Meetings. I normally conduct an evaluation that will last from 1-2 sessions. During this time, we both decide if I am the best person to provide the services you need in order to meet your treatment goals. If therapy has begun, I will usually schedule one 45-minute ses- sion per week at a time we agree on, although some sessions may be longer or more frequent. Once an appointment hour is scheduled, you will be expected to pay for it un- less you provide 24-hours advanced notice of cancellation. It is important to note that insurance companies do not provide reimbursement for cancelled sessions. Professional Fees My hourly fee varies depending on services and duration. In addition to weekly ap- pointments, I charge this amount for other professional services you may need. How- ever, I will break down the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services include report writing, telephone conversations lasting longer than 10-minutes, Skype appoint- ments or check-ins, consulting with other professionals with your permission, prepar- ing of records or treatment summaries, and the time spent performing any other ser- vices you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Be- cause of the difficulty of legal involvement, I charge $500 per hour for preparation and attendance at any legal proceedings. Contacting Me Due to my work schedule, I am often not immediately available by telephone. While I am usually in my office four days a week, I probably will not answer the phone when I am with a client. I will make every effort to return your call by the end of my business day, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. If you are unable to reach me and you feel that you can’t wait for me to return your call, contact your family physician, the nearest emergency room and ask for the psychologist or psychiatrist on call, or call 911. If I will be unavailable for an extended time, I will provide you with the name of a colleague contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality The law protects the privacy of all communications between a client and a therapist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, ad- xxxxx consent. Your signature on this Agreement provides consent for those activities, as follows: I may occasionally find it helpful to consult other health and mental health profes- sionals about a case. During consultation, I make every effort to avoid revealing the identity of my client. The other professionals are also legally bound to keep informa- tion confidential. If you don’t object, I will not tell you about these consultations un- less I feel that it is important to our work together. I will note all consultations in your Clinical Record. Disclosures required by health insurers or to collect overdue fees are discussed else- where in this Agreement. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the social worker-client privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client in order to defend myself. If a client files a worker’s compensation claim, I must, upon appropriate request, pro- vide a copy of the client’s record to the Labor and Industrial Commission or the Work- ers’ Compensation Division, or the client’s employer. There are some situations in which I am legally obligated to take actions, which I be- lieve are necessary to attempt to protect others from harm and I may have to reveal some information about a client’s treatment. These situations are unusual in my practice. If I have reasonable cause to suspect that a child has been or may be subjected to abuse or neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglect, the law requires that I file a report with Tennessee’s Department of Children’s Services. Once such a report is filed, I may be required to provide additional information. If I have reasonable cause to suspect that an elderly or disabled adult presents a like- lihood of suffering serious physical harm and is in need of protective services, the law requires that I file a report with Adult Protective Services. Once such a report is filed, I may be required to provide additional information. If I believe that it is necessary to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by the client on him/her- self or another person, I may be required to take protective action. These actions may include, and/or initiating hospitalization and/or contacting the potential victim, and/or the police and/or the client’s family. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure is reasonably likely to endanger you and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harm, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of 35 cents per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Records, you have a right of review, which I will discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents of our conversations, my analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentially.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include:
Appears in 3 contracts
Samples: Services Agreement, Services Agreement, Services Agreement
Meetings. I normally conduct an evaluation that will last from 1-2 sessions. During this time, we both decide if I am the best person to provide the services you need in order to meet your treatment goals. If therapy has begun, I will usually schedule one 45-minute ses- sion per week at a time we agree on, although some sessions may be longer or more frequent. Once When an appointment hour time is scheduled, you will be expected to pay for it un- less unless you provide 24-at least 48 hours advanced advance notice of cancellation. It is important to note that insurance companies do not provide reimbursement for cancelled sessions. Professional Fees My hourly fee varies depending on services and durationPROFESSIONAL FEES AND PAYMENT Our therapists set their own fees. In addition Please discuss this during your visit. If you want to weekly ap- pointmentsset up a payment plan, I charge you may also discuss this amount during your visit. You will be expected to pay for each session at the time it is held, unless another schedule is agreed upon or unless you have insurance coverage. If we file your insurance, you are expected to make your co-pay at each visit. Payment schedules for other professional services you may need. How- ever, I will break down the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services include (such as report writing, extended telephone conversations lasting longer than 10-minutes, Skype appoint- ments or check-insconversations, consulting with other professionals with your permission, prepar- ing preparation of records or treatment summaries, or legal testimony) will be agreed to when they are requested. We accept cash and personal checks. There will be a $20 service charge for returned checks. If your account has not been paid for more than 60 days and you have not made arrangements for payment, we have the option of using legal means to secure the payment. This may include collection agency or small claims court which will require disclosing otherwise confidential information. In most collection situations, the only information released regarding a client's treatment is his/her name, the nature of services provided, and the time spent performing any other ser- vices amount due. [If such legal action is necessary, its costs will be included in the claim.] INSURANCE REIMBURSEMENT In order for you may request of meto set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you become involved have a health insurance policy, it will usually provide some coverage for mental health treatment. Your therapist will fill out required forms and provide you with assistance in legal proceedings receiving the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of your xxxx. It is very important that require my participationyou find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Our office will provide you with any information we have based on our experience and will be happy to help you in understanding the information you receive from your insurance company. If your failure to comply with your insurance company's requirements regarding choice of therapists, authorizations, or other issues results in the denial of claims, you will be expected responsible for paying in full. If your coverage changes, it is your responsibility to notify the therapist and to comply with your new policy. You should also be aware that your contract with your health insurance company requires that we provide a clinical diagnosis and information about the services provided to you. Sometimes your therapist must provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, every effort will be made to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, we have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. You will be provided with a copy of any report submitted if you request it. By signing the appropriate section of this Agreement, you agree to the provision of requested information to your carrier. If you need to file your own insurance, you may use your billing invoice. Please remember to include your policy information. Once we have all of the information about your insurance coverage, your therapist will discuss what you can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your sessions. It is important to remember that you always have the right to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Be- cause of the difficulty of legal involvement, I charge $500 per hour for preparation and attendance at any legal proceedings. Contacting Me Due to my work schedule, I am often not immediately available by telephone. While I am usually in my office four days a week, I probably will not answer the phone when I am with a client. I will make every effort to return your call by the end of my business day, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. If you are unable to reach me and you feel that you can’t wait for me to return your call, contact your family physician, the nearest emergency room and ask for the psychologist or psychiatrist on call, or call 911. If I will be unavailable for an extended time, I will provide you with the name of a colleague contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality The law protects the privacy of all communications between a client and a therapist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, ad- xxxxx consent. Your signature on this Agreement provides consent for those activities, as follows: I may occasionally find it helpful to consult other health and mental health profes- sionals about a case. During consultation, I make every effort services yourself to avoid revealing the identity of my client. The other professionals are also legally bound to keep informa- tion confidential. If you don’t object, I will not tell you about these consultations un- less I feel that it is important to our work together. I will note all consultations in your Clinical Record. Disclosures required by health insurers or to collect overdue fees are discussed else- where in this Agreement. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the social worker-client privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client in order to defend myself. If a client files a worker’s compensation claim, I must, upon appropriate request, pro- vide a copy of the client’s record to the Labor and Industrial Commission or the Work- ers’ Compensation Division, or the client’s employer. There are some situations in which I am legally obligated to take actions, which I be- lieve are necessary to attempt to protect others from harm and I may have to reveal some information about a client’s treatment. These situations are unusual in my practice. If I have reasonable cause to suspect that a child has been or may be subjected to abuse or neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglect, the law requires that I file a report with Tennessee’s Department of Children’s Services. Once such a report is filed, I may be required to provide additional information. If I have reasonable cause to suspect that an elderly or disabled adult presents a like- lihood of suffering serious physical harm and is in need of protective services, the law requires that I file a report with Adult Protective Services. Once such a report is filed, I may be required to provide additional information. If I believe that it is necessary to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by the client on him/her- self or another person, I may be required to take protective action. These actions may include, and/or initiating hospitalization and/or contacting the potential victim, and/or the police and/or the client’s family. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what problems described above [unless this is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure is reasonably likely to endanger you and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harm, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of 35 cents per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Records, you have a right of review, which I will discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents of our conversations, my analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentiallyprohibited by contract].] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include:
Appears in 2 contracts
Samples: Therapist Client Services Agreement, www.charlieschaefer.com
Meetings. I normally conduct an evaluation that will last from 1-2 to 4 sessions. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If therapy has psychotherapy is begun, I will usually schedule one 45-45 or 60 minute ses- sion session (one appointment hour of 45 or 60 minutes duration) per week at a time we agree on, although some sessions may be longer or more frequent. Once an appointment hour is scheduled, you will be expected to pay for it un- less $100 unless you provide 24-24 hours advanced advance notice of cancellationcancellation [unless we both agree that you were unable to attend due to circumstances beyond your control]. It is important to note that insurance companies do not provide reimbursement for cancelled sessions. Professional Fees I will try to find another time to reschedule the appointment. PROFESSIONAL FEES My hourly fee varies depending on services is $250 for an initial session and duration$200 for subsequent sessions. In addition to weekly ap- pointmentsappointments, I charge this amount for other professional services you may need. How- ever, I will break down the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services include report writing, telephone conversations lasting longer than 10-10 minutes, Skype appoint- ments or check-ins, consulting with other professionals with your permission, prepar- ing preparation of records or treatment summaries, and the time spent performing any other ser- vices service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Be- cause Because of the difficulty of legal involvement, I charge $500 250 per hour for preparation and attendance at any legal proceedingsproceeding. Contacting Me CONTACTING ME (000) 000-0000 Due to my work schedule, I am often not immediately available by telephone. While I am usually in my office four days a weekbetween 9 AM and 7 PM, I probably will not answer the phone when I am with a clientpatient. When I am unavailable, my telephone is answered by voice mail that I monitor frequently, or by my secretary who knows where to reach me. I will make every effort to return your call by the end of my business daywithin 24 hours, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. If In emergencies, if you are unable to reach me and you feel that you can’t wait for me to return your call, contact your family physician, the nearest emergency room and ask for the psychologist or psychiatrist on callroom, or call 911. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client patient and a therapistpsychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form form that meets certain legal requirements imposed by HIPAAHIPAA and/or Illinois law. There are other situations that require only that you provide writtenHowever, ad- xxxxx consent. Your signature on this Agreement provides consent for those activitiesin the following situations, as followsno authori- zation is required: • I may occasionally find it helpful to consult other health and mental health profes- sionals professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my clientpatient. The other professionals are also legally bound to keep informa- tion the information confidential. If you don’t object, I will not tell you about these consultations un- less unless I feel that it is important to our work together. I will note all consultations in your Clinical Record. • You should be aware that I practice with other mental health professionals and that I employ administrative staff. In most cases, I need to share protected information with these individuals for both clinical and administrative purposes, such as scheduling, billing and quality assurance. All of the mental health professionals are bound by the same rules of confidentiality. All staff members have been given training about protecting your privacy and have agreed not to release any information outside of the practice without the permission of a professional staff member. • Disclosures required by health insurers or to collect overdue fees are discussed else- where elsewhere in this Agreement. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: • If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the social workerpsychologist-client patient privilege law. .I cannot provide disclose any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. • If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. • If a client patient files a complaint or lawsuit against me, I may disclose relevant information regarding that client patient in order to defend myself. • If a client files you file a worker’s compensation claim, and I rendering treatment or services in accordance with the provisions of Illinois Workers’ Compensation law, I must, upon appropriate request, pro- vide provide a copy of the client’s your record to the Labor and Industrial Commission your employer or the Work- ers’ Compensation Division, or the client’s employerhis/her appropriate designee. There are some situations in which I am legally obligated to take actions, which I be- lieve believe are necessary to attempt to protect others from harm and I may have to reveal some information about a clientpatient’s treatment. These situations are unusual in my practice. • If I have reasonable cause to suspect believe that a child has been or under 18 known to me in my professional capacity may be subjected to abuse an abused child or neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglectneglected child, the law requires that I file a report with Tennessee’s the local office of the Department of Children’s Children and Family Services. Once such a report is filed, I may be required to provide additional information. • If I have reasonable cause reason to suspect believe that an elderly adult over the age of 60 living in a domestic situation has been abused or disabled adult presents a like- lihood of suffering serious physical harm and is neglected in need of protective servicesthe preceding 12 months, the law requires that I file a report with Adult Protective Servicesthe agency designated to receive such reports by the Department of Aging. Once such a report is filed, I may be required to provide additional information. • If you have made a specific threat of violence against another or if I believe that you present a clear, imminent risk of serious physical harm to another, I may be required disclose information in order to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking your hospitalization. • If I believe that it is necessary to disclose information to protect against you present a clear and substantial clear, imminent risk of imminent serious harm being inflicted by the client on him/her- self physical or another personmental injury or death to yourself, I may be required to disclose information in order to take protective actionactions. These actions may include, and/or initiating include seeking your hospitalization and/or or contacting the potential victim, and/or the police and/or the client’s familyfamily members or others who can assist in protecting you. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records You should The laws governing confidentiality can be aware thatquite complex, pursuant to HIPAAand I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. PROFESSIONAL RECORDS The laws and standards of my profession require that I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure is reasonably likely to endanger you and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harm, you You may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a The fee for copying fee of 35 cents per page (and for certain other expenses)records is $50.00. The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Records, you have a right of review, which I will discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents of our conversations, my analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentially.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights PATIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include:include requesting that I amend your record; requesting restrictions on what information from your Clinical Records is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the Illinois Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights with you. MINORS & PARENTS Patients under 12 years of age and their parents should be aware that the law allows parents to examine their child’s treatment records. Parents of children between 12 and 18 cannot examine their child’s records unless the child consents and unless I find that there are no compelling reasons for denying the access. Parents are entitled to information concerning their child’s current physical and mental condition, diagnosis, treatment needs, services provided, and services needed. Since parental involvement is often crucial to successful treatment, in most cases, I require that patients between 12 and 18 years of age and their parents enter into an agreement that allows parents access to certain additional treatment information. If everyone agrees, during treatment, I will provide parents with general information about the progress of their child’s treatment, and his/her attendance at scheduled sessions. I will also provide parents with a summary of treatment when it is complete. Any other communication will require the child’s Authorization, unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have. BILLING AND PAYMENTS You will be expected to pay for each session at the time it is held. This includes your portion of your insurance coverage i.e. deductible not yet met, copayment, and co-insurance amounts. Payment schedules for other professional services will be agreed to when they are requested. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, we will be unable to schedule any more appointments until a payment is made. In addition to that, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require me to disclose otherwise confidential information. In most collection situations, the only information I release regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due. If such legal action is necessary, its costs will be included in the claim. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, I will provide you with what- ever information I can based on my experience and will be happy to help you in understanding the informa- tion you receive from your insurance company. If it is necessary to clear confusion, I will be willing to call the company on your behalf. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is some- times difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific prob- lems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in short-term therapy, some pa- tients feel that they need more services after insurance benefits end. Some managed-care plans will not allow me to provide services to you once your benefits end. If this is the case, I will do my best to find another provider who will help you continue your psychotherapy. You should also be aware that your contract with your health insurance company requires that you authorize me to provide it with information relevant to the services that I provide to you. If you are seeking reimbursement for services under your health insurance policy, you will be required to sign an authorization form that allows me to provide such information. I am required to provide a clinical diagnosis. Sometimes I am required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it.
Appears in 2 contracts
Samples: Psychologist Patient Services Agreement, Psychologist Patient Services Agreement
Meetings. I normally conduct an evaluation that Our first session will last from 1-2 sessionsabout 45 minutes. During this time, we can both decide if I am the best person to provide the psychiatric services you need in order to meet your treatment goals. If therapy has begunwe continue meeting, I will usually normally schedule one 4515-30 minute ses- sion per week session at intervals, which can be as short as one or two weeks or as long as two or three months, depending on how you are feeling and any changes in your medication. Between sessions you are always free to call me if you are having a time we agree on, although some sessions may be longer side effect or more frequentanything concerns you. Once an appointment hour time is scheduled, you will be expected to pay for it un- less unless you provide 24-24 hours advanced advance notice of cancellationcancellation (unless we both agree that you were unable to attend due to circumstances beyond your control.) If you do not cancel 24 hours in advance, you will be billed $35.00, one-half of the medication management appointment fee. It is important to note that insurance companies do not provide reimbursement for cancelled sessions. Professional Fees My hourly fee varies depending on services and duration. In addition to weekly ap- pointments, I charge this amount for other professional services you may need. How- ever(If it is possible, I will break down try to find another time to reschedule the hourly cost if I work appointment.) Please be aware that our practice does not make reminder calls, it is the patient’s responsibility to remember their scheduled appointment. PROFESSIONAL FEES My fee for periods of less than one hour. Note that these additional services the initial interview is $200.00, on-going medication management fees are not covered by insurance. Other services include report writing, telephone conversations lasting longer than 10-minutes, Skype appoint- ments or check-ins, consulting with other professionals with your permission, prepar- ing of records or treatment summaries, and the time spent performing any other ser- vices you may request of me$70.00 per session. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Be- cause (Because of the difficulty of legal involvement, involvement I charge $500 250.00 per hour for preparation and attendance at any legal proceedings. Contacting Me proceeding.) CONTACTING ME Due to my work schedule, I am often not immediately available by telephone. While When I am usually in unavailable, my office four days a weektelephone is answered by an answering service (machine, voice mail, or by my secretary that I probably will not answer the phone when I am with a clientmonitor frequently, or who knows where to reach me). I will make every effort to return your call by on the end of my business day, with the exception of weekends and holidayssame day you make it. If you are difficult to reach, please inform me of some times when you will be available. If you are unable to reach me and you feel that you can’t wait for me to return your call, contact your family physician, go to the nearest emergency room and ask for the psychologist or psychiatrist on call, or call 911room. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality The law protects the privacy of all communications between a client and a therapist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, ad- xxxxx consent. Your signature on this Agreement provides consent for those activities, as follows: I may occasionally find it helpful to consult other health and mental health profes- sionals about a case. During consultation, I make every effort to avoid revealing the identity of my client. The other professionals are also legally bound to keep informa- tion confidential. If you don’t object, I will not tell you about these consultations un- less I feel that it is important to our work together. I will note all consultations in your Clinical Record. Disclosures required by health insurers or to collect overdue fees are discussed else- where in this Agreement. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the social worker-client privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client in order to defend myself. If a client files a worker’s compensation claim, I must, upon appropriate request, pro- vide a copy of the client’s record to the Labor and Industrial Commission or the Work- ers’ Compensation Division, or the client’s employer. There are some situations in which I am legally obligated to take actions, which I be- lieve are necessary to attempt to protect others from harm and I may have to reveal some information about a client’s treatment. These situations are unusual in my practice. If I have reasonable cause to suspect that a child has been or may be subjected to abuse or neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglect, the law requires that I file a report with Tennessee’s Department of Children’s Services. Once such a report is filed, I may be required to provide additional information. If I have reasonable cause to suspect that an elderly or disabled adult presents a like- lihood of suffering serious physical harm and is in need of protective services, the law requires that I file a report with Adult Protective Services. Once such a report is filed, I may be required to provide additional information. If I believe that it is necessary to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by the client on him/her- self or another person, I may be required to take protective action. These actions may include, and/or initiating hospitalization and/or contacting the potential victim, and/or the police and/or the client’s family. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure is reasonably likely to endanger you and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harm, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of 35 cents per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Records, you have a right of review, which I will discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents of our conversations, my analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentially.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include:
Appears in 2 contracts
Samples: Psychiatrist – Patient Services Agreement, Psychiatrist – Patient Services Agreement
Meetings. I normally conduct an evaluation that will last from 1-2 to 4 sessions. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If therapy has begunpsychotherapy is started, I will usually schedule one 45-minute ses- sion session (one appointment hour of 45 minutes duration) per week at a time we agree on, although some sessions may be longer or more frequent. Once an appointment hour is scheduled, you will be expected to pay for it un- less unless you provide 24-hours advanced advance notice of cancellationcancellation the day before the appointment [unless we both agree that you were unable to attend due to circumstances beyond your control]. It is important to note that insurance companies do not provide reimbursement for cancelled sessions. Professional Fees PROFESSIONAL FEES My hourly fee varies depending on services fees are as follows: Initial Appointment $170, Individual Psychotherapy $140, Couples and durationFamily Therapy $145. In addition to weekly ap- pointmentsappointments, I charge this amount $170 for other professional services you may need. How- ever, though I will break down the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services include report writing, telephone conversations lasting longer than 10-10 minutes, Skype appoint- ments or check-ins, consulting with other professionals with your permission, prepar- ing preparation of records or treatment summaries, and the time spent performing any other ser- vices service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Be- cause Because of the difficulty of legal involvement, I charge $500 250 per hour for preparation and attendance at any legal proceedingsproceeding. Contacting Me CONTACTING ME Due to my work schedule, I am often not immediately available by telephone. While I am usually in my office four days a weekbetween 10 AM and 7 PM, I probably will not answer the phone when I am with a clientpatient. When I am unavailable, my telephone is answered by voice mail that I monitor frequently. I will make every effort to return your call by on the end of my business daysame day you make it, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. In emergencies, you can try me at 410-707- 2262. If you are unable to reach me and you feel that you can’t wait for me to return your call, contact your family physician, physician or the nearest emergency room and ask for the psychologist or psychiatrist on call, or call 911. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client patient and a therapistpsychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form form that meets certain legal requirements imposed by HIPAAHIPAA and/or Maryland law. There are other situations that require only that you provide writtenHowever, ad- xxxxx consent. Your signature on this Agreement provides consent for those activitiesin the following situations, as followsno authorization is required: • I may occasionally find it helpful to consult other health and mental health profes- sionals professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my clientpatient. The other professionals are also legally bound to keep informa- tion the information confidential. If you don’t object, I will not tell you about these consultations un- less unless I feel that it is important to our work together. I will note all consultations in your Clinical RecordRecord (which is called “PHI” in my Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information). • I also have a contract with Psychiatric Billing Services. As required by HIPAA, I have a formal business associate contract with this business, in which they promise to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I can provide you with the names of these organizations and/or a blank copy of this contract. • Disclosures required by health insurers or to collect overdue fees are discussed else- where elsewhere in this Agreement. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: • If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the social workerpsychologist-client patient privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. • If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. • If a client patient files a complaint or lawsuit against me, I may disclose relevant information regarding that client patient in order to defend myself. If a client files a worker’s compensation claim, I must, upon appropriate request, pro- vide a copy of the client’s record to the Labor and Industrial Commission or the Work- ers’ Compensation Division, or the client’s employer. There are some situations in which I am legally obligated to take actions, which I be- lieve believe are necessary to attempt to protect others from harm and I may have to reveal some information about a clientpatient’s treatment. These situations are unusual in my practice. ▪ If I have reasonable cause reason to suspect believe that a child or vulnerable adult has been or may be subjected to abuse or neglect neglect, or observe that a child being vulnerable adult has been subjected to conditions self-neglect, or circumstances that would reasonably result in abuse or neglectexploitation, the law requires that I file a report with Tennessee’s the appropriate government agency, usually the local office of the Department of Children’s Social Services. Once such a report is filed, I may be required to provide additional information. ▪ If I have reasonable cause know that a patient has a propensity for violence and the patient indicates that he/she has the intention to suspect that an elderly or disabled adult presents inflict imminent physical injury upon a like- lihood of suffering serious physical harm and is in need of protective services, the law requires that I file a report with Adult Protective Services. Once such a report is filed, I may be required to provide additional information. If I believe that it is necessary to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by the client on him/her- self or another personspecified victim(s), I may be required to take protective actionactions. These actions may includeinclude establishing and undertaking a treatment plan that is calculated to eliminate the possibility that the patient will carry out the threat, seeking hospitalization of the patient and/or informing the potential victim or the police about the threat. ▪ If I believes that that there is a imminent risk that a patient will inflict serious physical harm or death on him/herself, or that immediate disclosure is required to provide for the patient’s emergency health care needs, I may be required to take appropriate protective actions, including initiating hospitalization and/or contacting notifying family members or others who can protect the potential victim, and/or the police and/or the client’s familypatient. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records The laws governing confidentiality can be quite complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. PROFESSIONAL RECORDS You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where circumstances that disclosure is reasonably likely to endanger the life or physical safety of you and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harmperson, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of 35 cents $1.00 per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Records, you have a right of review, which I will discuss with you upon request. In addition, I may also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentially.] These Psychotherapy Notes are kept separate from your Clinical Record. Your While insurance companies can request and receive a copy of your Clinical Record, they cannot receive a copy of your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your writtensigned, signed written Authorization. Insurance companies cannot require your authorization Authorization as a condition of coverage nor penalize you in any way for your refusal refusal. You may examine and/or receive a copy of your Psychotherapy Notes unless I determine that knowledge of the health care information would be injurious to provide ityour health. Patient Rights PATIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include:include requesting that I amend your record; requesting restrictions on what information from your Clinical Records is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights with you. MINORS & PARENTS Patients under 16 years of age who are not emancipated and their parents should be aware that the law may allow parents to examine their child’s treatment records. While privacy in psychotherapy is very important, particularly with teenagers, parental involvement is also essential to successful treatment. Therefore, it is usually my policy to request an agreement from any patient between 16 and 18 and his/her parents allowing me to share general information about the progress of treatment and their child’s attendance at scheduled sessions. I will also provide parents with a summary of their child’s treatment when it is complete. Any other communication will require the child’s authorization, unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have. BILLING AND PAYMENTS You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. In circumstances of unusual financial hardship, I may be willing to negotiate a fee adjustment or payment installment plan. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require me to disclose otherwise confidential information. In most collection situations, the only information I release regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due. If such legal action is necessary, its costs will be included in the claim. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, I will be willing to call the company on your behalf. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in short-term therapy, some patients feel that they need more services after insurance benefits end. You should also be aware that your contract with your health insurance company requires that I provide it with information relevant to the services that I provide to you. Maryland permits me to send some information without your consent in order to file appropriate claims. I am required to provide them with a clinical diagnosis. Sometimes I am required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. Maryland law prevents insurers from making unreasonable demands for information, but there are no specific guidelines about what unreasonable includes. If I believe that your health insurance company is requesting an unreasonable amount of information, I will call it to your attention and we can discuss what to do. You can instruct me not to send requested information, but this could result in claims not being paid and an additional financial burden being placed on you. Once the insurance company has this information, it will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your sessions. It is important to remember that you always have the right to pay for my services yourself to avoid the problems described above unless prohibited by contract.
