complaint/grievance. The grievance policy for consumers is designed to facilitate effective service delivery.

PURPOSE: It is the policy of Nak Union, Inc. that all services provided to consumers will be carried out in an environment that is supportive, confidential, and respect for of the individual. Nak Union, Inc. will be accessible and will maximize the individual’s ability to make informed choices in relation to their lives.

PROCEDURES:Step 1

If any person believes that a member of Nak Union, Inc.’s staff as violating any one or more of the Consumer Rights misinterpreted or misapply the terms of the service agreement, he/she may bring forward the grievance to the Quality Assurance Officer.

Terms and Conditions:

Terms: The terms contained herein shall be defined as follows:

Grievance: A complaint by one or more consumers of an alleged violation, this interpretation or misapplication of the terms of the service agreement between Nak Unions’ Program and its consumers.

Representative: Someone of the consumer’s choice to represent them.

Quality Assurance Officer: The Team Leader of Nak Union, Inc.

Grievant: An employee or consumer of Nak Union, Inc.


Conditions:

If a grievance not filed within twenty (20) working days of the date the Grievant knew or should have known of the occurrence-giving rise to the grievance, it shall no longer exist.

Nothing contained herein shall interfere with the rights to meet voluntary with the Quality Assurance Officer.

The Nak Union, Inc. Quality Assurance Officer shall be available to assist the complainant in the filing of the grievance.

  • The parties may, upon mutual agreement in writing, extend time limits of the grievance procedure.
  • Nak Union, Inc. staff member who is being grieved against shall not be involved in assisting the complainant to complete the grievance, shall not be involved in the investigation of the process, and shall not be involved in the resolution of the grievance.
  • In the event that a grievance directed at the Nak Union, Inc. Quality Assurance Officer, the Chief Executive Officer shall assume the responsibility to investigate the allegation.

Step 2
Information Level

The person who believes he/she has valid basis for consumer inquiry or grievance may discuss the matter informally and on a verbal basis with Nak Union, Inc. Quality Assurance Officer, who shall in turn, investigate the complaint and rely with an answer to the complainant within seven (7) working days.

Step 3
Formal Level

If a consumer is not satisfied with the discussion and /or resolution at the formal level, the consumer may request in writing, a review of the complaint/grievance with Nak Union’s Chief Executive Officer. This must be filed within fifteen (15) working days after receiving the disposition notice.

The consumer may discuss the complaint directly with the CEO/ or designee. This review will be completed within ten (10) working days from the date of the request. The consumer will be informed of the outcome.

Step 4
Appeal Level

If the consumer is not satisfied with the resolution at the previous level, he/she may appeal the decision to the State of Georgia Department of Human Resources in accordance with their policy and procedures.

Note: Time limits designated in this process may be extended by the decision maker at each step for good cause only.

The consumer has the right to file a complaint with:
Department of Human Resources
Division of MH/DD/AD
Personal Advocacy Unit
Peachtree Street, N.W.
Atlanta, Georgia 30303-3171

Nak Union, Inc. DBA Nak Union Behavioral Health
5530 Old National Hwy Bldg. C, Suite B
College Park, GA 30349

Grievances/Complaint Policy
Receipt and Acknowledgment

I hereby acknowledge that I have received and have been given an opportunity to read a copy of Nak Union, Inc. Grievances/Complaint Policy form. I understand that if I have any questions regarding the Grievances/Complaint Policy form, I can contact Nak Union, Inc. 678-466-6458.

Signature of Client

If you are signing as a personal representative of an individual, please describe your legal authority to act for this individual (power of attorney, healthcare surrogate, etc.).