Appears in 2 contracts
Samples: Patient Services Agreement, Patient Services Agreement
Meetings. I normally conduct an evaluation that will last from 1-2 to 4 sessions. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If therapy has psychotherapy is begun, I will usually schedule one 45-45 to 50 minute ses- sion session per week at a time we agree on, although some sessions may be longer or more frequent. Once an appointment hour is scheduled, you will be expected to pay for it un- less unless you provide 24-24 hours advanced advance notice of cancellationcancellation [unless we both agree that you were unable to attend due to circumstances beyond your control]. It is important to note that insurance companies do not provide reimbursement for cancelled sessions. Professional Fees PROFESSIONAL FEES My hourly fee varies depending on services and durationis $160 for a weekly 45-50 minute individual session. In addition to weekly ap- pointmentsThe fee is $175 for a couples session, The fee for a one hour intake session is $200. I charge this amount $160 per hour for other professional services you may need. How- ever, though I will break down the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services include report writing, telephone conversations lasting longer than 10-10 minutes, Skype appoint- ments or check-ins, consulting with other professionals with your permission, prepar- ing preparation of records or treatment summaries, and the time spent performing any other ser- vices service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Be- cause of CONTACTING ME Email is the difficulty of legal involvement, I charge $500 per hour for preparation and attendance at any legal proceedingsbest way to reach me. Contacting Me Due to my work schedule, I am often not immediately available by telephone. While I am usually in my office four days a weekbetween 9 AM and 5 PM, I probably will not answer the phone when I am with a clientpatient. When I am unavailable, my telephone is answered by voice mail. I will make every effort to return your call by on the end of my business daysame day you make it, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. In emergencies, you can try me at 000 000-0000. If you are unable to reach me and you feel that you can’t wait for me to return your call, contact your family physician, physician or the nearest emergency room and ask for the psychologist or psychiatrist on call, or call 911. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client patient and a therapistpsychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, ad- xxxxx advance consent. Your signature on this Agreement provides consent for those activities, as follows: ● I may occasionally find it helpful to consult other health and mental health profes- sionals professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my clientpatient. The other professionals are also legally bound to keep informa- tion the information confidential. If you don’t object, I will not tell you about these consultations un- less unless I feel that it is important to our work together. I will note all consultations in your Clinical RecordRecord (which is called “PHI” in my Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information). Disclosures required by ● If I believe that a patient presents an imminent danger to his/her health insurers or safety, I may be obligated to seek hospitalization for him/her, or to collect overdue fees are discussed else- where in this Agreementcontact family members or others who can help provide protection. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: ● If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatmentthe professional services that I provided you, such information is protected by the social workerpsychologist-client patient privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. ● If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. ● If a client patient files a complaint or lawsuit against me, I may disclose relevant information regarding that client patient in order to defend myself. ● If a client patient files a worker’s compensation claim, and my services are being compensated through workers compensation benefits, I must, upon appropriate request, pro- vide provide a copy of the clientpatient’s record to the Labor and Industrial Commission patient’s employer or the Work- ers’ Compensation Division, or the client’s employerNorth Carolina Industrial Commission. There are some situations in which I am legally obligated to take actions, which I be- lieve believe are necessary to attempt to protect others from harm and I may have to reveal some information about a clientpatient’s treatment. These situations are unusual in my practice. ● If I have reasonable cause to suspect that a child has been under 18 is abused or may be subjected neglected, or if I have reasonable cause to abuse or neglect or observe believe that a child being subjected to conditions or circumstances that would reasonably result disabled adult is in abuse or neglectneed of protective services, the law requires that I file a report with Tennessee’s Department the County Director of Children’s Social Services. Once such a report is filed, I may be required to provide additional information. ● If I have reasonable cause believe that a patient presents an imminent danger to suspect that an elderly or disabled adult presents a like- lihood the health and safety of suffering serious physical harm and is in need of protective services, the law requires that I file a report with Adult Protective Services. Once such a report is filedanother, I may be required to provide additional information. If I believe that it is necessary to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by the client on him/her- self or another person, I may be required in order to take protective action. These actions may includeactions, and/or including initiating hospitalization and/or contacting hospitalization, warning the potential victim, if identifiable, and/or calling the police and/or the client’s familypolice. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records The laws governing confidentiality can be quite complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. PROFESSIONAL RECORDS The laws and standards of my profession require that I keep Protected Health Information about you in your Clinical Record. You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure is reasonably likely to endanger you and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harm, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of 35 cents per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Records, you have a right of review, which I will discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided Record and information revealed to me confidentially.] confidentially by others. These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization Authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights PATIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include:include requesting that I amend your record; requesting restrictions on what information from your Clinical Records is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights with you. MINORS & PARENTS Children of any age have the right to independently consent to and receive mental health treatment without parental consent and, in that situation, information about that treatment cannot be disclosed to anyone without the child’s agreement. While privacy in psychotherapy is very important, particularly with teenagers, parental involvement is also essential to successful treatment and this requires that some private information be shared with parents. It is my policy not to provide treatment to a child under 16 unless he/she agrees that I can share whatever information I consider necessary with his/her parents. For children 16 and over, I request an agreement between my patient and his/her parents allowing me to share general information about the progress of the child’s treatment and his/her attendance at scheduled sessions. I will also provide parents with a summary of their child’s treatment when it is complete. Any other communication will require the child’s Authorization, unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have. BILLING AND PAYMENTS You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require me to disclose otherwise confidential information. In most collection situations, the only information I release regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due. If such legal action is necessary, its costs will be included in the claim. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, I will be willing to call the company on your behalf. Due to the rising costs of healthcare, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in short-term therapy, some patients feel that they need more services after insurance benefits end. Some managed-care plans will not allow me to provide services to you once your benefits end. If this is the case, I will do my best to find another provider who will help you continue your psychotherapy. You should also be aware that your contract with your health insurance company requires that I provide it with information relevant to the services that I provide to you. I am required to provide a clinical diagnosis. Sometimes I am required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your sessions. It is important to remember that you always have the right to pay for my services yourself to avoid the problems described above unless prohibited by contract. Your signature below indicates that you have read the information in this document and agree to abide by its terms during our professional relationship. Your signature below also serves as an acknowledgment that you have been presented the HIPPA notice form described above.
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Samples: static1.squarespace.com, uploads.documents.cimpress.io
Meetings. For psychological assessment services, I normally generally conduct an evaluation initial intake interview to obtain background information and clarify what testing may be warranted. We will then schedule a testing session that will may last from 1-2 sessionstwo to six hours, depending on the referral concerns. During this timeA psychological assessment may also consist of me talking to your child's teachers and/or observing your child in his/her classroom, with your permission. Upon completion of the assessment, we both decide if I am will meet to discuss the best person to provide the services you need in order to meet your treatment goalsfindings and recommendations. If therapy has begunYou will also be provided with a written report including this information. For psychotherapy services, I generally spend the first 2 to 4 sessions evaluating the needs of your child and/or family, after which time I will usually develop a treatment plan. I typically schedule one 45-minute ses- sion psychotherapy sessions once per week for 50 minutes (one appointment hour of 50 minutes duration, with 10 minutes for administrative tasks) at a time we agree on, although some sessions may be longer shorter, longer, or more frequent. Once Although I make every effort to avoid interruptions and delays, I may occasionally be unavailable for part or all of our regularly scheduled appointments (e.g., due to emergencies with other patients). These possible interferences are sometimes unavoidable. I will try to provide you with a new appointment as soon as possible should this ever occur. Appointments are contracted time. When you make an appointment hour is scheduledwith me, I set aside that time to spend with you. Unlike many healthcare practices, I do not "overbook" my time. If you are unable to make a scheduled appointment, please cancel 24 hours prior to the appointment time so that I can offer the time to another client. If you do not cancel at least 24 hours prior to your appointment time, you will be responsible for the session fee. If you are late for a session, you will most likely miss part of your therapy time. PROFESSIONAL FEES I charge for all of my professional services. You will be expected to pay for it un- less you provide 24-hours advanced notice of cancellation. It is important to note that insurance companies do not provide reimbursement for cancelled sessions. Professional Fees My hourly fee varies depending on services and duration. In addition to weekly ap- pointments, I charge this amount for other each professional services you may need. How- ever, I will break down the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services include report writing, telephone conversations lasting longer than 10-minutes, Skype appoint- ments or check-ins, consulting with other professionals with your permission, prepar- ing of records or treatment summaries, and service at the time spent performing any other ser- vices you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Be- cause of the difficulty of legal involvement, I charge $500 per hour for preparation and attendance at any legal proceedings. Contacting Me Due to my work schedule, I am often not immediately available by telephone. While I am usually in my office four days a week, I probably will not answer the phone when I am with a client. I will make every effort to return your call by the end of my business day, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. If you are unable to reach me and you feel that you can’t wait for me to return your call, contact your family physician, the nearest emergency room and ask for the psychologist or psychiatrist on call, or call 911. If I will be unavailable for an extended time, I will provide you with the name of a colleague contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality The law protects the privacy of all communications between a client and a therapist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, ad- xxxxx consent. Your signature on this Agreement provides consent for those activities, as follows: I may occasionally find it helpful to consult other health and mental health profes- sionals about a case. During consultation, I make every effort to avoid revealing the identity of my client. The other professionals are also legally bound to keep informa- tion confidential. If you don’t object, I will not tell you about these consultations un- less I feel that it is important to our work together. I will note all consultations in your Clinical Record. Disclosures required by health insurers or to collect overdue fees are discussed else- where in this Agreement. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatmentdelivered, such information is protected by the social worker-client privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client in order to defend myself. If a client files a worker’s compensation claim, I must, upon appropriate request, pro- vide a copy of the client’s record to the Labor and Industrial Commission or the Work- ers’ Compensation Division, or the client’s employer. There are some situations in which I am legally obligated to take actions, which I be- lieve are necessary to attempt to protect others from harm and I may have to reveal some information about a client’s treatment. These situations are unusual in my practice. If I have reasonable cause to suspect that a child has been or may be subjected to abuse or neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglect, the law requires that I file a report with Tennessee’s Department of Children’s Services. Once such a report is filed, I may be required to provide additional information. If I have reasonable cause to suspect that an elderly or disabled adult presents a like- lihood of suffering serious physical harm and is in need of protective services, the law requires that I file a report with Adult Protective Services. Once such a report is filed, I may be required to provide additional information. If I believe that it is necessary to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by the client on him/her- self or another person, I may be required to take protective action. These actions may include, and/or initiating hospitalization and/or contacting the potential victim, and/or the police and/or the client’s family. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that unless we discuss any questions or concerns that you may have now or in the future. Professional Records You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure is reasonably likely to endanger you and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harm, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of 35 cents per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Records, you have a right of review, which I will discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents of our conversations, my analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentiallyagree otherwise beforehand.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include:
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Samples: www.marisanava.com
Meetings. I normally conduct an evaluation that will last from 1-2 to 4 sessions. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If therapy has psychotherapy is begun, I will usually schedule one 45-minute ses- sion session (one appointment hour of 45 minutes duration) per week at a time we agree on, although some sessions may be longer or more frequent. Once an appointment hour is scheduled, you will be expected to pay for it un- less unless you provide 24-24 hours advanced advance notice of cancellationcancellation [Monday appointments need to be cancelled by the previous Friday]. It is important to note that insurance companies do not provide reimbursement for cancelled sessions. Professional Fees PROFESSIONAL FEES My hourly fee varies standard fees range from$130 to $180 per 45-minute individual session depending on services the type of service offered. I offer a discount to those without insurance, those not choosing to use their insurance, and durationfor those who have insurance that we do not file. In addition addition, to weekly ap- pointmentsappointments, I charge this amount on a pro-rated basis for other professional services you may need. How- ever, I will break down the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services include report writing, telephone conversations lasting longer than 10-a few minutes, Skype appoint- ments or check-ins, consulting with other professionals with your permission, prepar- ing preparation of records or treatment summaries, and the time spent performing any other ser- vices service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Be- cause Because of the difficulty of legal involvement, I charge $500 180 per hour for preparation preparation, travel time, and attendance at any legal proceedingsproceeding. Contacting Me CONTACTING ME Due to my work schedule, I am often not immediately available by telephone. While I am usually in my office four days a weekMon-Fridays, I probably will not answer the phone when I am with a clientpatient. When I am unavailable, my telephone is answered by a confidential voice mail that I monitor frequently. I will make every effort to return your call by on the end of my business daysame day you make it, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. In emergencies, you can try me at my home number (851- 6639). If you are unable to reach me and you feel that you can’t wait for me to return your call, contact your family physician, the nearest emergency room and ask for the psychologist or psychiatrist on callRESPOND Program at Xxxxx Xxxx Hospital (250-7000), or call 911go to your nearest hospital emergency room. If I will be unavailable for an extended time, I will provide you with the name of a colleague contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client patient and a therapistpsychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, ad- xxxxx advance consent. Your signature on this Agreement provides consent for those activities, as follows: • I may occasionally find it helpful to consult other health and mental health profes- sionals professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my clientpatient. The other professionals are also legally bound to keep informa- tion the information confidential. If you don’t object, I will not tell you about these consultations un- less unless I feel that it is important to our work together. I will note all consultations in your Clinical RecordRecord (which is called “PHI” in my Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information • You should be aware that I employ administrative support staff. In most cases, I need to share protected information with these individuals for both clinical and administrative purposes, such as scheduling, billing and quality assurance. All staff members have been given training about protecting your privacy and have agreed not to release any information outside of the practice without the permission of a professional staff member. • Disclosures required by health insurers or to collect overdue fees are discussed else- where elsewhere in this Agreement. • If I believe that a patient presents an imminent danger to his/her or others’ health or safety, I may be obligated to seek hospitalization for him/ her, or to contact family members or others who can help provide protection. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: • If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatmentthe professional services that I provided you, such information is protected by the social workerpsychologist-client patient privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. • If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. • If a client patient files a complaint or lawsuit against me, I may disclose relevant information regarding that client patient in order to defend myself. • If a client patient files a worker’s compensation claim, and my services are being compensated through workers compensation benefits, I must, upon appropriate request, pro- vide provide a copy of the clientpatient’s record to the Labor and Industrial Commission patient’s employer or the Work- ers’ Compensation Division, or the client’s employerNorth Carolina Industrial Commission. There are some situations in which I am legally obligated to take actions, which I be- lieve believe are necessary to attempt to protect others from harm and I may have to reveal some information about a clientpatient’s treatment. These situations are unusual in my practice. • If I have reasonable cause to suspect that a child has been under 18 is abused or may be subjected neglected, or if I have reasonable cause to abuse or neglect or observe believe that a child being subjected to conditions or circumstances that would reasonably result disabled adult is in abuse or neglectneed of protective services, the law requires that I file a report with Tennessee’s Department the County Director of Children’s Social Services. Once such a report is filed, I may be required to provide additional information. • If I have reasonable cause believe that a patient presents an imminent danger to suspect that an elderly or disabled adult presents a like- lihood the health and safety of suffering serious physical harm and is in need of protective services, the law requires that I file a report with Adult Protective Services. Once such a report is filedanother, I may be required to provide additional information. If I believe that it is necessary to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by the client on him/her- self or another person, I may be required in order to take protective action. These actions may includeactions, and/or including initiating hospitalization and/or contacting hospitalization, warning the potential victim, if identifiable, and/or calling the police and/or the client’s familypolice. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records You should The laws governing confidentiality can be aware thatquite complex, pursuant to HIPAAand I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. PROFESSIONAL RECORDS The laws and standards of my profession require that I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in unusual circumstances that involve danger to yourself and/or others or the unusual circumstance where disclosure record makes reference to another person (unless such other person is a health care provider) and I believe that access is reasonably likely to endanger you and/or others or when another individual (cause substantial harm to such other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harmperson, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of 35 cents $.50 per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Recordsrecords, you have a right of review, which I will discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents of our conversations, my analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentially.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights PATIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include:include requesting that I amend your record; requesting restrictions on what information from your Clinical Records is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights with you. MINORS & PARENTS Children of any age have the right to independently consent to and receive mental health treatment without parental consent and, in that situation, information about that treatment cannot be disclosed to anyone without the child’s agreement. While privacy in psychotherapy is very important, particularly with teenagers, parental involvement is also essential to successful treatment and this requires that some private information be shared with parents. It is my policy not to provide treatment to a child under 15 unless he/she agrees that I can share whatever information I consider necessary with his/her parents. For children 15 and over, I request an agreement between my patient and his/her parents allowing me to share general information about the progress of the child’s treatment and his/her attendance at scheduled sessions. Any other communication will require the child’s Authorization, unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have. BILLING AND PAYMENTS You will be expected to pay at the beginning of each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require me to disclose otherwise confidential information. In most collection situations, the only information I release regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due. If such legal action is necessary, its costs will be included in the claim. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Prior to coming in for your first session, we recommend that you find out about your coverage, including deductibles and co-pays. Of course, I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, I will be willing to call the company on your behalf. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in short-term therapy, some patients feel that they need more services after insurance benefits end. You should also be aware that your contract with your health insurance company requires that I provide it with information relevant to the services that I provide to you. I am required to provide a clinical diagnosis. Sometimes I am required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank, which can have an impact on your future insurability. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your sessions. It is important to remember that you always have the right to pay for my services yourself to avoid the problems described above. If we participate with your insurance company, you are generally only responsible for deductibles and co- pays at each session. However, you are also responsible for any charges allowed by your insurance, but not ultimately paid by them. Please note that if a check payment is returned for any reason, your account will be electronically debited for the check amount and a $25.00 processing fee. YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THE INFORMATION IN THE PSYCHOLOGIST-PATIENT AGREEMENT, AGREE TO ABIDE BY ITS TERMS DURING OUR PROFESSIONAL RELATIONSHIP AND YOU ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED AND READ THE HIPAA NOTIFICATION OF PRIVACY POLICIES ATTACHED.
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Samples: caryneuropsychology.com
Meetings. I normally conduct an evaluation assessment that will last from 1-between 2 and 3 55 minute sessions. During this time, we can both decide if I am the best person to provide the services service you need in order to meet your treatment goals. If therapy has psychotherapy is begun, I will usually schedule one 45-55 minute ses- sion session (one appointment hour of 55 minutes duration) per week at a time we agree on, although some sessions may be longer or more frequent. Once an appointment hour is scheduled, you will be expected to pay for it un- less unless you provide 24-24 hours advanced advance notice of cancellation. It Since your appointment time is important reserved exclusively for you, you agree to give at least 24 hours’ notice if you cannot keep an appointment. If I do not receive this advance notice of your cancellation, your credit card on file will be billed for $60, one ½ of my full fee for the session missed- Please note that insurance companies do cannot provide reimbursement be billed for cancelled sessionsmissed appointments. Professional Fees PROFESSIONAL FEES My hourly fee varies depending on services and durationis $ 120. In addition to weekly ap- pointmentsappointments, I charge this amount for other professional services you may need. How- ever, I will break down the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services include report writing, telephone conversations lasting longer than 10-10 minutes, Skype appoint- ments or check-ins, consulting with other professionals with your permission, prepar- ing preparation of records or treatment summaries, and the time spent performing any other ser- vices services you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation preparation, and transportation costs, even if I am called to testify by another party. Be- cause [Because of the difficulty of legal involvement, I charge $500 120 per hour for preparation and attendance at any legal proceedings. Contacting Me proceeding.] CONTACTING ME Due to my work schedule, I am often not immediately available by telephone. While I am usually in my office four days a weekavailable between 9 AM and 5 PM, I probably will not answer the my phone when I am with a clientpatient. I will make every effort to return your call by on the end of my business daysame day you make it, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be are available. If you are unable to reach me and you feel that you can’t wait for me to return your call, contact your family physician, physician or the nearest emergency room and ask for the psychologist or psychiatrist psychotherapist [psychiatrist] on call. In case of an emergency, call 911 or call 911go to the nearest hospital. If I will be unavailable for an extended time, I will provide you with the name of a colleague contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client patient and a therapistpsychotherapist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, ad- xxxxx advanced consent. Your signature on this Agreement provides consent for those activities, as follows: • I may occasionally find it helpful to consult other health and mental health profes- sionals professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my clientpatient. The other professionals are also legally bound to keep informa- tion the information confidential. If you don’t object, I will not tell you about these consultations un- less unless I feel that it is important to our your work together. I will note all consultations in your Clinical Record. • Disclosures required by health insurers or to collect overdue fees are discussed else- where elsewhere in this Agreement. • If a patient threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her, or to contact family members if others who can help provide protection. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: • If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatmentmy professional services, such information is protected by the social workerpsychotherapist-client patient privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. • If a government agency is requesting the information for health oversight activities, I may be am required to provide it for them. • If a client patient files a complaint or lawsuit against me, I may disclose relevant information regarding that client patient in order to defend myself. • If a client patient files a worker’s compensation claim, I must, upon appropriate request, pro- vide am required to submit a copy of report the client’s record to the Labor and Industrial Commission or the Work- ersWorkers’ Compensation Division, or the client’s employer. There are some situations in which I am legally obligated to take actions, which I be- lieve believe are necessary to attempt to protect others from harm and I may have to reveal some information about a clientpatient’s treatment. These situations are unusual in my practice. • If I have reasonable cause to know or suspect that a child has been or may be subjected to abuse or neglect or observe if I have observed a child being subjected to circumstances or conditions or circumstances that which would reasonably result in abuse or neglect, the law requires that I file a report with Tennessee’s Department of Children’s Servicesthe appropriate governmental agency. Once such a report is filed, I may be required to provide additional information. • If I have reasonable cause to suspect believe that an elderly at-risk adult has been or disabled adult presents a like- lihood is at imminent risk of suffering serious physical harm and is in need of protective servicesbeing mistreated, self-neglected, or financially exploited, the law requires that I file a report with Adult Protective Servicesthe appropriate governmental agency. Once such a report is filed, I may be required to provide additional information. • If I believe that it is necessary to disclose information to protect a patient communicates a serious threat of imminent physical violence against a clear and substantial risk of imminent serious harm being inflicted by the client on him/her- self specific person or another personpersons, I may be required must make an effort to notify such person; and/or notify an appropriate law enforcement agency; and/or take protective action. These actions may include, and/or initiating other appropriate action including seeking hospitalization and/or contacting of the potential victim, and/or the police and/or the client’s familypatient. If such a situation arises, I will make every effort to for fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records You should The laws governing confidentiality can be aware thatquite complex, pursuant to HIPAAand I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. PROFESSIONAL RECORDS The laws and standards of my profession require that I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure is reasonably likely circumstances that involve danger to endanger you and/or yourself and others or when another individual (other than another health care provider) is referenced and I believe disclosing that where information puts the other person at risk of substantial harmhas been supplied to me confidentially by others, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstancessituations, I am allowed to charge a copying copy fee of 35 cents $1.00 per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Recordsrecords, you have a right of to review, which I will discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents of our conversations, my analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentially.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights PATIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your Clinical Records Record and disclosures disclosure of protected health information. These rights include:include requesting that I amend your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, with the attached Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights with you. MINORS & PARENTS Patients under 15 years of age who are not emancipated and their parents should be aware that the law may allow parents to examine their child’s treatment records, unless I decide that such access is likely to injure the child. Because the privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is my policy to request an agreement from parents that they consent to give up their access to their child’s records. If they agree, during treatment, I will provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. I will also provide parents with a summary of their child’s treatment when it is complete. Any other communication will require the child’s Authorization, unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have. BILLING AND PAYMENTS You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedule for other professional services will be agreed to when they are requested. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require me to disclose otherwise confidential information. In most collection situations, the only information I release regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due. [If such legal action is necessary, its costs will be included in the claim.] INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, my billing professional will call the company on your behalf. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometime difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in short-term therapy, some patients feel that they need more services after insurance benefits end. You should also be aware that your contract with your health insurance company requires that I provide it with information relevant to the services that I provide to you. I am required to provide a clinical diagnosis. Sometimes I am required to provide additional clinical information such as treatment plans, or summaries, or copies of your entire Clinical Record. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Through all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your session. It is important to remember that you always have the right to pay for my services yourself to avoid the problems described above. [Your signature below indicates that you have read the information in this document and agree to abide by its terms during our professional relationship.] [YOUR SIGNATURE BELOW INDICATED THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS AND ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPPA NOTICE FORM DESCRIBED ABOVE.] Signature Date
Appears in 1 contract
Samples: www.christinetalagamorgan.com
Meetings. I normally conduct an initial evaluation that will last from 1-2 sessionsduring the first session. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If therapy has psychotherapy is begun, I will usually schedule one sessions on a 45-minute ses- sion per week basis at a time we agree on, although some sessions may be longer or more frequentfrequency agreed upon by us. Once an appointment hour is scheduled, you will be expected to pay for it un- less unless you provide 24-24 hours advanced advance notice of cancellationcancellation [unless we both agree that you were unable to attend due to circumstances beyond your control]. It is important to note that insurance companies do not provide reimbursement for cancelled sessionsor missed sessions and therefore cannot be billed. Professional Fees Therefore, you will be responsible for the full fee. PROFESSIONAL FEES My hourly fee varies depending on services is $145 for individuals and duration$170 for couples/family. In addition to weekly ap- pointments, I charge this amount for other professional services you may need. How- ever, though I will break down the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services include report writing, telephone conversations lasting longer than 10-minutes, Skype appoint- ments or check-insconversations, consulting with other professionals with your permission, prepar- ing preparation of records or treatment summaries, and the time spent performing any other ser- vices service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Be- cause Because of the difficulty of legal involvement, I charge $500 145 per hour for preparation and attendance at any legal proceedingsproceeding. Contacting Me CONTACTING ME Due to my work schedule, I am often not immediately available by telephone, 000.000.0000. While I am usually in my office four days a weekbetween 9 AM and 6 PM, Mondays thru Thursdays, I probably will not answer the phone when I am with a client. When I am unavailable, my telephone is answered by voice mail. I check my messages once a day and will make every effort to return your call by the end of my business daywithin 48 hours, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. If you are unable to reach me and you feel that you can’t wait for me to return your call, contact your family physician, physician or the nearest emergency room and ask for the psychologist or psychiatrist on call, or call 911. If I will be unavailable for an extended time, I will provide you with the name of a colleague contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality The law protects the privacy of all communications between a client and a therapist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, ad- xxxxx consent. Your signature on this Agreement provides consent for those activities, as follows: I may occasionally find it helpful to consult other health and mental health profes- sionals about a case. During consultation, I make every effort to avoid revealing the identity of my client. The other professionals are also legally bound to keep informa- tion confidential. If you don’t object, I will not tell you about these consultations un- less I feel that it is important to our work together. I will note all consultations in your Clinical Record. Disclosures required by health insurers or to collect overdue fees are discussed else- where in this Agreement. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the social worker-client privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client in order to defend myself. If a client files a worker’s compensation claim, I must, upon appropriate request, pro- vide a copy of the client’s record to the Labor and Industrial Commission or the Work- ers’ Compensation Division, or the client’s employer. There are some situations in which I am legally obligated to take actions, which I be- lieve are necessary to attempt to protect others from harm and I may have to reveal some information about a client’s treatment. These situations are unusual in my practice. If I have reasonable cause to suspect that a child has been or may be subjected to abuse or neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglect, the law requires that I file a report with Tennessee’s Department of Children’s Services. Once such a report is filed, I may be required to provide additional information. If I have reasonable cause to suspect that an elderly or disabled adult presents a like- lihood of suffering serious physical harm and is in need of protective services, the law requires that I file a report with Adult Protective Services. Once such a report is filed, I may be required to provide additional information. If I believe that it is necessary to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by the client on him/her- self or another person, I may be required to take protective action. These actions may include, and/or initiating hospitalization and/or contacting the potential victim, and/or the police and/or the client’s family. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure is reasonably likely to endanger you and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harm, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of 35 cents per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Records, you have a right of review, which I will discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents of our conversations, my analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentially.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include:
Appears in 1 contract
Samples: Patient Services Agreement
Meetings. I normally conduct an evaluation that will last from 1-2 to 4 sessions. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If therapy has psychotherapy is begun, I will usually schedule one 45-53- minute ses- sion session (one appointment of 53 minutes duration) per week at a time we agree on, although some sometimes sessions may be longer or more frequent. Meeting regularly is important, allowing for continuity and greater progress. Once an appointment hour is scheduled, you will be expected to pay for it un- less unless you provide 24-24 hours advanced advance notice of cancellationcancellation (even if that 24 hours falls on a weekend or holiday). It is important to note that insurance companies do not provide reimbursement for cancelled sessions. Professional Fees My hourly fee varies depending on services and durationIf you are late for an appointment, the appointment will end at the usual time. PROFESSIONAL FEES In addition to weekly ap- pointmentsappointments, I charge this amount the same as my normal hourly fee for other professional services you may need. How- ever, though I will break down the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services include report writing, telephone conversations lasting longer than 10-5 minutes (there is a $35 flat fee and also prorated actual time beyond 5 minutes, Skype appoint- ments or check-ins), consulting with other professionals with your permission, prepar- ing preparation of records or treatment summaries, and the time spent performing any other ser- vices service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Be- cause Because of the difficulty of legal involvement, I charge $500 450.00 per hour for preparation preparation, transportation and attendance at any legal proceedingsproceeding. Contacting Me Legal fee are not covered by insurance. CONTACTING ME Due to my work schedule, I am often not immediately available by telephone. While I am usually in my office four days a weekbetween 9 AM and 5 PM, I probably will not answer the phone when I am with a clientpatient. When I am unavailable, my telephone is answered by voice mail. I will make every effort to return your call by within 3 hours and almost always the end of my business same day, with the exception of often including weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. If you are unable to reach me and you feel that you can’t wait for me to return your call, contact your family physician, physician or the nearest emergency room and ask for the psychologist or psychiatrist mental health professional on call, or call 911. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client patient and a therapistpsychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form authorization form that meets certain legal requirements imposed by HIPAAHIPAA and/or Illinois law. There are other situations that require only that you provide writtenHowever, ad- xxxxx consent. Your signature on this Agreement provides consent for those activitiesin the following situations, as followsno authorization is required: I may occasionally find it helpful to consult other health and mental health profes- sionals professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my clientpatient. The other professionals are also legally bound to keep informa- tion the information confidential. If you don’t object, I will not tell you about these consultations un- less unless I feel that it is important to our work together. I will note all consultations in your Clinical RecordRecord (which is called “PHI”). As required by HIPAA, if I have a formal business associate contract (ie with a billing service), there would be a contract in which they promise to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. You can ask and see any such contracts if you wish. Disclosures required by health insurers or to collect overdue fees are discussed else- where elsewhere in this Agreement. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the social workerpsychologist-client patient privilege law. I cannot provide disclose any information without your (a court order or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. If a government agency is requesting the information for health oversight activities, I may be required to provide it for to them. If a client patient files a complaint or lawsuit against me, I may disclose relevant information regarding that client patient in order to defend myself. If a client files you file a worker’s compensation claim, and I rendered treatment or services in accordance with the provisions of Illinois Workers’ Compensation law, I must, upon appropriate request, pro- vide provide a copy of the client’s your record to the Labor and Industrial Commission your employer or the Work- ers’ Compensation Division, or the client’s employertheir appropriate designee. There are some situations in which I am legally obligated to take actions, which I be- lieve believe, are necessary to attempt to protect others from harm and I may have to reveal some information about a clientpatient’s treatment. These situations are unusual in my practice. If you have made a specific threat or violence against another or if I believe that you present a clear, imminent risk of serious physical harm to another, I may be required disclose information in order to take protective actions. These actions may include notifying the potential victim, contacting the police, seeking your hospitalization and/or reporting you to the FOID data base. If I have reasonable cause to suspect believe that a child has been or under 18 known to me in my professional capacity may be subjected to abuse an abused or neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglectneglected child, the law requires that I file a report with Tennessee’s the local office of the Department of Children’s Children and Family Services. Once such a report is filed, I may be required to provide additional information. If I have reasonable cause reason to suspect believe that an elderly adult over the age of 60 living in a domestic situation has been abused or disabled adult presents a like- lihood of suffering serious physical harm and is neglected in need of protective servicesthe preceding 12 months, the law requires that I file a report with Adult Protective Servicesthe agency designated to receive such reports, ie the Department of Aging. Once such a report is filed, I may be required to provide additional information. If I believe that it is necessary to disclose information to protect against you present a clear and substantial clear, imminent risk of imminent serious harm being inflicted by the client on him/her- self physical or another personmental injury or death to yourself, I may be required to disclose information in order to take protective actionactions. These actions may includeinclude seeking your hospitalization or contacting family members or others who can assist in protecting you, and/or initiating hospitalization and/or contacting reporting you to the potential victim, and/or the police and/or the client’s familyDHS/ FOID data base. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records You should The laws governing confidentiality can be aware thatquite complex, pursuant to HIPAAand I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. The addendum describes my responsibility if PHI is hacked, which has never happened in my practice. PROFESSIONAL RECORDS The laws and standards of my profession require that I keep Protected Health Information (PHI) about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure is reasonably likely to endanger you and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harm, you You may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of 35 cents $25 plus $5.00 per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Records, you have a right of review, which I will discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents of our conversations, my analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentially.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights PATIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include:include requesting that I amend your record, requesting restrictions on what information from your Clinical Records is disclosed to others, requesting an accounting of disclosures of protected health information that you have neither consented to nor authorized, determining the location to which protected information disclosures are sent, having any complaints you make about my policies and procedures recorded in your records, and the right to a paper copy of this Agreement about my privacy policies and procedures. I am happy to discuss any of these rights with you. MINORS & PARENTS Parents/guardians of children between 12 and 18 cannot examine their child’s records unless the child consents and unless I find that there are no compelling reasons for denying the access. Parents are entitled to information concerning their child’s current physical and mental condition, diagnosis, treatment needs, services provided, and services needed. Since parental involvement is often crucial to successful treatment, in most cases, I require that patients between 12 and 18 years of age and their parents enter into an agreement that allows parents access to certain additional treatment information. If everyone agrees, during treatment I will provide parents with general information about the progress of their child’s treatment, and his/her attendance at scheduled sessions. Any other communication will require the minor’s authorization, unless I feel that the minor is in danger or is a danger to someone else, in which case, I will notify the parents/guardians of my concern. Before giving parents any information, I will discuss the matter with the minor, if possible, and do my best to handle any objections he/she may have. BILLING AND PAYMENTS You are expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require me to disclose otherwise confidential information. In most collection situations, the only information I release regarding a patient’s treatment is his/ her name, the nature of services provided, and the amount due. If such legal action is necessary, its costs will be included in the claim. All unpaid balances over 30 days old will accrue interest at 1½ % per month. This may be turned over to collections and will appear on your credit report if not paid within 30 days. You will also be responsible for the additional charges incurred in the collection and legal process. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and will be happy to help you understand the information you receive from your insurance company.
Appears in 1 contract
Samples: Services Agreement
Meetings. I normally conduct an evaluation that will last from 1-2 to 4 sessions. During this time, we can both decide if I am I’m the best person to provide help you create the services life you need in order to meet your treatment goalswant. If therapy has begunwe decide to continue, I will usually schedule one 4550-minute ses- sion session per week at a time we agree onweek, although some sessions may duration and frequency can vary. INSURANCE REIMBURSEMENT / PAYMENT OF FEES You will be longer or more frequentexpected to pay for each session at the time it is held, prior to the beginning of the session. Payment schedules for other professional services will be agreed upon when they are requested. If you have insurance, please understand that this is an agreement between you and your insurance company. If your insurance requires an authorization for your visits, please make sure that you obtain this authorization before your first appointment. If your insurance company denies your visits for any reason, you will be responsible for the full fee of each of these visits. Please be aware that insurance benefits quoted by your insurance company are not a guarantee of payment and that you are ultimately responsible to know the benefits of your policy. If you insurance company requires a deductible, Perceptions Counseling Solutions, LLC will accept a payment of $85 for the first session and $65 for future sessions, until the deductible has been met. We would also ask you to please be aware of the status of your deductible. Once an appointment hour is scheduled, you will be expected to pay for it un- less unless you provide 24-24 hours advanced advance notice of cancellationcancellation (by Friday at 5pm for Monday appointments), or unless we both agree that you were unable to come due to a medical emergency. It is important to note that insurance companies do not provide reimbursement for cancelled sessions. Professional Fees My hourly fee varies depending on services and duration. In addition to weekly ap- pointments, I charge this amount for other professional services you may need. How- ever, I will break down do everything possible to find another time to reschedule the hourly cost if I work appointment that week, but a late cancellation will still mean you are responsible for periods of less than one hourthe fee for that missed session. Note that these additional services are not covered by insurance. Other services include report writing, telephone conversations lasting longer than 10-minutes, Skype appoint- ments or check-ins, consulting with other professionals with your permission, prepar- ing of records or treatment summaries, and the time spent performing any other ser- vices you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Be- cause of the difficulty of legal involvement, I charge $500 per hour for preparation and attendance at any legal proceedings. Contacting Me _ (initials) CONTACTING ME Due to my work schedule, I am often not immediately available by telephonephone. While When I am usually in unavailable, my office four days a week, telephone is answered by voice mail that I probably will not answer the phone when I am with a clientmonitor frequently. I will make every effort to return your call by on the end of my same day. Otherwise, you can expect a return call on the next business day, with at the exception of weekends and holidayslatest. If you are difficult to reach, please inform me of some times when you will be available. If you are unable to reach me and you feel that you can’t wait for me to return your call, contact your family physician, physician or the nearest emergency room and ask for the psychologist or psychiatrist on callroom, or call 911. If I will be unavailable for an extended time, I will provide you with the name of a colleague contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality The law protects the privacy of all communications between a client and a therapist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, ad- xxxxx consent. Your signature on this Agreement provides consent for those activities, as follows: I may occasionally find it helpful to consult other health and mental health profes- sionals about a case. During consultation, I make every effort to avoid revealing the identity of my client. The other professionals are also legally bound to keep informa- tion confidential. If you don’t object, I will not tell you about these consultations un- less I feel that it is important to our work together. I will note all consultations in your Clinical Record. Disclosures required by health insurers or to collect overdue fees are discussed else- where in this Agreement. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the social worker281-client privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client in order to defend myself. If a client files a worker’s compensation claim, I must, upon appropriate request, pro- vide a copy of the client’s record to the Labor and Industrial Commission or the Work- ers’ Compensation Division, or the client’s employer. There are some situations in which I am legally obligated to take actions, which I be- lieve are necessary to attempt to protect others from harm and I may have to reveal some information about a client’s treatment. These situations are unusual in my practice. If I have reasonable cause to suspect that a child has been or may be subjected to abuse or neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglect, the law requires that I file a report with Tennessee’s Department of Children’s Services. Once such a report is filed, I may be required to provide additional information. If I have reasonable cause to suspect that an elderly or disabled adult presents a like- lihood of suffering serious physical harm and is in need of protective services, the law requires that I file a report with Adult Protective Services. Once such a report is filed, I may be required to provide additional information. If I believe that it is necessary to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by the client on him/her- self or another person, I may be required to take protective action. These actions may include, and/or initiating hospitalization and/or contacting the potential victim, and/or the police and/or the client’s family. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure is reasonably likely to endanger you and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harm, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of 35 cents per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Records, you have a right of review, which I will discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents of our conversations, my analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentiallyCARE.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include:
Appears in 1 contract
Samples: perceptions-counseling.com
Meetings. I normally conduct an evaluation that will last from 1-2 one to four sessions. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If therapy has psychotherapy is begun, I will usually schedule one 4530-50-minute ses- sion session (one appointment hour of 30-50 minutes duration) per week at a time we agree on, although some sessions may be longer or more frequent. Once an appointment hour is scheduled, you will be expected to pay for it un- less unless you provide 24-24 hours advanced advance notice of cancellationcancellation [unless we both agree that you were unable to attend due to circumstances beyond your control]. It is important to note that insurance companies do not provide reimbursement for cancelled sessions. Professional Fees PROFESSIONAL FEES My hourly fee varies depending is listed on services and durationthe attached sheet. In addition to weekly ap- pointmentsappointments, I charge this amount for other professional services you may need. How- ever, though I will break down the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services include report writing, telephone conversations lasting longer than 10-five minutes, Skype appoint- ments or check-ins, consulting with other professionals with your permission, prepar- ing preparation of records or treatment summaries, and the time spent performing any other ser- vices service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costscost, even if I am called to testify by another party. Be- cause Because of the difficulty of legal involvement, I charge $500 200 per hour for preparation and attendance at any legal proceedingsproceeding. Contacting Me CONTACTING ME Due to my work schedule, I am often not immediately available by telephone. I schedule all appointments and changes should be discussed with me personally. While I am usually in my office four days a weekbetween 9 a.m. and 5 p.m., I probably will not answer the phone when I am with a client. When I am unavailable, my telephone is answered by voicemail or by the receptionist. I will make every effort to return your call by on the end of my business daysame day you make it, with the exception of weekends and holidays. If you are difficult to reach, reach please inform me of some times when you will be available. If you are unable to reach me and you feel that you can’t wait for me to return your call, contact your family physician, physician or the nearest emergency room and ask for the psychologist or psychiatrist on call. For emergencies, or please call 911. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client patient and a therapistpsychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form form that meets certain legal requirements imposed by HIPAAHIPAA and/or Illinois law. There are other situations that require only that you provide writtenHowever, ad- xxxxx consent. Your signature on this Agreement provides consent for those activitiesin the following situations, as followsno authorization is required: ▪ I may occasionally find it helpful to consult other health and mental health profes- sionals professionals about a case. During consultation, I make every effort to avoid revealing the identity of my clientyour identity. The other professionals are also legally bound to keep informa- tion the information confidential. If you don’t object, I will not tell you about these consultations un- less unless I feel that it is important to our work together. I will note all consultations in your Clinical Record. ▪ You should be aware that I practice with other mental health professionals and that I employ administrative staff. In most cases, I need to share protected information with these individuals for both clinical and administrative purposes, such as scheduling, billing and quality assurance. All of the mental health professionals are bound by the same rules of confidentiality. All staff members have been given training about protecting your privacy and have agreed not to release any information outside of the practice without the permission of a professional staff member. ▪ I also have contracts with insurance companies, psychiatric consultants, professional schools (practicum students), legal services, accounting firms, electronic billing organizations, computer consultants and collection agencies. As required by HIPAA, I have a formal business associate contract with this/these business(es), in which it/they promise to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I can provide you with the names of these organizations and/or blank copy of this contract. ▪ Disclosures required by for health insurers or to collect for overdue fees are discussed else- where elsewhere in this Agreement. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: ▪ If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the social workerpsychologist-client patient privilege law. I cannot provide disclose any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court judge would be likely to order me to disclose information. ▪ If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. ▪ If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client in order to defend myself. ▪ If a client files you file a worker’s compensation claim, and I render treatment or services in accordance with the provisions of Illinois Workers’ Compensation law, I must, upon appropriate request, pro- vide provide a copy of the client’s your record to the Labor and Industrial Commission you employer or the Work- ers’ Compensation Division, or the client’s employerhis/her appropriate designee. There are some situations in which I am legally obligated to take actionsaction, which I be- lieve believe are necessary to attempt to protect others from harm and I may have to reveal some information about a client’s treatment. These situations are unusual in my practice. ▪ If I have reasonable cause to suspect believe that a child has been or under 18 known to me in my professional capacity may be subjected to abuse an abused child or neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglectneglected child, the law requires that I file a report with Tennessee’s the local office of Department of Children’s Children and Family Services. Once such a report is filed, I may be required to provide additional information. ▪ If I have reasonable cause reason to suspect believe that an elderly adult over the age of 60 living in a domestic situation has been abused or disabled adult presents a like- lihood of suffering serious physical harm and is neglected in need of protective servicesthe preceding 12 months, the law requires that I file a report with Adult Protective Servicesthe agency designated to receive such reports by the Department of Aging. Once such a report is filed, I may be required to provide additional information. ▪ If you have made a specific threat or violence toward another or if I believe that it is necessary to disclose information to protect against you present a clear and substantial clear, imminent risk of imminent serious physical harm being inflicted by the client on him/her- self or another personto another, I may be required to disclose information in order to take protective actionactions. These actions may include, and/or initiating hospitalization and/or contacting include notifying the potential victim, and/or contacting the police and/or the client’s familypolice, or seeking hospitalization for you. ▪ If I believe that you present a clear, imminent risk of serious physical or mental injury or death to yourself, I may be required to disclose information in order to take protective actions. These actions may include seeking your hospitalization or contacting family members or others who can assist in protecting you. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records The laws governing confidentiality can be quite complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. PROFESSIONAL RECORDS You should be aware that, pursuant to HIPAA, I keep Protected Health Information (PHI) about you in two sets of professional records. One set constitutes your Clinical Office Record. It includes personal information about your reasons address, phone number, insurance, social security number, sessions billed and financial information. In addition, I also keep a set of Psychotherapy Notes. These Notes are for seeking my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Office Record. Furthermore, a description of the ways in which your problem impacts your life, your they include diagnosis, the goals that we set for treatment, your progress towards those treatment goals, your medical notes from professional consultation and social history, your treatment history, any past treatment records that I receive from other providers. These Psychotherapy Notes are kept separate from your Office Record. While insurance companies can request and receive a copy of your Office Record, re- ports they cannot receive a copy of your Psychotherapy Notes without your authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any professional consultations, way for your billing records, and any reports that have been sent to anyone, including reports to your insurance carrierrefusal. Except in the unusual circumstance where disclosure is reasonably likely to endanger you and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harm, you You may examine and/or receive a copy of your Clinical Recordboth sets of records, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of 35 cents $.10 per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Records, you have a right of review, which I will discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents of our conversations, my analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentially.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights CLIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include:include requesting that I amend your record; requesting restrictions on what information from your Office Records is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights with you. MINORS AND PARENTS Clients under 12 years of age and their parents should be aware that the law allows parents to examine their child’s treatment records. Parents of children between 12 and 18 cannot examine their child’s records unless the child consents and unless I find that there are no compelling reasons for denying the access. Parents are entitled to information concerning their child’s current physical and mental condition, diagnosis, treatment needs, services provided and services needed. Since parental involvement is often crucial to successful treatment, in most cases, I require that clients between 12 and 18 years of age and their parents enter into an agreement that allows parents access to certain additional treatment information. If everyone agrees, during treatment, I will provide parents with general information about the progress of their child’s treatment, and his/her attendance at scheduled sessions. I will also provide parents with a summary of treatment when it is complete. Any other communication will require the child’s Authorization, unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have. BILLING AND PAYMENTS You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require me to disclose otherwise confidential information. In most collection situations, the only information I release regarding a client’s treatment is his/her name, the nature of services provided, and the amount due. If such legal action is necessary, its costs will be included in the claim. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill our forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you received from your insurance company. If it is necessary to clear confusion, my office staff and I are willing to call the company on your behalf.
Appears in 1 contract
Meetings. I normally conduct an evaluation that will last from 12-2 4 sessions. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If therapy has psychotherapy is begun, I will usually schedule one 45-50 minute ses- sion session (one appointment hour of 50 minute duration) per week at a time we agree on, although some sessions may be longer or more frequent. Once an appointment hour is scheduled, you will be expected to pay for it un- less unless you provide 24-hours advanced 48 hour advance notice of cancellationcancellation [unless we both agree that you were unable to attend due to circumstances beyond your control]. It is important to note that insurance companies do not provide reimbursement for cancelled sessions. You normally will be the one who decides therapy will end, with three exceptions. If we have contracted for a specific short-time piece of work, we will finish therapy at the end of that contract. For example, if you use my multiple session packages of four, eight or twelve sessions, you will need to use these sessions in this time frame. If I am not, in my judgment, able to help you because of the kind of problem you have or because my training and skills are, in my judgment, not appropriate, I will inform you of this fact and refer you to another therapist who may meet your needs. If you do violence to, threaten, verbally or physically, or harass myself, or the office, I reserve the right to terminate you unilaterally and immediately from treatment. If I terminate you from therapy, I will offer you referrals to other sources of care, but cannot guarantee that they will accept you for therapy. Professional Fees My hourly 50 minute fee varies depending on services in the office is $90 for individuals, couples, and durationfamilies. If you do not have insurance and lack resources to pay for counseling, a reduce fee (sliding scale) is available. Just ask me. In addition to weekly ap- pointmentsappointments, I charge this amount $90 for 50 minutes (unless other financial arrangements have been made) for other professional services you may need. How- ever, though I will break down the hourly cost if I work for periods of less than one hour. Note that these additional 50 minutes or prorate mutually agreed upon time and cost for services are not covered by insurance. Other services include such as: report writing, telephone or electronic conversations lasting longer than 10-minutes10 minutes in a week, Skype appoint- ments or check-ins, consulting attendance at meetings with other professionals with your permissionyou have authorized, prepar- ing preparation of records or treatment summaries, and the time spent performing any other ser- vices service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, time even if I am called to testify by another party. Be- cause Because of the difficulty of legal involvement, I charge $500 175 per hour for preparation and attendance at any legal proceedingsproceeding. Contacting Me Due to my work schedulework, I am often not immediately available by telephone. While I am usually can be in my office four days a weekbetween 10 am to 9 pm Monday - Friday and 10 am - 4 pm on Saturday, I probably will not let my answering machine answer my calls. I monitor my calls throughout the phone when I am with a clientday. I will make every effort usually return your call in a few hours and/or on the same day with the exception of Sundays and holidays. In the event of an emergency related to your treatment with me, during the hours of 10 am to 5 pm Monday-Friday, call my answering machine at 000-000-0000 and please identify in your message that your call is urgent. If you feel you cannot wait for me to return your call by the end of or there is a delay in my business day, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. If you are unable to reach me and you feel that you can’t wait for me ability to return your call, contact your family physician, primary care physician or the nearest emergency room and ask for to speak with a mental health professional. In an emergency involving immediate risk to someone’s safety or well-being, clients agree to go to the psychologist or psychiatrist on call, nearest hospital emergency room or call 911911 without waiting for me to return the call. If I will be am unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality The law protects the privacy of all communications between a client and a therapist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, ad- xxxxx consent. Your signature on this Agreement provides consent for those activities, as follows: I may occasionally find it helpful to consult other health and mental health profes- sionals about a case. During consultation, I make every effort to avoid revealing the identity of my client. The other professionals are also legally bound to keep informa- tion confidential. If you don’t object, I will not tell you about these consultations un- less I feel that it is important to our work together. I will note all consultations in your Clinical Record. Disclosures required by health insurers or to collect overdue fees are discussed else- where in this Agreement. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the social worker-client privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. Legal Proceeding / Court Involvement If you are involved in or contemplating litigationanticipate being involved in legal or court proceedings, please notify me as soon as possible. It is important for me to understand how, if at all, your involvement in these proceedings might affect our work together. It is also important for you should consult to know that I will not be a party to any legal proceedings involving current or former clients. My goal is to support my clients to achieve therapy goals, not to address legal issues that require an adversarial approach. Clients entering treatment are agreeing to not involve me in legal/court proceedings or attempt to obtain records of treatment for legal/court proceedings. This prevents misuse of your treatment for legal objectives. In the event you require my testimony or involvement in non-adversarial aspects of legal/court proceedings I will do so only with your attorney to determine whether a court would consent. I will be likely to order me unable to disclose any information pertaining to other family members or parties involved in treatment without their specific consent to disclose this information. If a government agency is requesting the information for health oversight activitiesA fee schedule will be applied, I may be required to provide it for them. If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client in order to defend myself. If a client files a worker’s compensation claim, I must, upon appropriate request, pro- vide a copy of the client’s record to the Labor and Industrial Commission or the Work- ers’ Compensation Division, or the client’s employer. There are some situations in which I am legally obligated to take actions, which I be- lieve are necessary to attempt to protect others from harm and I may have to reveal some information about a client’s treatment. These situations are unusual in my practice. If I have reasonable cause to suspect that a child has been or may be subjected to abuse or neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglect, the law requires that I file a report with Tennessee’s Department of Children’s Services. Once such a report is filed, I may be required to provide additional information. If I have reasonable cause to suspect that an elderly or disabled adult presents a like- lihood of suffering serious physical harm and is in need of protective services, the law requires that I file a report with Adult Protective Services. Once such a report is filed, I may be required to provide additional information. If I believe that it is necessary to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by the client on him/her- self or another person, I may be required to take protective action. These actions may include, and/or initiating hospitalization and/or contacting the potential victim, and/or the police and/or the client’s family. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. as outlined under Professional Records You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure is reasonably likely to endanger you and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harm, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of 35 cents per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Records, you have a right of review, which I will discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents of our conversations, my analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentiallyFees.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include:
Appears in 1 contract
Samples: Client Services Agreement
Meetings. I normally conduct an evaluation that will may last from 1-2 to 4 sessions. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If therapy has psychotherapy is begun, I will usually schedule one 45-45 to 50 minute ses- sion session per week at a time we agree on, although some sessions may be longer or may be more or less frequent. Please note that, unless you have requested that we call, we do not call to confirm your appointment. Please be aware that you are responsible for remembering the date and time of your appointment whether or not we leave a confirmation call. Once an appointment hour is scheduled, you will be expected to pay for it un- less unless you provide 24-24 hours advanced advance notice of cancellationcancellation (unless I feel that you were unable to attend due to circumstances beyond your control). It is important to note that insurance companies do not provide reimbursement for cancelled sessions. Professional Fees PROFESSIONAL FEES My hourly fee varies depending on services and durationschedule is available upon request. In addition to weekly ap- pointmentsappointments, I charge this amount for other professional services you may need. How- ever, I will break down the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services include such as report writing, telephone conversations lasting longer than 10-15 minutes, Skype appoint- ments or check-ins, consulting with other professionals with your permission, prepar- ing preparation of records or treatment summaries, and the time spent performing any other ser- vices service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Be- cause Because of the difficulty of legal involvement, I charge $500 100 per hour 15 minutes for preparation preparation, transportation, and attendance at any legal proceedingsproceeding. Contacting Me Please note that it is our policy to avoid being a party to litigation under most circumstances. CONTACTING ME Due to my work schedule, I am often not immediately available by telephone. While My hours vary from day-to-day. When I am usually in unavailable, my office four days a week, telephone is answered by voice mail that I probably will not answer the phone when I am with a clientmonitor frequently. I will make every effort to return your call by on the end of my business daysame day you make it, with the exception of weekends holidays, vacation days, and holidaysother days off. If you are difficult to reach, please inform me of some times when you will be available. In emergencies, you can follow our emergency back-up protocol as instructed on our voice mail. The therapist on call will contact you as soon as possible. If you are unable to reach me and you feel that you can’t cannot wait for me to return your call, contact your family physician, physician or the nearest emergency room and ask for the psychologist or psychiatrist on call, or call 911room. If I will be unavailable for an extended time, I our office will provide you with the name of a trusted colleague to contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality The law protects the privacy of all communications between a client and a therapist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, ad- xxxxx consent. Your signature on this Agreement provides consent for those activities, as follows: I may occasionally find it helpful to consult other health and mental health profes- sionals about a case. During consultation, I make every effort to avoid revealing the identity of my client. The other professionals are also legally bound to keep informa- tion confidential. If you don’t object, I will not tell you about these consultations un- less I feel that it is important to our work together. I will note all consultations in your Clinical Record. Disclosures required by health insurers or to collect overdue fees are discussed else- where in this Agreement. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the social worker-client privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client in order to defend myself. If a client files a worker’s compensation claim, I must, upon appropriate request, pro- vide a copy of the client’s record to the Labor and Industrial Commission or the Work- ers’ Compensation Division, or the client’s employer. There are some situations in which I am legally obligated to take actions, which I be- lieve are necessary to attempt to protect others from harm and I may have to reveal some information about a client’s treatment. These situations are unusual in my practice. If I have reasonable cause to suspect that a child has been or may be subjected to abuse or neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglect, the law requires that I file a report with Tennessee’s Department of Children’s Services. Once such a report is filed, I may be required to provide additional information. If I have reasonable cause to suspect that an elderly or disabled adult presents a like- lihood of suffering serious physical harm and is in need of protective services, the law requires that I file a report with Adult Protective Services. Once such a report is filed, I may be required to provide additional information. If I believe that it is necessary to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by the client on him/her- self or another person, I may be required to take protective action. These actions may include, and/or initiating hospitalization and/or contacting the potential victim, and/or the police and/or the client’s family. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure is reasonably likely to endanger you and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harm, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of 35 cents per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Records, you have a right of review, which I will discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents of our conversations, my analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentially.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include:
Appears in 1 contract
Samples: Patient Services Agreement
Meetings. I normally conduct an evaluation that will last from 1-2 sessionsto 4 weekly sessions depending on the nature and complexity of the problems you bring to treatment. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If therapy has psychotherapy is begun, I will usually schedule one 4555-minute ses- sion session per week at a week, unless otherwise agreed. The time we agree on, although some sessions may be longer or more frequent. Once an scheduled for your appointment hour is scheduled, you will be expected assigned to pay for it un- less you provide 24-hours advanced notice of cancellation. It is important to note that insurance companies do not provide reimbursement for cancelled sessions. Professional Fees My hourly fee varies depending on services and duration. In addition to weekly ap- pointments, I charge this amount for other professional services you may need. How- ever, I will break down the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services include report writing, telephone conversations lasting longer than 10-minutes, Skype appoint- ments or check-ins, consulting with other professionals with your permission, prepar- ing of records or treatment summaries, and the time spent performing any other ser- vices you may request of mealone. If you become involved in legal proceedings need to cancel or reschedule a session, I ask that require you provide me with 24 hours notice. If you miss a session without canceling, or cancel with less than 24 hours notice, my participation, policy is to collect the full amount of your individual session fee or the allowed co-payment or cancellation fee amount if you are using insurance benefits. The missed session fee will be expected waived if we both agree that you were unable to pay attend an appointment due to circumstances beyond your control or if it is possible to reschedule the appointment for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Be- cause of time the difficulty of legal involvement, I charge $500 per hour for preparation and attendance at any legal proceedings. Contacting Me Due to my work schedule, I am often not immediately available by telephone. While I am usually in my office four days a same week, I probably will not answer the phone when I am with a client. I will make every effort to return reschedule the same week if possible, however my schedule does not always permit this flexibility. Professional Fees My standard private pay fee for a psychotherapy session is $150.00. You are responsible for paying at the time of your call by the end session unless prior arrangements have been made. Payments must be made with a check or cash. I am not able to process credit card charges as payment. In circumstances of unusual financial hardship, I may be willing to negotiate a fee adjustment or payment installment plan. Additionally, I make it a practice to reserve a limited portion of my business daypractice hours at rates below my standard fee. Lower rates are dependent on financial circumstances and are negotiated on a sliding scale basis. Insurance Reimbursement In order for us to set realistic treatment goals and priorities, with the exception of weekends and holidaysit is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to which you are difficult entitled; however, you (not your insurance company) are responsible for full payment of my fees. It is very important that you find out exactly what mental health services your insurance policy covers and what the reimbursement procedure entails. In order to reachprocess claims, please inform me I will need to collect some information about you and your insurance coverage at the beginning of some times when treatment. For this purpose, I will ask you will be availableto complete a billing information form at the beginning of therapy. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you are unable to reach me and you feel that you can’t wait for me to return have questions about the coverage, call your call, contact your family physician, the nearest emergency room and ask for the psychologist or psychiatrist on call, or call 911plan administrator. If I will be unavailable for an extended time, I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the name information you receive from your insurance company. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a colleague contactperson’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While a lot can be accomplished in short-term therapy, if necessarysome patients feel that they need or desire more services after insurance benefits end. You may should also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx be aware that most insurance companies require you to communicate authorize me to provide them with mea clinical diagnosis. Limits Sometimes I have to provide additional clinical information such as treatment plans or summaries, or copies of Confidentiality The law protects the privacy entire record (in very rare cases). This information will become part of the insurance company files and will probably be stored in a computer. Though all communications between a client and a therapistinsurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In most situationssome cases, I can only release they may share the information about your treatment to others if you sign with a written Authorization Form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, ad- xxxxx consent. Your signature on this Agreement provides consent for those activities, as follows: I may occasionally find it helpful to consult other health and mental health profes- sionals about a case. During consultation, I make every effort to avoid revealing the identity of my client. The other professionals are also legally bound to keep informa- tion confidential. If you don’t object, I will not tell you about these consultations un- less I feel that it is important to our work togethernational medical information databank. I will note all consultations in your Clinical Record. Disclosures required by health insurers or to collect overdue fees are discussed else- where in this Agreement. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: If provide you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the social worker-client privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client in order to defend myself. If a client files a worker’s compensation claim, I must, upon appropriate request, pro- vide a copy of the client’s record to the Labor and Industrial Commission or the Work- ers’ Compensation Division, or the client’s employer. There are some situations in which any report I am legally obligated to take actions, which I be- lieve are necessary to attempt to protect others from harm and I may have to reveal some information about a client’s treatment. These situations are unusual in my practice. If I have reasonable cause to suspect that a child has been or may be subjected to abuse or neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglect, the law requires that I file a report with Tennessee’s Department of Children’s Services. Once such a report is filed, I may be required to provide additional information. If I have reasonable cause to suspect that an elderly or disabled adult presents a like- lihood of suffering serious physical harm and is in need of protective services, the law requires that I file a report with Adult Protective Services. Once such a report is filed, I may be required to provide additional information. If I believe that it is necessary to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by the client on him/her- self or another person, I may be required to take protective action. These actions may include, and/or initiating hospitalization and/or contacting the potential victim, and/or the police and/or the client’s family. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure is reasonably likely to endanger you and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harm, you may examine and/or receive a copy of your Clinical Recordsubmit, if you request it in writingit. Because these Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are professional recordsavailable and what will happen if they run out before you feel ready to end our sessions. It is important to remember that you always have the right to pay for my services yourself to avoid the problems described above. However, they can be misinterpreted and/or upsetting some managed-care plans will not allow me to untrained readersprovide services to you once your benefits end. For If this reasonis the case, I recommend that will do my best to find another provider who can help you initially review them in my presence, continue your psychotherapy should you wish to continue. Many insurance policies leave a percentage of the fee (which is called co- insurance) or have them forwarded a flat dollar amount (referred to another mental health professional so you can discuss as a co-payment) to be covered by the contentspatient. In most circumstances, I am allowed Either amount is to charge a copying fee be paid at the time of 35 cents per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Records, you have a right of review, which I will discuss with you upon requesteach visit by check or cash. In addition, some insurance companies also have a deductible, which is an out- of-pocket amount, which must be paid by the patient before the insurance companies are willing to begin paying any amount for services. This will typically mean that you will be responsible to pay for initial sessions with me until your deductible has been met; the deductible amount may also need to be met at the start of each calendar year. If I also keep am not a set of Psychotherapy Notes. These Notes are participating provider for my own use and are designed to assist me in providing your insurance plan, I will supply you with the best treatmenta receipt of payment for services, which you can submit to your insurance company for reimbursement. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents of our conversations, my analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information Please note that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentially.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including all insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way reimburse for your refusal to provide it. Patient Rights HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include:out-of-network providers.
Appears in 1 contract
Samples: www.tcicciarellipsyd.com
Meetings. I normally conduct an evaluation that will last from 1-2 to 4 sessions. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If therapy has begunpsychotherapy is started, I will usually schedule one 45-minute ses- sion session (one appointment hour of 45 minutes duration) per week at a time we agree on, although some sessions may be longer or more frequent. Once an appointment hour is scheduled, you will be expected to pay for it un- less unless you provide 24-hours advanced advance notice of cancellationcancellation the day before the appointment [unless we both agree that you were unable to attend due to circumstances beyond your control]. It is important to note that insurance companies do not provide reimbursement for cancelled sessions. Professional Fees PROFESSIONAL FEES My hourly fee varies depending on services fees are as follows: Initial Appointment $170, Individual Psychotherapy $140, Couples and durationFamily Therapy $145. In addition to weekly ap- pointmentsappointments, I charge this amount $170 for other professional services you may need. How- ever, though I will break down the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services include report writing, telephone conversations lasting longer than 10-10 minutes, Skype appoint- ments or check-ins, consulting with other professionals with your permission, prepar- ing preparation of records or treatment summaries, and the time spent performing any other ser- vices service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Be- cause Because of the difficulty of legal involvement, I charge $500 250 per hour for preparation and attendance at any legal proceedingsproceeding. Contacting Me CONTACTING ME Due to my work schedule, I am often not immediately available by telephone. While I am usually in my office four days a weekbetween 10 AM and 7 PM, I probably will not answer the phone when I am with a clientpatient. When I am unavailable, my telephone is answered by voice mail that I monitor frequently. I will make every effort to return your call by on the end of my business daysame day you make it, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. In emergencies, you can try me at 410-707- 2262. If you are unable to reach me and you feel that you can’t wait for me to return your call, contact your family physician, physician or the nearest emergency room and ask for the psychologist or psychiatrist on call, or call 911. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client patient and a therapistpsychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form form that meets certain legal requirements imposed by HIPAAHIPAA and/or Maryland law. There are other situations that require only that you provide writtenHowever, ad- xxxxx consent. Your signature on this Agreement provides consent for those activitiesin the following situations, as followsno authorization is required: • I may occasionally find it helpful to consult other health and mental health profes- sionals professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my clientpatient. The other professionals are also legally bound to keep informa- tion the information confidential. If you don’t object, I will not tell you about these consultations un- less unless I feel that it is important to our work together. I will note all consultations in your Clinical RecordRecord (which is called “PHI” in my Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information). • I also have a contract with Psychiatric Billing Services. As required by HIPAA, I have a formal business associate contract with this business, in which they promise to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I can provide you with the names of these organizations and/or a blank copy of this contract. • Disclosures required by health insurers or to collect overdue fees are discussed else- where elsewhere in this Agreement. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: • If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the social workerpsychologist-client patient privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. • If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. • If a client patient files a complaint or lawsuit against me, I may disclose relevant information regarding that client patient in order to defend myself. If a client files a worker’s compensation claim, I must, upon appropriate request, pro- vide a copy of the client’s record to the Labor and Industrial Commission or the Work- ers’ Compensation Division, or the client’s employer. There are some situations in which I am legally obligated to take actions, which I be- lieve believe are necessary to attempt to protect others from harm and I may have to reveal some information about a clientpatient’s treatment. These situations are unusual in my practice. § If I have reasonable cause reason to suspect believe that a child or vulnerable adult has been or may be subjected to abuse or neglect neglect, or observe that a child being vulnerable adult has been subjected to conditions self-neglect, or circumstances that would reasonably result in abuse or neglectexploitation, the law requires that I file a report with Tennessee’s the appropriate government agency, usually the local office of the Department of Children’s Social Services. Once such a report is filed, I may be required to provide additional information. § If I have reasonable cause know that a patient has a propensity for violence and the patient indicates that he/she has the intention to suspect that an elderly or disabled adult presents inflict imminent physical injury upon a like- lihood of suffering serious physical harm and is in need of protective services, the law requires that I file a report with Adult Protective Services. Once such a report is filed, I may be required to provide additional information. If I believe that it is necessary to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by the client on him/her- self or another personspecified victim(s), I may be required to take protective actionactions. These actions may includeinclude establishing and undertaking a treatment plan that is calculated to eliminate the possibility that the patient will carry out the threat, seeking hospitalization of the patient and/or informing the potential victim or the police about the threat. § If I believes that that there is a imminent risk that a patient will inflict serious physical harm or death on him/herself, or that immediate disclosure is required to provide for the patient’s emergency health care needs, I may be required to take appropriate protective actions, including initiating hospitalization and/or contacting notifying family members or others who can protect the potential victim, and/or the police and/or the client’s familypatient. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records The laws governing confidentiality can be quite complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. PROFESSIONAL RECORDS You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where circumstances that disclosure is reasonably likely to endanger the life or physical safety of you and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harmperson, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of 35 cents $1.00 per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Records, you have a right of review, which I will discuss with you upon request. In addition, I may also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentially.] These Psychotherapy Notes are kept separate from your Clinical Record. Your While insurance companies can request and receive a copy of your Clinical Record, they cannot receive a copy of your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your writtensigned, signed written Authorization. Insurance companies cannot require your authorization Authorization as a condition of coverage nor penalize you in any way for your refusal refusal. You may examine and/or receive a copy of your Psychotherapy Notes unless I determine that knowledge of the health care information would be injurious to provide ityour health. Patient Rights PATIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include:include requesting that I amend your record; requesting restrictions on what information from your Clinical Records is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights with you. MINORS & PARENTS Patients under 16 years of age who are not emancipated and their parents should be aware that the law may allow parents to examine their child’s treatment records. While privacy in psychotherapy is very important, particularly with teenagers, parental involvement is also essential to successful treatment. Therefore, it is usually my policy to request an agreement from any patient between 16 and 18 and his/her parents allowing me to share general information about the progress of treatment and their child’s attendance at scheduled sessions. I will also provide parents with a summary of their child’s treatment when it is complete. Any other communication will require the child’s authorization, unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have. BILLING AND PAYMENTS You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. In circumstances of unusual financial hardship, I may be willing to negotiate a fee adjustment or payment installment plan. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require me to disclose otherwise confidential information. In most collection situations, the only information I release regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due. If such legal action is necessary, its costs will be included in the claim. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, I will be willing to call the company on your behalf. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in short-term therapy, some patients feel that they need more services after insurance benefits end. You should also be aware that your contract with your health insurance company requires that I provide it with information relevant to the services that I provide to you. Maryland permits me to send some information without your consent in order to file appropriate claims. I am required to provide them with a clinical diagnosis. Sometimes I am required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. Maryland law prevents insurers from making unreasonable demands for information, but there are no specific guidelines about what unreasonable includes. If I believe that your health insurance company is requesting an unreasonable amount of information, I will call it to your attention and we can discuss what to do. You can instruct me not to send requested information, but this could result in claims not being paid and an additional financial burden being placed on you. Once the insurance company has this information, it will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your sessions. It is important to remember that you always have the right to pay for my services yourself to avoid the problems described above unless prohibited by contract.
Appears in 1 contract
Samples: Patient Services Agreement
Meetings. I normally conduct an evaluation that will last from 1-2 to 4 sessions. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If therapy has psychotherapy is begun, I will usually schedule one 45-minute ses- sion session (one appointment session of 45 minutes duration) per week at a time we agree on, although some sometimes sessions may be longer more or more less frequent. Once an appointment hour is scheduled, you will be expected to pay for it un- less unless you provide 24-48 hours advanced advance notice of cancellation. It is important to note that insurance companies do not provide reimbursement for cancelled sessions. Professional Fees PROFESSIONAL FEES My hourly fee varies depending on services and durationis $250 per session; each session is 45 minutes. In addition to weekly ap- pointmentsappointments, I charge this amount for other professional services you may need. How- ever, though I will break down the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurancesession. Other services include report writing, telephone conversations lasting longer than 10-a few minutes, Skype appoint- ments or check-ins, consulting with other professionals with your permission, prepar- ing preparation of records or treatment summaries, and the time spent performing any other ser- vices service you may request of me. I may increase my fee annually. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Be- cause Because of the difficulty of legal involvement, I charge $500 per 400/hour for preparation preparation, travel time, and attendance at any legal proceedingsproceeding. Contacting Me CONTACTING ME Due to my work schedule, I am often not immediately available by telephone. While I am usually in my office four days a week, I probably will generally do not answer the phone when I am with a client. When I am unavailable, my telephone is answered by an answering machine that I monitor frequently. I will make every effort to return your call by on the end of my business daysame day you make it, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. If you are unable to reach me and you feel that you can’t wait for me to return your call, contact your family physician, physician or the nearest emergency room and ask for the psychologist or psychiatrist on call, or call 911. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. You Please note that I do not use texting, and that my office phone cannot receive texts. I am happy to use email to schedule or rearrange appointment. However, if you want to contact me about a clinical matter, please leave a phone message rather than discuss the matter in an email, as emails in general cannot be completely secure. I do not accept friend or contact requests from current or former clients on any social networking site (e.g., LinkedIn). I believe that adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits blur the boundaries of Confidentiality The law protects the privacy of all communications between a client and a therapist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, ad- xxxxx consent. Your signature on this Agreement provides consent for those activities, as follows: I may occasionally find it helpful to consult other health and mental health profes- sionals about a case. During consultation, I make every effort to avoid revealing the identity of my client. The other professionals are also legally bound to keep informa- tion confidentialour therapeutic relationship. If you don’t objecthave questions about this, I will not tell you please bring them up when we meet and we can talk more about these consultations un- less I feel that it is important to our work together. I will note all consultations in your Clinical Record. Disclosures required by health insurers or to collect overdue fees are discussed else- where in this Agreement. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the social worker-client privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client in order to defend myself. If a client files a worker’s compensation claim, I must, upon appropriate request, pro- vide a copy of the client’s record to the Labor and Industrial Commission or the Work- ers’ Compensation Division, or the client’s employer. There are some situations in which I am legally obligated to take actions, which I be- lieve are necessary to attempt to protect others from harm and I may have to reveal some information about a client’s treatment. These situations are unusual in my practice. If I have reasonable cause to suspect that a child has been or may be subjected to abuse or neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglect, the law requires that I file a report with Tennessee’s Department of Children’s Services. Once such a report is filed, I may be required to provide additional information. If I have reasonable cause to suspect that an elderly or disabled adult presents a like- lihood of suffering serious physical harm and is in need of protective services, the law requires that I file a report with Adult Protective Services. Once such a report is filed, I may be required to provide additional information. If I believe that it is necessary to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by the client on him/her- self or another person, I may be required to take protective action. These actions may include, and/or initiating hospitalization and/or contacting the potential victim, and/or the police and/or the client’s family. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure is reasonably likely to endanger you and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harm, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of 35 cents per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Records, you have a right of review, which I will discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents of our conversations, my analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentiallyit.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include:
Appears in 1 contract
Samples: www.drrobinrosenberg.com
Meetings. I normally conduct an evaluation that typically meet with parent(s)/legal guardian and the son or daughter at the initial intake/consultation. At this meeting, I ask the family for detailed information about the problems the son or daughter has been experiencing. At the end of the session, I will last from 1-2 sessions. During this time, we both decide let the family know if I am think I can be helpful given the best person history they have provided. I ask parents/legal guardians to provide go home and talk with their son or daughter about the services you need in order meeting. I ask them to meet your treatment goalslet me know by phone or e-mail if they would like to schedule another appointment. If therapy has psychotherapy is begun, I will usually schedule one 45-55 minute ses- sion session (one appointment hour of 55 minutes duration) per week or at specified intervals at a time we agree on, although some sessions may be longer or more frequent. PROFESSIONAL FEES The fee for the initial intake/consultation is $210.00. Fees for subsequent 55 minute sessions are $175.00. I require keeping a credit card on file. This card will be charged on the date of service, unless you prefer to pay with cash or check at time of service. You will be provided a receipt for your records. Once an appointment hour is scheduled, you will be expected to pay for it un- less unless you provide 24-24 hours advanced advance notice of cancellation. It is important cancellation (unless we both agree that you were unable to note that insurance companies do not provide reimbursement for cancelled sessions. Professional Fees My hourly fee varies depending on services and duration. In addition attend due to weekly ap- pointments, I charge this amount for other professional services you may need. How- ever, I will break down the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services include report writing, telephone conversations lasting longer than 10-minutes, Skype appoint- ments or check-ins, consulting with other professionals with circumstances beyond your permission, prepar- ing of records or treatment summaries, and the time spent performing any other ser- vices you may request of me. control.) If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Be- cause Because of the difficulty of legal involvement, I charge $500 175.00 per hour for preparation and attendance at any legal proceedingsproceeding. Contacting Me This includes preparation, driving time, and all time spent in court. In addition, a charge of $75 per hour will be assessed by my assistant regarding any legal proceeding. CONTACTING ME Due to my work schedule, I am often not immediately available by telephone. While When I am usually in unavailable you may leave a message on my office four days a week, I probably will not answer the phone when I am with a clientvoice mail at 000-000-0000. I will make every effort to return your call by the end of my business day, with the exception of weekends and holidayswithin 24 hours. If you are difficult to reach, please inform me of some times when you will be available. If you are unable facing a life threatening emergency, you should go to reach me and you feel that you can’t wait for me to return your call, contact your family physician, the nearest emergency room and ask for the psychologist or psychiatrist mental health professional on call, or call 911. If I will be unavailable The phone number for an extended time, I will provide you with the name Suicide Center of a colleague contact, if necessaryNorth Texas is (000) 000-0000. You can also text “CONNECT” to 741741 anytime to reach trained, caring volunteers at the National Crisis Text Line. The National Suicide Prevention lifeline phone number is (000)000-0000. All email communication goes through my administrative assistant (xxxxxxxxx000@xxxxx.xxx) and should not be used to contact me in an emergency. E- mail, phone texts and similar forms of communication may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx be vulnerable to communicate with meunauthorized access which can compromise privacy and confidentiality. Limits Electronic means of Confidentiality communication are not fail-safe in terms of encryption and do not provide the same protection as face to face therapy sessions. Please do not use electronic communication to send sensitive information. LIMITS OF CONFIDENTIALITY The law protects the privacy of all communications between a client patient and a therapistpsychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, ad- xxxxx advance consent. Your signature on this Agreement provides consent for those activities, as follows: I may occasionally find it helpful to consult other health and mental health profes- sionals professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my clientpatient. The other professionals are also legally bound to keep informa- tion the information confidential. If you don’t n't object, I will not tell you about these consultations un- less unless I feel that it is important to our work together. I will note all consultations in your Clinical RecordRecord (which is called "PHI" in my Notice of Psychologist's Policies and Practices to Protect the Privacy of Your Health Information). Disclosures required by health insurers • If a patient seriously threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her, or to collect overdue fees are discussed else- where in this Agreementcontact family members or others who can help provide protection. Texas law provides that a professional may disclose confidential information only to medical or law enforcement personnel if the professional determines that there is a probability of imminent physical injury by the patient to the patient or others, or there is a probability of immediate mental or emotional injury to the patient. There are some situations where I am permitted or required to disclose information without either your consent or Authorizationauthorization: • If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the social worker-client privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. • If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. • If a client patient files a complaint or lawsuit against me, I may disclose relevant information regarding that client patient in order to defend myself. • If a client patient files a worker’s 's compensation claim, I must, upon appropriate request, pro- vide provide records relating to treatment or hospitalization for which compensation is being sought. • If a copy of the client’s record patient fails to the Labor and Industrial Commission or the Work- ers’ Compensation Divisionpay for services I have rendered, or the client’s employerI may disclose relevant information in a suit seeking payment. There are some situations in which I am legally obligated to take actions, which I be- lieve believe are necessary to attempt to protect others from harm and I may have to reveal some information about a client’s patient's treatment. These situations are unusual in my practice. • If I have reasonable cause to suspect believe that a child under 18 has been or may be subjected to abuse abused or neglected (including physical injury, substantial threat of harm, mental or emotional injury, or any kind of sexual contact or conduct), or that a child is a victim of a sexual offense, or that an elderly or disabled person is in a state of abuse, neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglectexploitation, the law requires that I file make a report with Tennessee’s to the appropriate governmental agency, usually the Department of Children’s Protective and Regulatory Services. Once such a report is filed, I may be required to provide additional information. • If I have reasonable cause to suspect determine that an elderly or disabled adult presents there is a like- lihood of suffering serious probability that the patient will inflict imminent physical harm and is in need of protective services, the law requires that I file a report with Adult Protective Services. Once such a report is filed, I may be required to provide additional information. If I believe that it is necessary to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by the client injury on him/her- self herself, or another personanother, or that the patient will inflict imminent mental or emotional harm upon others, I may be required to take protective action. These actions may include, and/or initiating action by disclosing information to medical or law enforcement personnel or by securing hospitalization and/or contacting of the potential victim, and/or the police and/or the client’s familypatient. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and and, I will limit my disclosure to what is necessary. By signing this agreement, you authorize me to contact any person/entity in a position to prevent harm to the patient or a third party if I determine there is a probability of harm to the patient or a third party. In addition, I have an assistant, Xxx Xxxxxx, and part-time assistant Xxxxxx Xxxxxx who work in the office assisting with paper work and office duties. This work brings them into contact with PHI of the clients with whom I work. As employees working with a psychologist, they are bound by the same duties of confidentiality required of me. I have educated them about the requirement that they view only that portion of PHI required to complete administrative tasks included but not limited to correspondence (scheduling, sending copies of this document…) with a patient’s parents or patient by mail, telephone, or e-mail, filing, copying, and data entry of responses to questionnaires. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records You should The laws governing confidentiality can be aware thatquite complex and I am not an attorney. In situations where specific advice is required, pursuant to HIPAA, formal legal consultation may be needed. PROFESSIONAL RECORDS The laws and standards of my profession require that I keep Protected Health Information about you or your child in two sets of professional records. One set constitutes your Clinical Record. It , The Clinical Record includes information about you or your child's reasons for seeking therapy, a description of the ways in which your the problem impacts on you or your child's life, your the diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrierchild's school. Except in the unusual circumstance where disclosure is reasonably likely circumstances that involve danger to endanger you yourself and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harmothers, you may examine and/or receive a copy of your Clinical Record, Record if you request it in writing. You should be aware that pursuant to Texas law, psychological test data are not part of a patient's record. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of 35 cents $.50 per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Recordsrecords, you have a right of review, which I will discuss with you upon your request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents of our conversations, my analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentially.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights PATIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your Clinical Records Record and disclosures of protected health information. These rights include:include requesting that I amend your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and my privacy policies and procedures. MINORS & PARENTS Patients under 18 years of age who are not emancipated and their parents should be aware that the law may allow parents to examine their child's treatment records. However, if the treatment is for suicide prevention, chemical addiction or dependency, or sexual, physical or emotional abuse, the law provides that parents may not access their child's records. For children and adolescents, because privacy in psychotherapy is often critical in building rapport with the therapist which is crucial to successful progress, it is my policy to discuss the manner in which I will communicate with the son or daughter and the parents. This discussion will typically take place early on in therapy so that all parties are informed as to how we will work together. SAFE HARBOR AGREEMENT
Appears in 1 contract
Samples: Services Agreement
Meetings. I normally conduct an evaluation assessment that will last from 1-2 1 to 3 sessions. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If therapy Once psychotherapy has begun, I will usually schedule one 4555-minute ses- sion session per week at a time we agree on, although some sessions may be longer longer, more frequent or more frequentspaced out. Once an appointment hour is scheduled, you will be expected to pay for it un- less unless you provide 24-24 hours advanced advance notice of cancellation. It is important to note that insurance companies do not provide reimbursement for cancelled canceled sessions. Professional Fees PROFESSIONAL FEES My hourly fee varies depending on services and durationfor private pay patients is $100.00. For other patients, my fee is determined by the contract I have with their health insurance provider. In addition to weekly ap- pointmentstherapy appointments, I charge this amount for other professional services you may need. How- ever, I will break down the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services include report writing, telephone conversations lasting longer than 10-15 minutes, Skype appoint- ments or check-ins, consulting with other professionals with your permission, prepar- ing preparation of records or treatment summaries, and the time spent performing any other ser- vices service you may request of me. If you become involved in legal proceedings me that require my participation, you will be expected to pay for all falls within the scope of my professional time, including preparation practice and transportation costs, even if I am called to testify by another partylicensure. Be- cause of the difficulty of legal involvement, I charge $500 per hour for preparation and attendance at any legal proceedings. Contacting Me CONTACTING ME Due to my work schedule, I am often not immediately available by telephone. While At this time, my usual office hours are between 10 AM and 8 PM Monday through Friday and 8 AM to 2 PM on Saturdays. When I am usually in my office four days a weekthe office, I probably will not may be able to answer the phone when (000-000-0000) unless I am with another patient. When I am unavailable, my telephone is answered by a clientvoicemail that I try to monitor frequently. I will make every effort to return your call by on the end of my business daysame day you make it, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. In emergencies, you can try me at my cell number at 000-000-0000. If you are unable to reach me and you feel that you can’t wait for me to return your call, contact your family physician, physician or the nearest emergency room and ask for the psychologist or psychiatrist on call, or call 911room. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client patient and a therapistpsychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, ad- xxxxx advance consent. Your signature on this Agreement provides consent for those activities, as follows: • I may occasionally find it helpful to consult other health and mental health profes- sionals professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my clientpatient. The other professionals are also legally bound to keep informa- tion the information confidential. If you don’t object, I will not tell you about these consultations un- less unless I feel that it is important to our work together. I will note all consultations in your Clinical Record. • Disclosures required by health insurers or to collect overdue fees are discussed else- where elsewhere in this Agreement. • If a patient seriously threatens to harm himself/herself I may be obligated to seek hospitalization for him/her, or to contact family members or others who can help provide protection. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: • If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatmentthe professional services I provided to you, such information is protected by the social workertherapist-client patient privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. • If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. • If I am treating a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client in order to defend myself. If a client patient who files a worker’s compensation claim, I mustmay, upon appropriate request, pro- vide a copy of the client’s record be required to the Labor and Industrial Commission or the Work- ers’ Compensation Division, or the client’s provide otherwise confidential information to your employer. There are some situations in which I am legally obligated to take actions, which I be- lieve believe are necessary to attempt to protect others from harm and I may have to reveal some information about a clientpatient’s treatment. These situations are unusual in my practice. • If I have reasonable cause reason to suspect believe that a child has been who I am evaluating or may be subjected to abuse or neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglecttreating is an abused child, the law requires that I file a report with Tennessee’s the appropriate government agency, usually the Department of Children’s ServicesPublic Welfare. Once such a report is filed, I may be required to provide additional information. • If I have reasonable cause reason to suspect believe that an elderly person or disabled other adult presents a like- lihood of suffering serious physical harm and is in need of protective servicesservices (regarding abuse, neglect, exploitation or abandonment), the law requires that I file a allows me to report with Adult Protective Servicesthis to appropriate authorities, usually the Department of Aging, in the case of an elderly person. Once such a report is filed, I may be required to provide additional information. • If I believe that it one of my patients presents a specific and immediate threat of serious bodily injury regarding a specifically identified or a reasonably identifiable victim and he/she is necessary likely to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by carry out the client on him/her- self threat or another personintent, I may be required to take protective action. These actions may includeactions, and/or initiating hospitalization and/or contacting such as warning the potential victim, and/or contacting the police and/or the client’s family. police, or initiating proceedings for hospitalization If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records You should The laws governing confidentiality can be aware thatquite complex, pursuant to HIPAAand I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. PROFESSIONAL RECORDS The laws and standards of my profession require that I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in unusual circumstances that involve danger to yourself and/or others or where information has been supplied to me confidentially by others, or the unusual circumstance where disclosure record makes reference to another person (unless such other person is a health care provider) and I believe that access is reasonably likely to endanger you and/or others or when another individual (cause substantial harm to such other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harmperson, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of 35 cents 50¢ per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Recordsrecords, you have a right of review, review (except for information has been supplied to me confidentially by others) which I will discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents of our conversations, my analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentially.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights PATIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your Clinical Records Record and disclosures of protected health information. These rights include:include requesting that I amend your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the Notice form referred to above, and my privacy policies and procedures. I am happy to discuss any of these rights with you. BILLING AND PAYMENTS You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. In circumstances of unusual financial hardship, I may be willing to negotiate a fee adjustment or payment installment plan. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, I will be willing to call the company on your behalf. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in short- term therapy, some patients feel that they need more services after insurance benefits end. Please feel free to discuss with me the option of continuing treatment on a private basis until such time as a new benefit year applies. You should also be aware that your contract with your health insurance company requires that I provide it with information relevant to the services that I provide to you. I am required to provide a clinical diagnosis. Sometimes I am required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier.
Appears in 1 contract
Samples: kirkcounseling.com
Meetings. I We normally conduct an evaluation that will last from 1-2 to 4 sessions. During this time, you can determine if we both decide if I am are the best person therapists to provide the services you need in order to meet your treatment goals. If therapy has psychotherapy is begun, I we will usually schedule one 4555-minute ses- sion session (one appointment hour of 55 minutes duration) per week at a time we you agree onupon with your therapist, although some sessions may be longer or more frequent. Once an appointment hour is scheduled, you will be expected to pay for it un- less unless you provide 24-24 hours advanced advance notice of cancellationcancellation [unless we agree that you were unable to attend due to circumstances beyond your control]. It is important to note that insurance companies do not provide reimbursement for cancelled sessions. [If it is possible, we will try to find another time to reschedule the appointment.] Professional Fees My hourly Our regular session fee varies depending on services and durationis $150.00 for any PhD level practitioner, $140.00 for any Master’s level practitioner. In addition to weekly ap- pointmentsappointments, I we charge this amount for other professional services you may need. How- ever, I though we will break down the hourly cost if I we work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services include report writing, telephone conversations lasting longer than 10-10 minutes, Skype appoint- ments or check-ins, consulting with other professionals with your permission, prepar- ing preparation of records or treatment summaries, and the time spent performing any other ser- vices service you may request of meus. If you become involved in legal proceedings that require my your therapist’s participation, you will be expected to pay for all of my our professional time, including preparation and transportation costs, even if I am we are called to testify by another party. Be- cause [Because of the difficulty of legal involvement, I we charge $500 300.00 per hour for preparation and attendance at any legal proceedings. proceeding.] Contacting Me Us Due to my our work scheduleschedules, I am we are often not immediately available by telephone. While I am we are usually in my the office four days a weekbetween 9:00am and 6:00pm Monday through Thursday, I your therapist probably will not be able answer the phone because he/she is usually with patients. When we are unavailable, our telephones are answered by the receptionist [during normal office hours, 9:00am to 5:00pm Monday through Thursday], an answering service [when I am with a clientthe secretary is not present and you dial 000.000.0000], or voice mail [when the secretary is not present and you dial 000.000.0000]. I During our office hours, the receptionist usually informs us of phone calls between our appointments. The answering service can usually reach us after hours in an emergency. The voice mail is usually taken by the secretary. We will make every effort to return your call by on the end of my business daysame day you make it, with the exception of weekends Friday - Sunday, after hours, and holidays. If you are difficult to reach, please inform me us of some times when you will be available. [In emergencies and after hours, please call 000.000.0000 to reach the answering service.] If you are unable to reach me your therapist and you feel that you can’t wait for me to a return your call, contact your family physician, physician or the nearest emergency room and ask for the psychologist or psychiatrist on call, or call 911. If I your therapist will be unavailable for an extended time, I we will provide you with the name of a colleague to contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality The law protects the privacy of all communications between a client and a therapist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, ad- xxxxx consent. Your signature on this Agreement provides consent for those activities, as follows: I may occasionally find it helpful to consult other health and mental health profes- sionals about a case. During consultation, I make every effort to avoid revealing the identity of my client. The other professionals are also legally bound to keep informa- tion confidential. If you don’t object, I will not tell you about these consultations un- less I feel that it is important to our work together. I will note all consultations in your Clinical Record. Disclosures required by health insurers or to collect overdue fees are discussed else- where in this Agreement. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the social worker-client privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client in order to defend myself. If a client files a worker’s compensation claim, I must, upon appropriate request, pro- vide a copy of the client’s record to the Labor and Industrial Commission or the Work- ers’ Compensation Division, or the client’s employer. There are some situations in which I am legally obligated to take actions, which I be- lieve are necessary to attempt to protect others from harm and I may have to reveal some information about a client’s treatment. These situations are unusual in my practice. If I have reasonable cause to suspect that a child has been or may be subjected to abuse or neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglect, the law requires that I file a report with Tennessee’s Department of Children’s Services. Once such a report is filed, I may be required to provide additional information. If I have reasonable cause to suspect that an elderly or disabled adult presents a like- lihood of suffering serious physical harm and is in need of protective services, the law requires that I file a report with Adult Protective Services. Once such a report is filed, I may be required to provide additional information. If I believe that it is necessary to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by the client on him/her- self or another person, I may be required to take protective action. These actions may include, and/or initiating hospitalization and/or contacting the potential victim, and/or the police and/or the client’s family. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure is reasonably likely to endanger you and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harm, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of 35 cents per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Records, you have a right of review, which I will discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents of our conversations, my analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentially.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include:
Appears in 1 contract
Samples: Patient Services Agreement
Meetings. I normally conduct an evaluation that will last from 1-2 to 4 sessions. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If therapy has psychotherapy is begun, I will usually schedule one 45-45 – 50 minute ses- sion session (one appointment hour of 45 -50 minutes duration) per week at a time we agree on, although some sessions may be longer or more frequent. Once an appointment hour is scheduled, you will be expected to pay for it un- less unless you provide 24-24 hours advanced advance notice of cancellationcancellation (unless we both agree that you were unable to attend due to circumstances beyond your control). It is important to note that insurance companies do not provide reimbursement for cancelled sessions. Professional Fees If it is possible, I will try to find another time to reschedule the appointment. PROFESSIONAL FEES My hourly fee varies depending on services and durationis $120. In addition to weekly ap- pointmentsappointments, I charge this amount for other professional services you may need. How- ever, though I will break down the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services include report writing, telephone conversations lasting longer than 10-5 minutes, Skype appoint- ments or check-ins, consulting with other professionals with your permission, prepar- ing preparation of records or treatment summaries, and the time spent performing any other ser- vices service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Be- cause Because of the difficulty of legal involvement, I charge $500 300 per hour for preparation and attendance at any legal proceedingsproceeding. Contacting Me CONTACTING ME Due to my work schedule, I am often not immediately available by telephone. While I am usually in my office four days a weekbetween 9 am and 8 pm, I probably will not answer the phone when I am with a clientpatient. When I am unavailable, my telephone is answered by an answering machine that I monitor frequently. I will make every effort to return your call by the end of my business daywithin 48 hours, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. If you are unable to reach me and you feel that you can’t n't wait for me to return your call, contact your family physician, physician or the nearest emergency room and ask for the psychologist or psychiatrist on call, or call 911. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality necessary LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client patient and a therapistpsychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, ad- xxxxx advance consent. Your signature on this Agreement provides consent for those activities, as follows: • I may occasionally find it helpful to consult other health and mental health profes- sionals professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my clientpatient. The other professionals are also legally bound to keep informa- tion the information confidential. If you don’t n't object, I will not tell you about these consultations un- less unless I feel that it is important to our work together. I will note all consultations in your Clinical RecordRecord (which is called “PHI” in my Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information). • You should be aware that I practice with other mental health professionals and that I employ administrative staff. In most cases, I need to share protected information with these individuals for both clinical and administrative purposes, such as scheduling, billing and quality assurance. All of the mental health professionals are bound by the same rules of confidentiality. Al staff members have been given training about protecting your privacy and have agreed not to release any information outside of the practice without the permission of a professional staff member. • Disclosures required by health insurers or to collect overdue fees are discussed else- where elsewhere in this Agreement. • If I believe that a patient presents an imminent danger to his/her health or safety, I may be obligated to seek hospitalization for him/her, or to contact family members or others who can help provide protection. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: • If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatmentthe professional services that I provided you, such information is protected by the social workerpsychologist-client patient privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. PUT SOMETHING HERE ABOUT NOT DOING COURT CUSTODY LITIGATION, AND NOT APPEARING IN COURT • If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. • If a client patient files a complaint or lawsuit against me, I may disclose relevant information regarding that client patient in order to defend myself. • If a client patient files a worker’s compensation claim, and my services are being compensated through workers compensation benefits, I must, upon appropriate request, pro- vide provide a copy of the clientpatient’s record to the Labor and Industrial Commission patient’s employer or the Work- ers’ Compensation DivisionNorth Carolina Industrial Commission. PUT SOMETHING HERE ABOUT Your insurance company audits your record, or I must, upon appropriate request, provide a copy of the clientpatient’s employerrecord to the patient’s insurance company. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. • There are some situations in which I am legally obligated to take actions, which I be- lieve believe are necessary to attempt to protect others from harm and I may have to reveal some information about a clientpatient’s treatment. These situations are unusual in my practice. • If I have cause to suspect that child under 18 is abused or neglected, or if I have reasonable cause to suspect believe that a child has been or may be subjected to abuse or neglect or observe a child being subjected to conditions or circumstances that would reasonably result disabled adult is in abuse or neglectneed of protective services, the law requires that I file a report with Tennessee’s Department the County Director of Children’s Social Services. Once such a report is filed, I may be required to provide additional information. • If I have reasonable cause believe that a patient presents an imminent danger to suspect that an elderly or disabled adult presents a like- lihood the health and safety of suffering serious physical harm and is in need of protective services, the law requires that I file a report with Adult Protective Services. Once such a report is filedanother, I may be required to provide additional information. If I believe that it is necessary to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by the client on him/her- self or another person, I may be required in order to take protective action. These actions may includeactions, including imitating hospitalization, warning the potential victim if identifiable, and/or initiating hospitalization and/or contacting calling the potential victim, and/or the police and/or the client’s familypolice. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records You should The laws governing confidentiality can be aware thatquite complex, pursuant to HIPAAand I am not an attorney. In situations where specific advise is required, formal legal advise may be needed. PROFESSIONAL RECORDS The laws and standards of my profession require that I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. (It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. .) Except in unusual circumstances that involve danger to yourself and/or others or the unusual circumstance where disclosure record makes reference to another person (unless such other person is a health care provider) and I believe that access is reasonably likely to endanger you and/or others or when another individual (cause substantial harm to such other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harmperson, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. (Your clinical record includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier.) Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of 35 cents $.50 per page (( and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Recordsrecords, you have a right of review, which I will discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents of our conversations, my analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentially.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights PATIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include:include requesting that I amend your record; requesting restrictions on what information from your Clinical Records is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights with you. MINORS & PARENTS Children of any age have the right to independently consent to and receive mental health treatment without parental consent and, in that situation, information about that treatment cannot be disclosed to anyone without the child’s agreement. While privacy in psychotherapy is very important, particularly with teenagers, parental involvement is also essential to successful treatment and this requires that some private information be shared with parents. It is my policy not to provide treatment to an individual under 25 years of age. BILLING AND PAYMENTS You will be expected to pay your copay, deductible, or out-of-pocket fee if you are not using insurance, for each session at the time it is held. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require me to disclose otherwise confidential information. In most collection situations, the only information I release regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due. If such legal action is necessary, its costs will be included in the claim or charged to the client. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company. Some managed-care plans will not allow me to provide services to you once your benefits end. If this is the case, I will do my best to find another provider who will help you continue your psychotherapy, or we can discuss out of pocket payment. You should also be aware that your contract with your health insurance company requires that I provide it with information relevant to the services that I provide to you. I am required to provide a clinical diagnosis. Sometimes I am required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situation, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide information to your carrier. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your sessions. It is important to remember that you always have the right to pay for my services to avoid the problems described about, unless this is prohibited by your insurance contract. Your signature below indicates that you have read the information in this document and agree to abide by its terms during our professional relationship. YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS AND ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPAA NOTICE FORM DESCRIBED ABOVE.
Appears in 1 contract
Samples: Patient Services Agreement
Meetings. I normally conduct an evaluation that will last from 1-2 to 4 sessions. During this time, we can both decide if I am the best person to provide the services you need in order need. For those primarily seeing me for a baseline assessment and orientation to the Alpha-Stim technology, I meet your treatment goalsfor one session before loaning or selling the device. If therapy has psychotherapy is begun, I will usually schedule one 45-50- minute ses- sion session (one appointment hour of 50 minutes duration) per week at a time we agree on, although some sessions may be longer or more frequent. Once an appointment hour is scheduled, you will be expected to pay for it un- less unless you provide 24-48 hours advanced [2 days] advance notice of cancellationcancellation [unless we both agree that you were unable to attend due to circumstances beyond your control]. It is important to note that insurance companies do not provide reimbursement for cancelled sessions. Professional Fees My [If it is possible, I will try to find another time to reschedule the appointment.] PROFESSIONAL FEES I am not on any insurance panels and payment is requested at the time of service. Bills are provided so that you may submit to your insurance for reimbursement, but this arrangement is between yourself and the insurance company. The fee for the initial baseline assessment and orientation to Alpha-Stim is charged at the $185.00 50-minute meeting rate, plus the 1st month’s loan fee. For longer term psychotherapy clients, the initial 90-minute intake evaluation fee is 350.00. Subsequently, my hourly fee varies depending on services and durationis $185.00. In addition to weekly ap- pointmentsappointments, I charge this amount for other professional services you may need. How- ever, though I will break down the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services include report writing, telephone conversations lasting longer than 10-15 minutes, Skype appoint- ments or check-ins, consulting with other professionals with your permission, prepar- ing preparation of records or treatment summaries, and the time spent performing any other ser- vices service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Be- cause [Because of the difficulty of legal involvement, I charge $500 240.00 per hour for preparation and attendance at any legal proceedings. Contacting Me proceeding.] CONTACTING ME Due to my work schedule, I am often not immediately available by telephone. While I am usually in my office four days a weekworking between 11AM and 7 PM, I probably will not answer the phone when I am with a client. When I am unavailable, my telephone is answered by voice mail that I monitor frequently. I will make every effort to return your call by on the end of my business daysame day you make it, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. If you are unable to reach me and you feel that you can’t wait for me to return your call, contact your family physician, the nearest emergency room and ask for the psychologist or psychiatrist on call, or call 911. If I will be unavailable for an extended time, I will provide you with the name of a colleague contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality The law protects the privacy of all communications between a client and a therapist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, ad- xxxxx consent. Your signature on this Agreement provides consent for those activities, as follows: I may occasionally find it helpful to consult other health and mental health profes- sionals about a case. During consultation, I make every effort to avoid revealing the identity of my client. The other professionals are also legally bound to keep informa- tion confidential. If you don’t object, I will not tell you about these consultations un- less I feel that it is important to our work together. I will note all consultations in your Clinical Record. Disclosures required by health insurers or to collect overdue fees are discussed else- where in this Agreement. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the social worker-client privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client in order to defend myself. If a client files a worker’s compensation claim, I must, upon appropriate request, pro- vide a copy of the client’s record to the Labor and Industrial Commission or the Work- ers’ Compensation Division, or the client’s employer. There are some situations in which I am legally obligated to take actions, which I be- lieve are necessary to attempt to protect others from harm and I may have to reveal some information about a client’s treatment. These situations are unusual in my practice. If I have reasonable cause to suspect that a child has been or may be subjected to abuse or neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglect, the law requires that I file a report with Tennessee’s Department of Children’s Services. Once such a report is filed, I may be required to provide additional information. If I have reasonable cause to suspect that an elderly or disabled adult presents a like- lihood of suffering serious physical harm and is in need of protective services, the law requires that I file a report with Adult Protective Services. Once such a report is filed, I may be required to provide additional information. If I believe that it is necessary to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by the client on him/her- self or another person, I may be required to take protective action. These actions may include, and/or initiating hospitalization and/or contacting the potential victim, and/or the police and/or the client’s family. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure is reasonably likely to endanger you and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harm, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of 35 cents per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Records, you have a right of review, which I will discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents of our conversations, my analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentially.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include:
Appears in 1 contract
Samples: Services Agreement
Meetings. I normally conduct an evaluation that will last from 1-2 1 to 3 sessions. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If therapy has begun, I will usually schedule one 45-Psychotherapy sessions are 45 to 50- minute ses- sion per week at a time we agree on, although some sessions may be longer or more frequentsessions. Once an appointment hour is scheduled, you will be expected to pay for it un- less unless you provide 24-24 hours advanced advance notice of cancellationcancellation [unless we both agree that you were unable to attend due to circumstances beyond your control]. It is important to note that insurance companies do not provide reimbursement for cancelled sessions. Professional Fees PROFESSIONAL FEES My hourly per session fee varies depending on services and durationis $155. In addition to weekly ap- pointmentsappointments, I charge this amount for other professional services you may need. How- ever, though I will break down the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services include report writing, telephone conversations lasting longer than 10-5 minutes, Skype appoint- ments or check-ins, consulting with other professionals with your permission, prepar- ing preparation of records or treatment summaries, and the time spent performing any other ser- vices service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Be- cause Because of the difficulty of legal involvement, I charge $500 325 per hour for preparation and attendance at any legal proceedingsproceeding. Contacting Me CONTACTING ME Due to my work schedule, I am often not immediately available by telephone. While I am usually in my office four days a weekbetween 9 AM and 7PM Tuesdays, Wednesdays, Thursdays and Fridays. I probably will not answer the phone when I am with a clientpatient. When I am unavailable, my telephone is answered by voice mail, that I monitor frequently. My voicemail also provides a number to call with urgent messages. For routine calls, I will make every effort to return your call by on the end of my business daysame day you make it, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. If you are unable to reach me and you feel that you can’t wait for me to return your call, contact your family physician, the nearest emergency room and ask for the psychologist physician or psychiatrist on call, or call 911Danbury Hospital Crisis Unit at (000) 000-0000. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client patient and a therapistpsychotherapist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, ad- xxxxx advance consent. Your signature on this Agreement provides consent for those activities, as follows: • I may occasionally find it helpful to consult other health and mental health profes- sionals professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my clientpatient. The other professionals are also legally bound to keep informa- tion the information confidential. If you don’t object, I will not tell you about these consultations un- less unless I feel that it is important to our work together. I will note all consultations in your Clinical RecordRecord (which is called “PHI” in my Notice of Policies and Practices to Protect the Privacy of Your Health Information). • Disclosures required by health insurers or to collect overdue fees are discussed else- where elsewhere in this Agreement. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: • If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the social workerpsychotherapist-client patient privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. • If a government agency is requesting the information for health oversight activities, I may be required to provide it for themit. • If a client patient files a complaint or lawsuit against me, I may disclose relevant information regarding that client patient in order to defend myself. • If a client patient files a worker’s compensation claim, I must, upon appropriate request, pro- vide a copy of the client’s record furnish all treatment reports to the Labor patient’s employer and Industrial Commission to the patient or the Work- ers’ Compensation Division, or the client’s employerhis/her attorney. There are some situations in which I am legally obligated to take actions, which I be- lieve believe are necessary to attempt to protect others from harm and I may have to reveal some information about a clientpatient’s treatment. These situations are unusual in my practice. • If I have reasonable cause reason to suspect or believe that a child under 18 years of age (1) has been abused or may be subjected neglected, (2) has had non-accidental physical injury, or injury which is at variance with the history given of such injury, inflicted upon such child, or (3) is placed at imminent risk of serious harm, then I must report this suspicion or belief to abuse or neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglect, the law requires that I file a report with Tennessee’s Department of Children’s ServicesChildren and Families. Once such a report is filed, I may be required to provide additional information. • If I have reasonable cause reason to believe or suspect that an elderly or disabled adult presents a like- lihood of suffering serious physical harm and is in need of protective servicesor incompetent individual has been abused, I may have to report this to the law requires that I file a report with Adult Protective Servicesappropriate authority. Once such a report is filed, I may be required to provide additional information. • If I believe that it is necessary to disclose information to protect against a clear and substantial patient presents an imminent risk of imminent serious harm being inflicted by the client on him/her- self or personal injury to another personidentifiable individual, I may be required to take protective actionactions. These actions may include, and/or initiating hospitalization and/or contacting include notifying the potential victim, and/or contacting the police and/or police, or seeking hospitalization for the clientpatient. I may also have to take protective action if another’s familyproperty is endangered. • If a patient presents an imminent risk of personal injury to him/herself, I may be obligated to seek hospitalization for him/her, or to contact family members or others who can help provide protection. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records The laws governing confidentiality can be quite complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. PROFESSIONAL RECORDS You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure is reasonably likely circumstances that involve danger to endanger you and/or yourself and others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harm, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstancessituations, I am allowed to charge a copying fee of 35 cents $2.00 per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Recordsrecords, you have a right of review, which I will discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation information from others provided to me confidentially.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights CLIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your Clinical Records Record and disclosures of protected health information. These rights include:include requesting that I amend your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights with you. MINORS & PARENTS Patients under 16 years of age who are not emancipated and their parents should be aware that the law may allow parents to examine their child’s treatment records unless I decide that such access is likely to injure the child. (There are some circumstances in which I can provide treatment for not more than 6 sessions to a child under 16 without parental consent or notification, but the requirements for such nonconsensual treatment are complicated and can be discussed on request.) Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is sometimes my policy to request an agreement from parents that they consent to give up their access to their child’s records. If they agree, during treatment, I will provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. I will also provide parents with a summary of their child’s treatment when it is complete. Any other communication will require the child’s consent, unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have. BILLING AND PAYMENTS You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require me to disclose otherwise confidential information. In most collection situations, the only information I release regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due. [If such legal action is necessary, its costs will be included in the claim.] INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, I will be willing to call the company on your behalf. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in short-term therapy, some patients feel that they need more services after insurance benefits end. [Some managed-care plans will not allow me to provide services to you once your benefits end. If this is the case, I will do my best to find another provider who will help you continue your psychotherapy.] You should also be aware that your contract with your health insurance company requires that I provide it with information relevant to the services that I provide to you. I am required to provide a clinical diagnosis. Sometimes I am required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your sessions. It is important to remember that you always have the right to pay for my services yourself to avoid the problems described above [unless prohibited by contract].
Appears in 1 contract
Samples: www.drmikestern.com
Meetings. I normally conduct an evaluation that will last from 1-2 sessionsinitial intake session to obtain relevant background information and to identify your current needs and reasons for seeking therapy. During this timetime and the first several sessions, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If therapy has begunyou decide to begin psychotherapy, I will usually schedule one 45-minute ses- sion session per week at a time we agree on, although some sessions may be longer or more frequent. Once If you schedule further appointments, please let me know if you can’t make it. I can’t charge insurance for missed appointments and don’t like to charge clients. If you miss more than an appointment hour or two without notice I probably won’t schedule further meetings. PROFESSIONAL FEES The charges for my services are based on the usual, customary and reasonable fee profiles for the Oklahoma City area. My fee for an Initial Psychological Interview is scheduled$175. The Psychotherapy fee is $150 per 45 minute psychological therapy session. This fee also includes my time spent on your behalf, including record keeping and consultation. Fees for psychological assessments vary according to the extent and nature of the assessment and can range from $250 to $2000. Please clarify assessment fees before proceeding with any psychological evaluation. I also encourage you will be to discuss fees with me at any time. My clients are expected to pay for it un- less you provide 24-hours advanced notice of cancellationservices at the time that they are provided unless other arrangements have been made in advance. It is important for you to note understand that I am ethically prohibited from billing health insurance companies do not provide reimbursement for cancelled sessionsany forensic evaluation or forensic consultation. Professional Fees My hourly fee varies depending on services and duration. In addition to weekly ap- pointments, I charge this amount for other professional services you may need. How- ever, I will break down the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services include report writing, telephone conversations lasting longer than 10-minutes, Skype appoint- ments or check-ins, consulting with other professionals with your permission, prepar- ing of records or treatment summaries, and the time spent performing any other ser- vices you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Be- cause of the difficulty of legal involvement, I charge $500 per hour for preparation and attendance at any legal proceedings. Contacting Me CONTACTING ME Due to my work scheduleschedule and off-site consulting agreements, I am often not rarely immediately available by telephone. While I am usually in my office four days My telephone is answered by RSVP Telephone Answering Service. A telephone secretary will take your message and immediately send me a week, I probably will not answer the phone when I am with a clienttext page. I will make every effort to return your call by on the end of my business day, with the exception of weekends and holidayssame day you make it. If you are difficult to reach, please inform me of some times when you will be available. If you are unable to reach me and you feel that you can’t wait for me to return your call, contact your family physician, physician or the nearest emergency room and ask for the psychologist or psychiatrist on call, or call 911. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client and a therapistpsychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, ad- xxxxx advance consent. Your signature on this Agreement provides consent for those activities, as followsthe following: I may occasionally find it helpful to consult other health and mental health profes- sionals professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my client. The other professionals are also legally bound to keep informa- tion the information confidential. If you don’t object, I will not tell you about these consultations un- less unless I feel that it is important to our work together. I will note all consultations in your Clinical RecordRecord (which is called “PHI” in my Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information). You should be aware that I employ administrative staff. In most cases, I need to share protected information with these individuals for administrative purposes, such as billing. All staff members have been given training about protecting your privacy and have agreed not to release any information outside of the practice without my permission. Disclosures required by health insurers or to collect overdue fees are discussed else- where elsewhere in this Agreement. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the social workerpsychologist-client privilege law. I cannot provide any information without your (or your personal or legal representative’s) written authorization, authorization or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client in order to defend myself. If a client files a worker’s compensation claim, I mustmay disclose information relevant to that claim to the appropriate parties, upon appropriate request, pro- vide a copy including the Administrator of the client’s record to the Labor and Industrial Commission or the Work- ersWorkers’ Compensation Division, or the client’s employerCourt. There are some situations in which I am legally obligated to take actions, which I be- lieve believe are necessary to attempt to protect others from harm and I may have to reveal some information about a client’s treatment. These situations are unusual in my practice. If I have reasonable cause to suspect that a child has been or may be subjected to abuse or neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglect, the law requires that I file a report with Tennessee’s Department of Children’s Services. Once such a report is filed, I may be required to provide additional information. If I have reasonable cause to suspect that an elderly or disabled adult presents a like- lihood of suffering serious physical harm and is in need of protective services, the law requires that I file a report with Adult Protective Services. Once such a report is filed, I may be required to provide additional information. If I believe that it is necessary to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by the client on him/her- self or another person, I may be required to take protective action. These actions may include, and/or initiating hospitalization and/or contacting the potential victim, and/or the police and/or the client’s family. treatment If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. These situations are unusual in my practice. If I have reason to believe that a child under the age of 18 years is the victim of abuse or neglect, the law requires a report to the appropriate government agency, usually the Department of Human Services. Once such a report is filed, I may be required to provide additional information. If I have reason to believe that a vulnerable adult is suffering from abuse, neglect, or exploitation, the law requires that I report to the appropriate government agency, usually the Department of Human Services. Once such a report is filed, I may be required to provide additional information. If a client communicates an explicit threat to kill or inflict serious bodily injury upon a reasonably identifiable victim and he/she has the apparent intent and ability to carry out the threat, or if a client has a history of violence and I have reason to believe that there is a clear and imminent danger that the client will attempt to kill or inflict serious bodily injury upon a reasonably identified person, I may be required to take protective actions. These actions may include notifying the potential victim, contacting the police, and/or seeking hospitalization for the client. If a client threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her, or to contact family members or others who can help provide protection. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records You should The laws governing confidentiality can be aware thatquite complex, pursuant to HIPAAand I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. PROFESSIONAL RECORDS The laws and standards of my profession require that I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure is reasonably likely circumstances that involve danger to endanger you yourself and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that where information puts the other person at risk of substantial harmhas been supplied to me confidentially by others, you may examine and/or receive a copy of your Clinical Record, Record if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of 35 cents $0.10 per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Recordsrecords, you have a right of review, which I will discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents of our conversations, my analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentially.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights CLIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your Clinical Records Record and disclosures of protected health information. These rights include:include requesting that I amend your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights with you. MINORS & PARENTS OR GUARDIANS Clients under 18 years of age who are not emancipated and their parents or guardians should be aware that the law allows parents or guardians to examine their child’s treatment records. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is my policy to request an agreement from parents or guardians that, during treatment, I will provide them only with general information about the progress of the child’s treatment and his/her attendance at scheduled sessions. Other communication will require the child’s agreement, unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify the parents or guardians of my concern.
Appears in 1 contract
Samples: Client Services Agreement
Meetings. I normally conduct an evaluation that will last from 1-2 to 4 sessions. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If therapy has psychotherapy is begun, I will usually schedule one 45-minute ses- sion session (one appointment hour of 45 minutes duration) per week at a time we agree on, although some sessions may be longer or more frequent. Once we schedule an appointment hour is scheduledappointment, you will be expected to pay are responsible for it un- less you provide payment for this appointment. I have a 24-hours advanced notice of cancellationhour cancellation policy, and will allow for two cancellations within these parameters during a calendar year. It is important If we are able to note that insurance companies do mutually find a time to reschedule the appointment within the week you will not provide reimbursement be charged for cancelled sessionsthe missed appointment. Professional Fees PROFESSIONAL FEES My hourly fee varies depending on services is $275 for individual therapy sessions and duration. In addition to weekly ap- pointments, I charge this amount $350 for other professional services you may need. How- ever, I will break down the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services include report writing, telephone conversations lasting longer than 10-minutes, Skype appoint- ments or check-ins, consulting with other professionals with your permission, prepar- ing of records or treatment summaries, and the time spent performing any other ser- vices you may request of mecouples/family therapy sessions. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Be- cause Because of the difficulty of legal involvement, I charge $500 275.00 per hour for preparation and attendance at any legal proceedingsproceeding. Contacting Me CONTACTING ME Due to my work schedule, I am often not immediately available by telephone. While When I am usually in unavailable, my office four days telephone is answered by a week, private voice mail that I probably will not answer the phone when I am with a clientmonitor frequently. I will make every effort to return your call by on the end of my business daysame day you make it, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. If you are unable to reach me and you feel that you can’t wait for me to return your call, contact your family physician, the nearest emergency room and ask for the psychologist or psychiatrist on call, or call 911. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality The law protects the privacy of all communications between a client and a therapist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, ad- xxxxx consent. Your signature on this Agreement provides consent for those activities, as follows: I may occasionally find it helpful to consult other health and mental health profes- sionals about a case. During consultation, I make every effort to avoid revealing the identity of my client. The other professionals are also legally bound to keep informa- tion confidential. If you don’t object, I will not tell you about these consultations un- less I feel that it is important to our work together. I will note all consultations in your Clinical Record. Disclosures required by health insurers or to collect overdue fees are discussed else- where in this Agreement. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the social worker-client privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigationemergencies, you should consult with your attorney can first try to determine whether a court would be likely to order reach me to disclose informationat my office number. If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client in order to defend myself. If a client files a worker’s compensation claim, I must, upon appropriate request, pro- vide a copy of the client’s record to the Labor and Industrial Commission or the Work- ers’ Compensation Division, or the client’s employer. There are some situations in which I am legally obligated to take actions, which I be- lieve are necessary to attempt to protect others from harm and I may have to reveal some information about a client’s treatment. These situations are unusual in my practice. If I have reasonable cause to suspect that a child has been or may be subjected to abuse or neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglect, the law requires that I file a report with Tennessee’s Department of Children’s Services. Once such a report is filed, I may be required to provide additional information. If I have reasonable cause to suspect that an elderly or disabled adult presents a like- lihood of suffering serious physical harm and is in need of protective services, the law requires that I file a report with Adult Protective Services. Once such a report is filed, I may be required to provide additional information. If I believe that it is necessary to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by the client on him/her- self or another person, I may be required to take protective action. These actions may include, and/or initiating hospitalization and/or contacting the potential victim, and/or the police and/or the client’s family. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure is reasonably likely to endanger you and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harm, you may examine and/or receive a copy of your Clinical RecordHowever, if you request it in writingare unable to reach me immediately, call 911 or go to the nearest emergency room and ask for the psychologist or psychiatrist on call. Because these are professional records, they can Please be misinterpreted and/or upsetting sure to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss leave me a message about the contents. In most circumstances, I am allowed to charge a copying fee of 35 cents per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Records, you have a right of review, which I will discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents of our conversations, my analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentiallyemergency.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include:
Appears in 1 contract
Samples: Patient Services Agreement
Meetings. I normally conduct an evaluation that The frequency of our meetings will last from 1-2 sessions. During this time, we both decide if I am the best person to provide the services you need in order to meet depend on your treatment goals. If therapy has begunTypically, I will usually schedule one 45-minute ses- sion per week at a time we agree onsession or one 60-minute session every other week, although some sessions may be longer or more frequentfrequent based on a schedule we have agreed on. Once an appointment hour is scheduledCouples, family sessions, and business consultations may be 1.5 sessions long. You will be allowed 1 late cancellation (less than 24 hours notice) in a rolling year without charge. After 1 late cancellation, you will be expected charged a fee of $65. For Monday appointments, 24 hours notice is the appropriate time on Friday NOT Sunday. Any no-shows (cancellation less than 3 hours notice) will be charged from the first occurrence. A no show will be charged a full session fee. Any late cancellation during holiday season (i.e., week surrounding Thanksgiving, Christmas and New Years) will be charged the full fee even if it is a first occurrence. PROFESSIONAL FEES I will provide a free 15-minute phone or in office consultation to pay anyone who wants it to help you decide whether you want to pursue services with me. If you decide to continue, the fee for it un- less you provide 24our first meeting is $230. This session costs more due to the extra time involved in an initial evaluation. My fee for subsequent 45-hours advanced notice of cancellation. It minute individual, couples, or family sessions is important to note that insurance companies do not provide reimbursement for cancelled sessions. Professional Fees My hourly fee varies depending on services and duration$135; 60-minute sessions are charged at $180, 90-minute sessions are charged at $270. In addition to weekly ap- pointmentsappointments, I charge this amount for other professional services you may need. How- everneed (other than routine record-keeping), although I will break down the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services include report writing, telephone conversations lasting longer than 10-minutes, Skype appoint- ments or check-insconversations, consulting with other professionals with your permission, prepar- ing of records or treatment summaries, and the time spent performing any other ser- vices service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Be- cause Because of the difficulty of legal involvement, I charge $500 per hour for preparation and attendance at any legal proceedings. Contacting Me Due to my work schedule, I am often not immediately available by telephone. While I am usually in my office four days a week, I probably will not answer the phone when I am proceeding with a client. I will make every effort to return your call by the end minimum of my business day, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you 4 hours time which will be available. If you are unable to reach me and you feel that you can’t wait for me to return your call, contact your family physician, the nearest emergency room and ask for the psychologist or psychiatrist on call, or call 911. If I will be unavailable for an extended time, I will provide you with the name due in advance of a colleague contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with any appearance by me. Limits of Confidentiality The law protects Fees for workshops and business consultations will vary depending on the privacy of all communications between a client and a therapist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, ad- xxxxx consent. Your signature on this Agreement provides consent for those activities, as follows: I may occasionally find it helpful to consult other health and mental health profes- sionals about a case. During consultation, I make every effort to avoid revealing the identity of my client. The other professionals are also legally bound to keep informa- tion confidential. If you don’t object, I will not tell you about these consultations un- less I feel that it is important to our work together. I will note all consultations in your Clinical Record. Disclosures required by health insurers or to collect overdue fees are discussed else- where in this Agreement. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the social worker-client privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client in order to defend myself. If a client files a worker’s compensation claim, I must, upon appropriate request, pro- vide a copy of the client’s record to the Labor and Industrial Commission or the Work- ers’ Compensation Division, or the client’s employer. There are some situations in which I am legally obligated to take actions, which I be- lieve are necessary to attempt to protect others from harm and I may have to reveal some information about a client’s treatment. These situations are unusual in my practice. If I have reasonable cause to suspect that a child has been or may be subjected to abuse or neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglect, the law requires that I file a report with Tennessee’s Department of Children’s Services. Once such a report is filed, I may be required to provide additional information. If I have reasonable cause to suspect that an elderly or disabled adult presents a like- lihood of suffering serious physical harm and is in need of protective services, the law requires that I file a report with Adult Protective Services. Once such a report is filed, I may be required to provide additional information. If I believe that it is necessary to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by the client on him/her- self or another person, I may be required to take protective action. These actions may include, and/or initiating hospitalization and/or contacting the potential victim, and/or the police and/or the client’s family. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure is reasonably likely to endanger you and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harm, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of 35 cents per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Records, you have a right of review, which I will discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents of our conversations, my analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentiallyspecific requirements.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include:
Appears in 1 contract
Samples: drsonjabenson.com
Meetings. I normally conduct an evaluation that will last from 1-2 to 4 sessions. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If therapy has psychotherapy is begun, I will usually schedule one 45-minute ses- sion session or appointment per week at a time we agree on, although some sessions may be longer or more frequent. As you progress toward your goal(s), we’ll likely meet less often and then end our sessions. Once an appointment hour is scheduled, you will be expected to pay for it un- less unless you provide 2448-hours advanced advance notice of cancellation. It is important to note that insurance companies do not provide reimbursement for cancelled sessions. Professional Fees PROFESSIONAL FEES My hourly fee varies depending on services and durationoffice assistant will discuss appointment fees, which are $ each (please fill in after discussing with her). In addition to weekly ap- pointmentsappointments, I charge this amount for other professional services you may need. How- ever, though I will break down prorate the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurance45 minutes. Other services include report writing, telephone conversations lasting longer than 10-5 minutes, Skype appoint- ments or check-ins, consulting with other professionals with your permission, prepar- ing preparation of records or treatment summaries, and the time spent performing any other ser- vices service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Be- cause Because of the difficulty of legal involvement, I charge $500 300 per hour 45-minute period for preparation preparation, and my fee is higher for attendance at any legal proceedingsproceeding. Contacting Me CONTACTING ME Due to my work schedule, I am often not immediately available by telephone. While I am usually in my office four days a weekbetween 9 AM and 6 PM, I probably will not answer the phone when I am with a clientpatient. I am sometimes available between 9AM and 11 AM on Monday through Thursday. When I am unavailable, my telephone is answered by voice mail or my assistant who now handles many of my scheduling and other calls. We return calls during regular business hours and will make every effort try to return your call by within 24-hours, if not on the end of my business daysame day you make it, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. [In emergencies, you can call me at 000-000-0000.] If you are unable to reach me and you feel that you can’t wait for me to return your call, contact your family physician, physician or the nearest emergency room and ask for the psychologist [or psychiatrist psychiatrist] on call, or call 911. If I will be unavailable for an extended time, I will provide you with the name and phone number of a colleague to contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client patient and a therapistpsychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, ad- xxxxx advance consent. Your signature on this Agreement provides consent for those activities, as follows: • I may occasionally find it helpful to consult other health and mental health profes- sionals professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my clientpatient. The other professionals are also legally bound to keep informa- tion the information confidential. If you don’t object, I will not tell you about these consultations un- less unless I feel that it is important to our work together. I will note all consultations in your Clinical RecordRecord (which is called “PHI” in my Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information). • You should be aware that I share office space with other mental health professionals and that I may employ administrative staff. In most cases, I may need to share protected information with these individuals for both clinical and administrative purposes, such as scheduling, billing and quality assurance. All staff members have been given training about protecting your privacy and have agreed not to release any information outside of the practice without the permission of a professional staff member. • Disclosures required by health insurers or to collect overdue fees are discussed else- where elsewhere in this Agreement. • If a patient threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her or to contact family members or others who can help provide protection. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: • If you are a patient is involved in a court proceeding and a request is made for information concerning your diagnosis and treatmentmy professional services, such information is protected by the social worker-client psychologist- patient privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. • If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. • If a client patient files a complaint or lawsuit against me, I may disclose relevant information regarding that client patient in order to defend myself. • If a client patient files a worker’s compensation claim, and I am providing treatment related to the claim, I must, upon appropriate request, pro- vide a copy furnish copies of the client’s record to the Labor all medical reports and Industrial Commission or the Work- ers’ Compensation Division, or the client’s employerbills. There are some situations in which I am legally obligated to take actions, which I be- lieve believe are necessary to attempt to protect others from harm and I may have to reveal some information about a clientpatient’s treatment. These situations are unusual in my practice. ▪ If I have reasonable cause reason to suspect believe that a child has been or may be subjected to abuse or neglect or observe a child is being subjected to conditions or circumstances that would reasonably result in abuse or neglectabused, the law requires that I file a report with Tennessee’s Department of Children’s Servicesthe appropriate governmental agency. Once such a report is filed, I may be required to provide additional information. ▪ If I have reasonable cause to suspect believe that an elderly or a disabled adult presents or elder person has had a like- lihood physical injury or injuries inflicted upon such disabled adult or elder person, other than by accidental means, or has been neglected or exploited, I must report to an agency designated by the Department of suffering serious physical harm and is in need of protective services, the law requires that I file a report with Adult Protective ServicesHuman Resources. Once such a report is filed, I may be required to provide additional information. ▪ If I believe determine that it is necessary a patient presents a serious danger of violence to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by the client on him/her- self or another personanother, I may be required to take protective actionactions. These actions may include, and/or initiating hospitalization and/or contacting include notifying the potential victim, and/or contacting the police police, and/or seeking hospitalization for the client’s familypatient. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records The laws governing confidentiality can be quite complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. PROFESSIONAL RECORDS You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure circumstances that involve danger to yourself or others or makes reference to another person (unless such other person is a health care provider) and I believe that access is reasonably likely to endanger you and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the cause substantial harm to such other person at risk of substantial harm[or if information is supplied to me confidentially by others, (you can elect to put this information in your psychotherapy notes, see below)] you or your legal representative may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstancessituations, I am allowed to charge a fee for copying fee of 35 cents per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Recordsrecords, you have a right of review, review of this decision (except for information provided to me confidentially by others) which I will discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. Record [They also include in- formation from others provided and information supplied to me confidentially.] confidentially by others]. These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights PATIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your Clinical Records Record and disclosures of protected health information. These rights include:include requesting that I amend your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights with you. MINORS & PARENTS Patients under 18 years of age, who are not emancipated, and their parents should be aware the law allows parents to examine their child’s treatment records unless I believe doing so would endanger the child or we agree otherwise. Because privacy in psychotherapy is crucial to success, particularly with teenagers, it is my policy to request an agreement from parents that they consent to give up their access to their child’s records. If they agree, during treatment, I will provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. I will also provide parents with a summary of their child’s treatment when it is complete. Any other communication will require the child’s authorization, unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have. BILLING AND PAYMENTS You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require me to disclose otherwise confidential information. In most collection situations, the only information I release regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due. [If such legal action is necessary, its costs will be included in the claim.] INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with receipts you can submit to receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, we may call the company together. Insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in short-term therapy, some patients feel that they need more services after insurance benefits end. [Some managed-care plans will not reimburse you for my services to you once your benefits end. If this is the case, you may continue to work with me without your being reimbursed, or I will try to find a new provider who will help you continue your psychotherapy.] You should also be aware that if you seek reimbursement your contract with your health insurance company requires that my receipt includes information relevant to the services that I provide to you. Usually the receipt must have your clinical diagnosis. Sometimes insurance companies seek treatment plans or summaries, or copies of your entire Clinical Record (except for psychotherapy notes). In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. We can discuss what we can expect to accomplish with the insurance benefits available to you and what will happen if they run out before you feel ready to end your sessions. It is important to remember that you always have the right to pay for my services yourself to avoid the problems described above. YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS AND ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPAA NOTICE FORM DESCRIBED ABOVE. Printed Name of Patient Printed Name of Person Signing Agreement
Appears in 1 contract
Samples: drrenmassey.com
Meetings. I normally conduct an evaluation that will last from 1-2 to 4 sessions. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If therapy has psychotherapy is begun, I will usually schedule one 45 or 50-minute session (one appointment hour of 45-minute ses- sion duration) per week at a time we agree on, although some sessions may be longer longer, more frequent, or more less frequent. Once an appointment hour is scheduled, you will be expected to pay for it un- less unless you provide 24-24 hours advanced advance notice of cancellation. It is important to note that insurance companies do not provide reimbursement for cancelled sessions. Professional Fees PROFESSIONAL FEES My hourly fee varies depending on services for the first session, a diagnostic session, is $180.00 and durationfor subsequent sessions it is $165.00. In addition to weekly ap- pointmentsappointments, I charge this amount for other professional services you may need. How- ever, though I will break down the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services include report writing, telephone conversations lasting longer than 10-5 minutes, Skype appoint- ments or check-ins, consulting with other professionals with your permission, prepar- ing preparation of records or treatment summaries, and the time spent performing any other ser- vices service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Be- cause Because of the difficulty of legal involvement, I charge $500 200 per hour for preparation and attendance at of any legal proceedingsproceeding. Contacting Me I charge $400.00 per hour for depositions and $600.00 per hour for testimony (both for time on the stand as well as time waiting to testify), plus reimbursement for any related travel expenses. CONTACTING ME Due to my work schedule, I am often not immediately available by telephone. While When I am usually in unavailable, my office four days a week, telephone is answered by voice mail that I probably will not answer the phone when I am with a clientmonitor frequently. I will make every effort to return your call by the end of my business day, with the exception of weekends and holidayspromptly. If you are difficult to reach, please inform me of some times when you will be available. If you are unable to reach me and you feel that you can’t wait for me to return your call, contact your family physician, then call 911 or proceed to the nearest emergency room and ask for the psychologist or psychiatrist on call, or call 911room. If I will be unavailable for an extended time, I will provide you with on my voice mail the name of a colleague to contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client patient and a therapistpsychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form form that meets certain legal requirements imposed by HIPAAHIPAA and Illinois law. There are other situations that require only that you provide writtenHowever, ad- xxxxx consent. Your signature on this Agreement provides consent for those activitiesin the following situations, as followsno authorization is required: • I may occasionally find it helpful to consult other health and mental health profes- sionals professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my clientpatient. The other professionals are also legally bound to keep informa- tion the information confidential. If you don’t do not object, I will not tell you about these consultations un- less I feel that it is important to our work together. I will note all consultations in your Clinical RecordRecord (which is called “PHI” in my Notice of Psychologist’s Policies and Practices to protect the Privacy of Your Health Information). • Disclosures required by health insurers or to collect overdue fees are discussed else- where elsewhere in this the Agreement. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: • If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the social workerpsychologist-client patient privilege law. I cannot provide disclose any information without your (a court order or your legal representative’s) written authorization, or a court orderconsent. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. • If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. • If a client patient files a complaint or lawsuit against me, I may can disclose relevant information regarding that client patient in order to defend myself. Please be advised that in Illinois, a person filing a complaint against a professional waives his or her right to confidentiality. • If a client files you file a worker’s compensation claim, and I render treatment or services in accordance with the provisions of Illinois Worker’s Compensation law, I must, upon appropriate request, pro- vide provide a copy of the client’s your record to the Labor and Industrial Commission your employer or the Work- ers’ Compensation Division, or the client’s employerhis/ her appropriate designee. There are some situations in which I am legally obligated to take actions, which I be- lieve believe are necessary to attempt to protect you or others from harm and I may have to reveal some information about a clientpatient’s treatment. These situations are unusual in my practice. • If I have reasonable cause to suspect believe that a child has been or under 18 known to me in my professional capacity may be subjected to abuse an abused child or neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglectneglected child, the law requires that I file a report with Tennessee’s the local office of the Department of Children’s Children and Family Services. Once such a report is filed, I may be required to provide additional information. • If I have reasonable cause reason to suspect believe that an elderly adult over the age of 60 living in a domestic situation has been abused or disabled adult presents a like- lihood of suffering serious physical harm and is neglected in need of protective servicesthe preceding 12 months, the law requires that I allows me to file a report with Adult Protective Servicesthe agency designated to receive such reports by the Department of Aging. Once such a report is filed, I may be required to provide additional information. • If you have made a specific threat of violence against another, and if I believe that it is necessary to disclose information to protect against you present a clear and substantial clear, imminent risk of imminent serious physical harm being inflicted by the client on him/her- self or another personto another, I may be required to disclose information in order to take protective actionactions. These actions may include, and/or initiating hospitalization and/or contacting include notifying the potential victim, and/or contacting the police and/or the client’s familypolice, or seeking your hospitalization. • If I believe that you present a clear, imminent risk of serious physical or mental injury or death to yourself, I may be required to disclose information in order to take protective actions. These actions may include seeking your hospitalization or contacting family members or others who can assist in protecting you. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. Please be advised that if you threaten harm to yourself or another, I may be required by Illinois law to notify the State Police. This may result in the revocation of your Firearm Owner’s Identification (FOID) card. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records You should be aware that, pursuant to HIPAA, PROFESSIONAL RECORDS The laws and standards of my profession require that I keep Protected Health Information (PHI) about you in two sets of professional records. One set constitutes your Clinical RecordRecords. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure is reasonably likely to endanger you and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harm, you You may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of 35 cents per $1.00 per-page (and for certain other expenses). The exceptions You should be aware that, pursuant to this policy are contained HIPAA, I may keep documentation about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the attached Notice Form. If way in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I refuse receive for other providers, reports of any professional consultations, your request for access billing records, and any reports that have been sent to anyone, including reports to your Clinical Records, you have a right of review, which I will discuss with you upon requestinsurance carrier. In addition, I also may keep a set of Psychotherapy Notes. These Notes notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client patient to clientpatient, they can include the con- tents contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They may also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentially.] These The Psychotherapy Notes are kept separate from your Clinical Record. Your While insurance companies (if applicable) can request and receive a copy of your Clinical Record, they cannot receive a copy of your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal refusal. You may examine and/or receive a copy of both sets of records, if you request it in writing, unless any applicable law dictates otherwise. Because these are professional records, they can be misinterpreted and/or upsetting to provide ituntrained readers. Patient Rights For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of $1.00 per-page (and for certain other expenses). PATIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include:include requesting that I amend your record; requesting restrictions on what information from your Clinical Records is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights with you. MINORS & PARENTS Patients under 12 years of age and their parents should be aware that the law allows parents to examine their child’s treatment records. Parents of children between 12 and 18 cannot examine their child’s records unless the child consents and unless I find that there are no compelling reasons for denying the access. Parents are entitled to information concerning their child’s current physical and mental condition, diagnosis, treatment needs, services provided, and services needed. Since parental involvement is often crucial to successful treatment, in most cases, I require that patients between 12 and 18 years of age and their parents enter into an agreement that allows parents access to certain additional treatment information. If everyone agrees, during treatment, I will provide parents with general information about the progress of their child’s treatment, and his/her attendance at scheduled sessions. I will also provide parents with a summary of treatment when it is complete. Any other communication will require the child’s authorization, unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have. BILLING AND PAYMENTS You will be expected to pay for each session at the time it is held, unless we agree otherwise. Payment schedules for other professional services will be agreed to when they are requested. [In circumstances of unusual financial hardship, I may be willing to negotiate a fee adjustment or payment installment plan.] If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require me to disclose otherwise confidential information. In most collection situations, the only information I release regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due. If such legal action is necessary, its costs will be included in the claim. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. It is very important that you find out exactly what mental health services your insurance policy covers and provide this information to me. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company on your behalf.
Appears in 1 contract
Samples: Patient Services Agreement
Meetings. I normally conduct an initial evaluation that will last from 1-2 1 to 3 sessions. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If therapy has psychotherapy is begun, I will usually schedule one 45-minute ses- sion session (one appointment hour of minutes duration) per week or every other week at a time we agree on, although some sessions may be longer or more frequent. Once an appointment hour is scheduled, you will be expected to pay for it un- less unless you provide 24-24 hours advanced advance notice of cancellation. It There are times when circumstances occur (such as illness, family emergencies, etc) that are beyond your control and I understand that and will be flexible as much as possible. However, it is important to note that insurance companies do not provide reimbursement for cancelled sessions. Professional Fees PROFESSIONAL FEES My hourly fee varies depending on services is $175.00 for the initial evaluation, $180.00 for EMDR sessions, and duration$140.00 for subsequent one hour psychotherapy visits. If you prefer, we can do a 45 minute session for $120.00. In addition to weekly ap- pointmentsappointments, I charge this amount for some other professional services you may need. How- ever, though I will break down the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services include report writing, telephone conversations lasting longer than 10-15 minutes, Skype appoint- ments or check-ins, consulting with other professionals with your permission, prepar- ing preparation of records or treatment summaries, and the time spent performing any other ser- vices services you may request of me. If you become involved in legal proceedings that require my participationIF THIS INVOLVES LEGAL TESTIMONY OR WORK WITH THE COURTS, you will be expected to pay for all of my professional timeMY HOURLY FEE IS $250.00 PER HOUR AND INCLUDES CONSULTATION WITH YOUR ATTORNEY, including preparation and transportation costsPREPARATION AND TRANSPORTATION COSTS, even if AND REPORT WRITING, EVEN IF I am called to testify by another partyAM CALLED TO TESTIFY BY ANOTHER PARTY. Be- cause of the difficulty of legal involvement, I charge $500 per hour for preparation and attendance at any legal proceedings. Contacting Me CONTACTING ME Due to my work schedule, I am often not immediately available by telephone. While When I am usually in unavailable, my office four days a week, I probably will not answer the phone when I am with a clienttelephone is answered by my voicemail. I will make every effort to return your call by on the end of my business daysame day you make it, with the exception of weekends weekends, holidays and holidaysvacation time. If you are difficult to reach, please inform me of some times when you will be available. If In emergencies, during times when I am unavailable, please leave me a voicemail message and a number you are unable to reach me and you feel that you can’t wait for me to return your call, can be reached. Then please contact your family physician, the nearest emergency room and ask for the psychologist or psychiatrist on call, 9-1-1 or call 911the Crisis Unit at Community North Hospital at 000-000-0000. If I will be unavailable for an extended time, I will provide you with the name of a colleague contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality The law protects the privacy of all communications between a client and a therapist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, ad- xxxxx consent. Your signature on this Agreement provides consent for those activities, as follows: I may occasionally find it helpful to consult other health and mental health profes- sionals about a case. During consultation, I make every effort to avoid revealing the identity of my client. The other professionals are also legally bound to keep informa- tion confidential. If you don’t object, I will not tell you about these consultations un- less I feel that it is important to our work together. I will note all consultations in your Clinical Record. Disclosures required by health insurers or to collect overdue fees are discussed else- where in this Agreement. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the social worker-client privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. If a government agency is requesting the information for health oversight activities, I may be required an emergency contact to provide it service for them. If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client in order to defend myself. If a client files a worker’s compensation claim, I must, upon appropriate request, pro- vide a copy of the client’s record to the Labor and Industrial Commission or the Work- ers’ Compensation Division, or the client’s employer. There are some situations in which I am legally obligated to take actions, which I be- lieve are necessary to attempt to protect others from harm and I may have to reveal some information about a client’s treatment. These situations are unusual in my practice. If I have reasonable cause to suspect that a child has been or may be subjected to abuse or neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglect, the law requires that I file a report with Tennessee’s Department of Children’s Services. Once such a report is filed, I may be required to provide additional information. If I have reasonable cause to suspect that an elderly or disabled adult presents a like- lihood of suffering serious physical harm and is in need of protective services, the law requires that I file a report with Adult Protective Services. Once such a report is filed, I may be required to provide additional information. If I believe that it is necessary to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by the client on him/her- self or another person, I may be required to take protective action. These actions may include, and/or initiating hospitalization and/or contacting the potential victim, and/or the police and/or the client’s family. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure is reasonably likely to endanger you and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harm, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of 35 cents per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Records, you have a right of review, which I will discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents of our conversations, my analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentiallyneeded.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include:
Appears in 1 contract
Samples: melodystiles.com
Meetings. I normally conduct an evaluation that will last from 1-2 sessionsA therapy session lasts 50 minutes. During this time, we both decide if I am Within a reasonable period of time after the best person to provide the services you need in order to meet your treatment goals. If therapy has beguninitiation of treatment, I will usually schedule one 45-minute ses- sion per week at a time we agree ondiscuss with you my working understanding of the problem, although some sessions may be longer treatment plan, therapeutic objectives, and view of the possible outcomes of treatment. If you have any unanswered questions about any of the procedures used in the course of your therapy, their possible risks, my expertise in employing them, or more frequentabout the treatment plan, please bring this up with me. Once an appointment hour is scheduled, you will be expected to pay for it un- less unless you provide 24-24 hours advanced advance notice of cancellation, unless we both agree that you were unable to attend due to circumstances beyond your control. It is important to note that insurance companies do not provide reimbursement for cancelled canceled sessions. Professional Fees PROFESSIONAL FEES My hourly fee varies depending on services and durationis $250. In addition to weekly ap- pointmentsappointments, I charge this amount for other professional services you may need. How- ever, though I will break down the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services include report writing, telephone conversations lasting longer than 10-15 minutes, Skype appoint- ments or check-ins, consulting with other professionals with your permission, prepar- ing preparation of records or treatment summaries, and the time spent performing any other ser- vices service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Be- cause [Because of the difficulty of legal involvement, I charge $500 550 per hour for preparation and attendance at any legal proceedingsproceeding]. Contacting Me Due CONTACTING ME The best way to reach me is on my work schedule, I am often not immediately available by telephonemobile phone at 000-000-0000. While I am usually in my office four days a week, I probably will not answer the phone when I am with a client. I will make This voice mail is checked several times every effort to return your call by the end of my business day, 24 hours with the exception of weekends and holidays. If You can typically expect a return telephone call within 24 hours. In the event of a life- threatening situation you are difficult advised to reachcall 911 immediately. When I am on vacation, please inform me of some times when you will be available. If you are unable to reach me and you feel that you can’t wait for me to return your call, contact your family physician, the nearest emergency room and ask for the psychologist or psychiatrist on call, or call 911. If I will make arrangements for another licensed mental health professional to be unavailable for an extended timeavailable if needed, I and will provide you with the name of a colleague contact, if necessaryappropriate contact information. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications communication between a client and a therapistpsychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, ad- xxxxx advance consent. Your signature on this Agreement provides consent for those activities, as follows: I may occasionally find it helpful to consult other health and mental health profes- sionals about a case. During consultation, I make every effort to avoid revealing the identity of my client. The other professionals are also legally bound to keep informa- tion confidential. If you don’t object, I will not tell you about these consultations un- less I feel that it is important to our work together. I will note all consultations in your Clinical Record. Disclosures required by health insurers or to collect overdue fees are discussed else- where in this Agreement. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the social worker-client privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client in order to defend myself. If a client files a worker’s compensation claim, I must, upon appropriate request, pro- vide a copy of the client’s record to the Labor and Industrial Commission or the Work- ers’ Compensation Division, or the client’s employer. There are some situations in which I am legally obligated to take actions, which I be- lieve are necessary to attempt to protect others from harm and I may have to reveal some information about a client’s treatment. These situations are unusual in my practice. If I have reasonable cause to suspect that a child has been or may be subjected to abuse or neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglect, the law requires that I file a report with Tennessee’s Department of Children’s Services. Once such a report is filed, I may be required to provide additional information. If I have reasonable cause to suspect that an elderly or disabled adult presents a like- lihood of suffering serious physical harm and is in need of protective services, the law requires that I file a report with Adult Protective Services. Once such a report is filed, I may be required to provide additional information. If I believe that it is necessary to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by the client on him/her- self or another person, I may be required to take protective action. These actions may include, and/or initiating hospitalization and/or contacting the potential victim, and/or the police and/or the client’s family. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure is reasonably likely to endanger you and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harm, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of 35 cents per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Records, you have a right of review, which I will discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents of our conversations, my analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentially.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include:
Appears in 1 contract
Samples: www.drlizbias.com
Meetings. I normally conduct an evaluation that will last from 1-2 During these first few sessions. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If therapy has begun, I will usually schedule one 4550-minute ses- sion per week sessions at a time frequency that we agree on, although some sessions may be longer or more frequentupon. Once an appointment hour is scheduled, you will be expected to pay for it un- less unless you provide 24-48 hours advanced advance notice of cancellation. If you have an appointment scheduled for a time on Monday, you must contact me by that time on the prior Thursday. It is important to note that insurance companies do not provide reimbursement for cancelled sessions. Professional Fees If it is possible, I will try to find another time to reschedule the appointment within that same week. I will also do my best to schedule someone else into your cancelled time if possible. I do not work on Federal Holidays. I realize that things such as illness, incliment weather, business trips or other life events occur, and it will not always be possible to provide 48 hours notice. However, due to the nature of a psychotherapy practice, your hour has been set aside and it is often difficult to fill it at the last minute (versus, for example, a physician’s office where walk-in and emergent appointments are typical). You will therefore be charged for the missed appointment even when unavoidable life events come up. An option to use when you are unable to come to my office for your appointment is to have a phone or video session. PROFESSIONAL FEES My hourly fee varies depending on services is $225.00. Payment is required at each session. I accept cash, check, cash app (Venmo, Zelle), credit card (Master Card, Visa, Discover, and durationAmerican Express HAS, FSA with a 2.7% convenience fee)). If you do not pay your xxxx in a timely manner , I have the right to cease treatment until you pay your balance. I also have the right to contact a collections agency for any outstanding balances. I will provide receipts at whatever interval is convenient so that you can file for out-of-network reimbursement. I will also complete any insurance forms that will help you receive reimbursement by your insurance company. In addition to weekly ap- pointmentsappointments, I may charge this amount for other professional services you may need. How- ever, though I will break down the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services may include report writing, frequent telephone conversations lasting longer than 10-15 minutes, Skype appoint- ments or check-ins, consulting with other professionals with your permission, prepar- ing preparation of records or treatment summaries, and the time spent performing any other ser- vices service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Be- cause of the difficulty of legal involvement, CONTACTING ME Since I charge $500 per hour for preparation and attendance am often in session while at any legal proceedings. Contacting Me Due to my work schedulework, I am often not immediately available by telephone. While When I am usually in unavailable, my office four days a week, telephone has voice mail that I probably will not answer the phone when I am with a clientmonitor frequently. I will make every effort to return your call by on the end of my business daysame day you make it, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. If you are unable to reach me and you feel that you can’t wait for me to return your call, contact your family physician, physician or the nearest emergency room and ask for the psychologist or psychiatrist on call, or call 911. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client patient and a therapistpsychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, ad- xxxxx advance consent. Your signature on this Agreement provides consent for those activities, as follows: I may occasionally find it helpful to consult other health and mental health profes- sionals professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my clientpatient. The other professionals are also legally bound to keep informa- tion the information confidential. If you don’t object, I will not tell you about these consultations un- less unless I feel that it is important to our work together. I will note all consultations in your Clinical RecordRecord (which is called “PHI” in my Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information). Disclosures required by health insurers or to collect overdue fees are discussed else- where elsewhere in this Agreement. If a patient seriously threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her, or to contact family members or others who can help provide protection. Washington, DC, law provides that a professional may disclose confidential information only to medical or law enforcement personnel if the professional determines that there is a probability of imminent physical injury by the patient to the patient or others, or there is a probability of immediate mental or emotional injury to the patient. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the social workerpsychologist-client patient privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. If a client patient files a complaint or lawsuit against me, I may disclose relevant information regarding that client patient in order to defend myself. If a client patient files a worker’s compensation claim, I must, upon appropriate request, pro- vide a copy of the client’s record provide records relating to the Labor and Industrial Commission treatment or the Work- ers’ Compensation Division, or the client’s employerhospitalization for which compensation is being sought. There are some situations in which I am legally obligated to take actions, which I be- lieve believe are necessary to attempt to protect others from harm and I may have to reveal some information about a clientpatient’s treatment. These situations are unusual in my practice. If I have reasonable cause to suspect believe that a child under 18 has been or may be subjected to abuse abused or neglected (including physical injury, substantial threat of harm, mental or emotional injury, or any kind of sexual contact or conduct), or that a child is a victim of a sexual offense, or that an elderly or disabled person is in a state of abuse, neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglectexploitation, the law requires that I file make a report with Tennessee’s to the appropriate governmental agency, usually the Department of Children’s Protective and Regulatory Services. Once such a report is filed, I may be required to provide additional information. If I have reasonable cause to suspect determine that an elderly there is a probability that the patient will inflict imminent physical injury on another, or disabled adult presents a like- lihood of suffering serious physical that the patient will inflict imminent physical, mental or emotional harm and is in need of protective services, the law requires that I file a report with Adult Protective Services. Once such a report is filed, I may be required to provide additional information. If I believe that it is necessary to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by the client on upon him/her- self herself, or another personothers, I may be required to take protective action. These actions may include, and/or initiating action by disclosing information to medical or law enforcement personnel or by securing hospitalization and/or contacting of the potential victim, and/or the police and/or the client’s familypatient. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records The laws governing confidentiality can be quite complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. PROFESSIONAL RECORDS You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure is reasonably likely circumstances that involve danger to endanger you and/or others or when another individual (other than another health care provider) is referenced yourself and I believe disclosing that information puts the other person at risk of substantial harmothers, you may examine and/or receive a copy of your Clinical Record, Record if you request it in writing. You should be aware that pursuant to Washington DC law, psychological test data are not part of a patient’s record. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of 35 10 cents per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical RecordsRecord, you have a right of review, which I will discuss with you upon your request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentially.] These Psychotherapy Notes are kept separate from your Clinical Record. Your While insurance companies can request and receive a copy of your Clinical Record, they cannot receive a copy of your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your writtensigned, signed written Authorization. Insurance companies cannot require your authorization Authorization as a condition of coverage nor penalize you in any way for your refusal refusal. You may examine and/or receive a copy of your Psychotherapy Notes unless I determine that release would be harmful to provide ityour physical, mental or emotional health. Patient Rights PATIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your Clinical Records Record and disclosures of protected health information. These rights includeinclude requesting that I amend your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and my privacy policies and procedures. BILLING AND PAYMENTS You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. [In circumstances of unusual financial hardship, I may be willing to negotiate a fee adjustment or payment installment plan.] If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require me to disclose otherwise confidential information. In most collection situations, the only information I release regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due. [If such legal action is necessary, its costs will be included in the claim.] INSURANCE REIMBURSEMENT If I do not take your insurance, I am happy to provide you with whatever documentation or assistance is necessary for you to submit for reimbursement. Should you choose to submit to your insurance company, it is important to evaluate what resources you have available to pay for your treatment and what mental health services your insurance policy covers. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, I will be willing to call the company on your behalf. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in short-term therapy, some patients feel that they need more services after insurance benefits end. [Some managed-care plans will not allow me to provide services to you once your benefits end. If this is the case, I will do my best to find another provider who will help you continue your psychotherapy.] You should also be aware that your contract with your health insurance company requires that I provide it with information relevant to the services that I provide to you. I am required to provide a clinical diagnosis. Sometimes I am required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier. Once you have gathered all of the information about your insurance coverage, we can discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your sessions. It is important to remember that you always have the right to pay for my services yourself to avoid the problems described above [unless prohibited by contract]. Signature of Patient:_________________________________ Date: __________________ Rev. 6/18
Appears in 1 contract
Samples: Patient Services Agreement
Meetings. I normally conduct an evaluation that The frequency of our sessions will be discussed and determined by mutual agreement. Intake and Consultation sessions will typically last from 1-2 sessions. During this time, we both decide if I am the best person to provide the services you need in order to meet your treatment goals. If therapy has begun, I for 60 minutes while psychotherapy sessions will usually schedule one 45-minute ses- sion per week at a time we agree on, although some sessions may be longer or more frequentlast for 45 minutes. Once an appointment hour is scheduled, you will be expected to pay for it un- less unless you provide 24-24 hours advanced advance notice of cancellation. It is important to note that insurance companies do not provide reimbursement for cancelled sessionssessions that you did not attend. Professional Fees My hourly PROFESSIONAL FEES We have arrived at mutually agreed upon initial fee. I reserve the right to make periodic adjustments in your fee varies depending on services and durationschedule. I will give you at least 30 days notice of any change to your fee. In addition to weekly ap- pointmentsappointments, I charge this amount for other professional services you may need. How- ever, though I will break down the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services include professional services, including report writing, extended telephone conversations lasting longer than 10-minutes, Skype appoint- ments or check-insconversations, consulting with other professionals with your permission, prepar- ing preparation of records or treatment summaries, and the time spent performing any other ser- vices service you may request of meme may incur additional charges. In the unusual situation when a session extends significantly beyond the usual time frame, your charge may be adjusted on a pro rata basis for that session. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Be- cause Charges for psychological assessment are always discussed in advance of testing, and include a copy of any Assessment report that has been requested at the difficulty of legal involvement, I charge $500 per hour for preparation and attendance at any legal proceedingstime testing was arranged. Contacting Me Due to my work schedule, CONTACTING ME I am often not immediately available by telephone. While I am usually in my office four days a week, I probably will not answer Messages may be left for me at the phone when I am with a clientabove telephone number. I will make every effort to return your call by the end of routinely check my voice mailbox for messages during regular business day, with the exception of weekends and holidayshours. If you are difficult to reach, please inform me of some times when you will be available. If you are unable to reach me and you feel that you can’t wait for me to return your call, contact your family physician, the nearest emergency room and ask for the psychologist or psychiatrist on call, or call 911. If I will be unavailable for an extended time, I will provide leave on my voicemail message indicating the length of my absence and inform you with in advance. If you experience a life-threatening emergency, go to the name nearest hospital emergency room and request to be seen by the mental health professional. LIMITS ON CONFIDENTIALITY The ethics codes of a colleague contactthe American Psychological Association New York State law, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality The law protects and the federal HIPAA all protect the privacy of all communications between a client patient and a therapistmental health professional. In most situations, I can only release information about your treatment to others if you sign a written authorization. This Authorization Form will remain in effect for a length of time you and I determine. You may revoke the authorization at any time, unless I have taken action in reliance on it. However, there are some disclosures that meets certain legal requirements imposed by HIPAA. There are other situations that do not require only that you provide written, ad- xxxxx consent. Your signature on this Agreement provides consent for those activitiesyour Authorization, as follows: I may occasionally find it helpful to consult other health and mental health profes- sionals about a case. During consultation, I make every effort to avoid revealing the identity of my client. The other professionals are also legally bound to keep informa- tion confidential. If you don’t object, I will not tell you about these consultations un- less I feel that it is important to our work together. I will note all consultations in your Clinical Record. Disclosures required by health insurers or to collect overdue fees are discussed else- where in this Agreement. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: • If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the social workertherapist-client patient privilege law. I cannot provide any information without your (or your legal representative’srepresentatives) written authorization, or a court order. There are very rare occasions when the court may override privilege. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. • If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. • If a client patient files a complaint or lawsuit against me, I may disclose relevant information regarding that client patient in order to defend myself. • If a client patient files a worker’s compensation claim, I mustmay be required, upon appropriate request, pro- vide a copy of to provide information contained within the clientpatient’s record to the Labor and Industrial Commission City or State of New York, the Work- ers’ Compensation Divisionpatient’s employer, or the client’s employerinsurer. • Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement. There are some situations in which I am legally obligated to take actions, which I be- lieve are necessary actions in order to attempt to protect others certain individuals from harm harm, and I may have to reveal some information about a clientpatient’s treatment. These situations are unusual in my practice. • If I know or have reasonable cause reason to suspect that a child has been been, or may be subjected to abuse is in immediate danger of being, a mentally or neglect physically abused or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglectneglected child, the law requires that I file a report with Tennessee’s the appropriate governmental agency, usually the Child Protective Services Division of the Department of Children’s Human Services. Once such a report is filed, I may be required to provide additional information. • If I have reasonable substantial cause to suspect believe that an elderly or disabled adult presents a like- lihood of suffering serious physical harm and is in need of protective servicesservices because of abuse, neglect or exploitation by someone other than my patient, the law requires that I file a report with Adult Protective the appropriate governmental agency, usually the Department of Human Services. Once such a report is filed, I may be required to provide additional information. If • In an emergency, if I believe that it is necessary to disclose information to protect against a clear and patient presents a substantial risk of imminent and serious harm being inflicted by the client on injury to him/her- self or another personherself, I may be required to take protective actionactions, including notifying individuals who can protect the patient or initiating emergency hospitalization. • If I believe that a patient presents a substantial risk of imminent and serious injury to another individual, I may be required to take protective actions. These actions may include, and/or initiating hospitalization and/or contacting include notifying the potential victim, and/or contacting the police and/or police, or seeking hospitalization for the client’s familypatient. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. In all other situations, I will ask you for an advance authorization before disclosing any information about you. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records The laws governing confidentiality can be quite complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. PROFESSIONAL RECORDS You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure is reasonably likely to endanger you and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing circumstances that information puts the other person at involve a substantial risk of substantial harmimminent psychological impairment or imminent serious physical danger to yourself and others, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to by untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstancessituations, I am allowed to charge a copying fee of 35 cents $.50 per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Recordsrecords, you have a right of review, which I will discuss with you upon request. In addition, I may also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They , and they also include in- formation information from others provided to me confidentially.] . These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights HIPAA provides As with your Clinical Record, you with several new or expanded may examine these notes. A written request to review them will be handled as described above for your Clinical Record. PATIENT RIGHTS You have certain rights with regard to your Clinical Records Record and disclosures of protected health information. These rights include:include requesting that I amend your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and my privacy policies and procedures. I am willing to discuss any of these rights with you. MINORS & PARENTS Psychologists can provide psychological services to minors without parental consent if the psychologist determines that the minor is knowingly and voluntarily seeking the services and provision of the services is clinically indicated for the minor’s well being. These services can only be provided for 90 days, but can be continued if the psychologist redetermines that the services are still clinically indicated. Parents do not have access to records of this treatment. Patients under 18 years of age but who are over 14 and who are not emancipated and whose parents have consented to treatment should be aware that parents can only review the child’s records with the written authorization of the child. Children under 14, whose parents have consented to the treatment, should be aware that their parents can examine their child’s treatment records unless I decide that such access is likely to injure the child, or we all agree otherwise. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, and because it is important for parents to have some information about their child’s treatment, it is usually my policy to request an agreement of both the parents and child about what information parents will receive about their child’s treatment. If the patient agrees, during treatment, I will provide parents only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. I will also provide parents with a summary of their child’s treatment when it is complete. Any other communication will require the child’s Authorization, unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have.
Appears in 1 contract
Samples: Mental Health Services
Meetings. I normally conduct an evaluation that will last from 1-2 sessions. During this time, our first session we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If therapy has psychotherapy is begun, I will usually schedule one 4550-minute ses- sion mnute appointment per week at a time we agree on, although some sessions may be longer or more frequent. Once an appointment hour is scheduled, you will be expected to pay for it un- less call and cancel if you provide 24-hours advanced notice of cancellationknow you cannot make an appointment. It is important to note that insurance companies do not provide reimbursement for cancelled sessions. Professional Fees My hourly fee varies depending on services and duration. In addition to weekly ap- pointments, I charge this amount for other professional services you may need. How- ever, I will break down the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services include report writing, telephone conversations lasting longer than 10-minutes, Skype appoint- ments or check-ins, consulting with other professionals with your permission, prepar- ing of records or treatment summaries, and the time spent performing any other ser- vices you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Be- cause of the difficulty of legal involvement, I charge $500 per hour for preparation and attendance at any legal proceedings. Contacting Me CONTACTING ME Due to my work schedule, I am often not immediately available by telephone. While I am usually in my office four days a weekbetween 8 AM and 5 PM, I probably will not answer the phone when I am with a clientpatient. When I am unavailable the behavioral health staff or my voicemail will answer my telephone. I will make every effort to return your call by on the end of my business daysame day you make it, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. If you are unable to reach me and you feel that you can’t wait for me to return your call, contact your family physician, physician or the nearest emergency room and ask for room. You can also call the psychologist or psychiatrist on call, or call 911Yakima County 24 hour line at (000) 000-0000. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits Confederated Tribes and Bands of Confidentiality the Yakama Nation Behavioral Health Established by the Treaty of June 9, 1855 LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client patient and a therapist. In therapist in most situations, . I can only release information about your treatment to others if you sign a written Authorization Form form that meets certain legal requirements imposed by state law and/or HIPAA. There are other situations that require only that you provide written, ad- xxxxx consent. Your With your signature on this Agreement provides consent for those activitiesa proper Authorization form, as follows: I may disclose information in the following situations. • I may occasionally find it helpful to consult other health and mental health profes- sionals professionals about a case. During consultation, If I consult with a professional who is not involved in your treatment. I make every effort to avoid revealing the identity of my clientyour identity. The other These professionals are also legally bound to keep informa- tion the information confidential. If you don’t object, I will not tell you about these consultations un- less unless I feel that it is important to our work together. I will note all consultations in your Clinical Record. Disclosures • You should be aware that I practice with other mental health professionals and that we have administrative staff in most cases. I need to share protected information with these individuals for both clinical and administrative purposes, such as scheduling, billing, and quality assurance. All of the mental health professionals are bound by the same rules of confidentiality. All staff members have been given training about protecting your privacy and have agreed not to release any information outside of the office without the permission of a professional staff member. • If you are involved in a court proceeding and a request is made for information concerning the professional services I provided you, such information is protected by the therapist-patient privilege law. I cannot provide any information without 1) your written authorization, 2) you informing me that you are seeking a protective order against my compliance with a subpoena that has been properly served on me and of which you have been notified in a timely manner, or 3) a court order requiring the disclosure. If you are involved in or contemplating litigation, you should consult with your attorney about likely required by health insurers or to collect overdue fees are discussed else- where in this Agreementcourt disclosures. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the social worker-client privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. • If a government agency is requesting the information for health oversight activities, . I may be required to provide it for them. • If a client patient files a complaint or lawsuit against me, I may disclose relevant information regarding that client patient in order to defend myself. • If a client patient files a worker’s compensation claim, and the services I am providing are relevant to the injury for which the claim was made. I must, upon appropriate request, pro- vide request provide a copy of the clientpatient’s record to the patient’s employer and the Department of Labor and Industrial Commission or the Work- ers’ Compensation Division, or the client’s employerIndustries. There are some situations in which I am legally obligated to take actions, which I be- lieve believe are necessary to attempt to protect others from harm and I may have to reveal some information about a clientpatient’s treatment. These situations are unusual in my practice. • If I have reasonable cause to suspect believe that a child has been or may be subjected to abuse or neglect or observe a child being subjected to conditions or circumstances that would reasonably result in suffered abuse or neglect, the law requires that I file a report with Tennessee’s Department of Children’s Servicesappropriate government agency. Once such a report is filed, I may be required to provide additional information. • If I have reasonable cause to suspect believe that an elderly abandonment, abuse, financial exploitation, or disabled neglect of a vulnerable adult presents a like- lihood of suffering serious physical harm and is in need of protective serviceshas occurred, the law requires that I file a report with Adult Protective Servicesthe appropriate government agency. Once such a report is filed, I may be required to provide additional information. • If I reasonably believe that it there is necessary an imminent danger to disclose information to protect against a clear and substantial risk the health or safety of imminent serious harm being inflicted by the client on him/her- self patient or another personany other individual, I may be required to take protective actionactions. These actions may include, and/or initiating hospitalization and/or contacting include notifying the potential victim, and/or contacting the police and/or police, seeking hospitalization for the client’s familypatient, or contacting family members or others who can help provide protection. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records You should The laws governing confidentiality can be aware thatquite complex, pursuant to HIPAAand I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. PROFESSIONAL RECORDS The laws and standards of my profession requires that I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance circumstances that I conclude that disclosure could reasonably be expected to cause danger to the life or safety of you or another or that disclosure could reasonably be expected to lead to your identification of the person who provided information to me in confidence under circumstances where disclosure confidentiality is reasonably likely to endanger you and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harmappropriate, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, presence or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of 35 cents per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Recordsrecords, you have a right of review, which whis I will discuss with you upon request. You should be aware that pursuant to HIPAA, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. If includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone including reports to your insurance carrier. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentially.] These Psychotherapy Notes are kept separate from your Clinical Record. Your The YNBH is taking part in suicide prevention efforts, information on treatment received & referrals made will be used for this purpose. No personal identifiers will be linked to these reports. While insurance companies can request and receive a copy of your Clinical Record, they cannot receive a copy of your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your writtensigned, signed written Authorization. Insurance companies cannot require your authorization Authorization as a condition of coverage nor penalize you in any way for your refusal to provide itrefusal. Patient Rights PATIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include:include requesting that I amend your record, requesting restrictions on what information from your Clinical Records is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of the Agreement, the yellow Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights with you. MINORS & PARENTS Patients over the age of 13 have the right to consent to and receive individual psychotherapy and information about that treatment cannot be disclosed to anyone without the child’s agreement. Parents have the right to review the records of children under the age of 13, unless the court has denied access for good cause. I decide that such access is likely to injure the child, or we agree otherwise. Since parental involvement in therapy is important, it is my policy to request an agreement between a child patient age 13 and over and his/her parents, allowing me to share general information about the progress of the child’s treatment and his/her attendance at scheduled sessions. I will also provide patients with a summary of their child’s treatment when it is complete. Any other communications will require the child’s Authorization, unless I feel that the child is in danger to someone else, in which case, I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the child if possible, and do my best to handle any objections he/she may have.
Appears in 1 contract
Samples: www.yakamanation.us
Meetings. I normally conduct an evaluation that will last from 1-2 1 to 4 sessions. During this time, time we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If therapy has psychotherapy is begun, I will usually schedule one 45-minute ses- sion appointment session of 45 minutes duration per week (charged as one appointment hour) at a time we agree on, although some sessions may be longer or more frequent. Once an appointment hour session is scheduled, you will be expected to pay for it un- less unless you provide 24-24 hours advanced advance notice of cancellationcancellation or we both agree that you were unable to attend due to circumstances beyond your control. Monday cancellations must be made by the previous Friday. It is important to note that insurance companies do not provide reimbursement for cancelled sessionssessions and the amount due is the full fee, not the co-payment. Professional Fees PROFESSIONAL FEES My hourly fee varies depending on services and durationis $130.00. In addition to weekly ap- pointmentsappointments, I charge this amount for other professional services you may need. How- ever, though I will break down the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services include report writing, telephone conversations lasting longer than 10-10 minutes, Skype appoint- ments or check-ins, consulting with other professionals with your permission, prepar- ing preparation of records or treatment summaries, and the time spent performing any other ser- vices service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Be- cause Because of the difficulty of legal involvement, I charge $500 150.00 per hour for preparation and attendance at any legal proceedingsproceeding. Contacting Me CONTACTING ME Due to my work schedule, I am often not immediately available by telephone. While I am usually in my office four days a weekbetween 9 AM and 5 PM, I probably will not answer the phone when I am with a client. When I am unavailable, my telephone is answered by automatic voice mail, which I monitor frequently. I will make every effort to return your phone call by on the end of my business daysame day you make it, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. If you are unable In emergencies, call 911, or go to reach me and you feel that you can’t wait for me to return your call, contact your family physician, the nearest emergency room and ask for the psychologist or psychiatrist on call, or call 911. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client and a therapistpsychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, ad- xxxxx advance consent. Your signature on this Agreement provides consent for those activities, as follows: • I may occasionally find it helpful to consult other health and mental health profes- sionals professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my client. The other professionals are also legally bound to keep informa- tion the information confidential. If you don’t do not object, I will not tell you about these consultations un- less unless I feel that it is important to our work together. I will note all consultations in your Clinical RecordRecord (which is called “PHI” in my Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information). • You should be aware that I practice with other mental health professionals and that I employ administrative staff. In most cases, I need to share protected information with these individuals for both clinical and administrative purposes, such a scheduling, billing and quality assurance. All of the mental health professionals are bound by the same rules of confidentiality. All staff members have been given training about protecting your privacy and have agreed not to release any information outside of the practice without the permission of a professional staff member. • Disclosures required by health insurers or to collect overdue fees are discussed else- where elsewhere in this Agreement. • If a client seriously threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her, or to contact family members or others who can help provide protection. Texas law requires that a professional may disclose confidential information only to medical or law enforcement personnel if the professional determines that there is a probability of imminent physical injury by the client to the client or others, or there is a probability of immediate, mental or emotional injury to the client. There are some situations where I am permitted or required to disclose information without either your consent or Authorizationauthorization: • If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the social workerpsychologist-client privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. • If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. • If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client in order to defend myself. • If a client files a worker’s compensation claim, I must, upon appropriate request, pro- vide a copy of the client’s record provide records relating to the Labor and Industrial Commission treatment or the Work- ers’ Compensation Division, or the client’s employerhospitalization for which compensation is being sought. There are some situations in which I am legally obligated to take actions, which I be- lieve believe are necessary to attempt to protect others from harm and I may have to reveal some information about a client’s treatment. These situations are unusual in my practice. • If I have reasonable cause to suspect believe that a child under 18 has been or may be subjected to abuse abused or neglected (including physical injury, substantial threat of harm, mental or emotional injury, or any kind of sexual contact or conduct), or that a child is a victim of a sexual offense, or that an elderly or disabled person is in a state of abuse, neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglectexploitation, the law requires that I file make a report with Tennessee’s to the appropriate government agency, usually the Department of Children’s Protective and Regulatory Services. Once such a report is filed, I may be required to provide additional information. • If I have reasonable cause to suspect determine that an elderly or disabled adult presents there is a like- lihood of suffering serious physical harm and is in need of protective services, the law requires probability that I file a report with Adult Protective Services. Once such a report is filed, I may be required to provide additional information. If I believe that it is necessary to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by the client will inflict imminent physical injury on another, or that the client will inflict imminent physical, mental or emotional harm upon him/her- self herself, or another personothers, I may be required to take protective action. These actions may include, and/or initiating action by disclosing information to medical or law enforcement personnel or by securing hospitalization and/or contacting the potential victim, and/or the police and/or of the client’s family. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records The laws governing confidentiality can be quite complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. PROFESSIONAL RECORDS You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards those these goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure is reasonably likely circumstances that involve danger to endanger you and/or others or when another individual (other than another health care provider) is referenced yourself and I believe disclosing that information puts the other person at risk of substantial harmothers, you may examine and/or receive a copy of your Clinical Record, Record if you request it in writing. You should be aware that pursuant to Texas law, psychological test data are not part of a patient’s record. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of 35 cents $.25 per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical RecordsRecord, you have a right of review, which I will discuss with you upon your request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentially.] These Psychotherapy Notes are kept separate from your Clinical Record. Your While insurance companies can request and receive a copy of your Clinical Record, they cannot receive a copy of your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your writtensigned, signed written Authorization. Insurance companies cannot require your authorization Authorization as a condition of coverage nor penalize you in any way for your refusal refusal. You may examine and/or receive a copy of your Psychotherapy Notes unless I determine that release would be harmful to provide ityour physical, mental or emotional health. Patient Rights PATIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your Clinical Records Record and disclosures disclosure of protected health information. These rights include:include requesting that I amend your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures records in your records; and the right to a paper copy of this Agreement, the attached Notice form, and my privacy policies and procedures. MINORS AND PARENTS Clients under 18 years of age who are not emancipated and their parents should be aware that the law may allow parents to examine their child’s treatment records. However, if the treatment is for suicide prevention, chemical addiction or dependency, or sexual, physical or emotional abuse, the law requires that parents may not access their child’s records. For children between 16 and 18, because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is my policy to request an agreement from the client and his/her parents that the parents consent to give up their access to their child’s records. If they agree, during treatment, I will provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. I will also provide parents with a summary of their child’s treatment when it is complete. Any other communication will require the child’s Authorization, unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have. BILLING AND PAYMENTS You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you received from your insurance company. If it is necessary to clear confusion, I will be willing to call the company on your behalf. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in short- term therapy, some clients feel that they need more services after insurance benefits end. [Some managed-care plans will not allow me to provide services to you once your benefits end. If this is the case, I will do my best to find another provider who will help you continue your psychotherapy.] You should also be aware that your contract with your health insurance company requires that I provide it with information relevant to the services that I provide to you. I am required to provide a clinical diagnosis. Sometimes I am required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you will agree that I can provide requested information to your carrier. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your sessions. It is important to remember that you always have the right to pay for my services yourself to avoid the problems described [unless prohibited by contract]. YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS AND ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPAA NOTICE FORM DESCRIBED ABOVE.
Appears in 1 contract
Meetings. I normally We usually conduct an evaluation that will last from 1-2 one to two sessions. During this time, we can both decide if I am we are the best person to provide the services you need in order to meet your treatment goals. If therapy has psychotherapy is begun, I we will usually schedule one 4550-minute ses- sion appointment per week at a time we agree on, although some sessions may be longer or more more/less frequent. Once an appointment hour is scheduled, you will be expected to pay for it un- less if you do not provide 24-24 hours advanced advance notice of cancellationcancellation [unless we both agree that you were unable to attend due to circumstances beyond your control]. It is important to note that insurance companies do not provide reimbursement to us for cancelled and missed sessions. Professional Fees My hourly If it is possible, we will try to find another time to reschedule the appointment. Please turn to the next page 1 PROFESSIONAL FEES Our fee varies depending on services is $130 for psychotherapy visits (typically a 50-minute appointment, as described above) and duration$150 for intake evaluations (also typically a 50-minute appointment). In addition to weekly ap- pointmentsappointments, I we charge this amount for other professional services you may need. How- ever, I though we will break down down, at our discretion, the hourly cost if I we work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services include report writing, telephone conversations lasting longer than 10-15 minutes, Skype appoint- ments or check-ins, consulting with other professionals with your permission, prepar- ing preparation of records or treatment summaries, and the time spent performing any other ser- vices service you may request of meus. If you become involved in legal proceedings that require my our participation, you will be expected to pay for all of my our professional time, including preparation preparation, travel time and transportation costs, and time waiting to appear, even if I am we are called to testify by another party. Be- cause [Because of the difficulty of legal involvement, I we charge $500 200 per hour for preparation and attendance at any legal proceedings. Contacting Me proceeding.] CONTACTING US Due to my our work scheduleschedules, I am we are often not immediately available by telephone. While I am usually in my office four days a week, I We probably will not answer the phone when I am we are with a clientpatient. I When we are unavailable, our telephone is answered by voicemail. We will typically make every effort to return your call by on the end of my business daysame day you make it, with the exception of weekends and holidays. If you are difficult to reach, please inform me us of some times when you will be available. If you are unable to reach me us and you feel that you can’t wait for me us to return your call, contact your family physician, the nearest emergency room physician or Laurelwood Hospital at (000) 000-0000 and ask for the psychologist or psychiatrist on call, or call 911intake. If I we will be unavailable for an extended time, I we will provide you with the name of a colleague to contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality LIMITS ON CONFIDENTIALITY The law generally protects the privacy of all communications between a client patient and a therapistpsychologist. In most situations, I we can only release information about your treatment to others if you sign a written Authorization Form authorization form that meets certain legal requirements imposed by HIPAA. HIPAA does allow us, however, to provide certain of your confidential information for treatment, payment or healthcare operations. There are other situations that require only that you provide where, we like to obtain your written, ad- xxxxx advance consent. Your signature on this Agreement provides consent for those activities, as follows: I • We may occasionally find it helpful to consult other health and mental health profes- sionals professionals about a case. During a consultation, I we make every effort to avoid revealing the identity of my clientour patient. The other professionals are also legally bound to keep informa- tion the information confidential. If you don’t object, I we will not tell you about these consultations un- less I unless we feel that it is important to our work together. I We will note all consultations in your Clinical RecordRecord (which is called “PHI” in our Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information). • You should be aware that we practice with other mental health professionals and that we employ administrative staff. In most cases, we need to share protected information with these individuals for both clinical and administrative purposes, such as scheduling, billing and quality assurance. All of the mental health professionals are bound by the same rules of confidentiality. All staff members have been given training about protecting your privacy and have agreed not to release any information outside of the practice without the permission of a professional staff member. • Disclosures required by health insurers or to collect overdue fees are discussed else- where elsewhere in this Agreement. There are some situations where I am we are permitted or required to disclose information without either your consent or Authorization: • If you are involved in a court proceeding and a request is made for information concerning your evaluation, diagnosis and or treatment, such information is generally protected by the social workerpsychologist-client patient privilege law. I We cannot typically provide any information without your (or your personal or legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me us to disclose information. • If a government agency is requesting the information for health oversight activities, I we may be required to provide it for them. • If a client patient files a complaint or lawsuit against meone of us, I we may disclose relevant information regarding that client patient in order to defend myselfourselves. • If a client patient files a worker’s compensation claim, I mustthe patient must execute a release so that we may release the information, upon appropriate request, pro- vide a copy of the client’s record records or reports relevant to the Labor and Industrial Commission or claim. Please turn to the Work- ers’ Compensation Division, or the client’s employer. next page 2 There are some situations in which I am we may be legally obligated or allowed to take actionsaction and in those situations, which I be- lieve we believe are necessary to attempt to protect others from harm and I we may have to reveal some confidential information about a client’s treatmentpatient. These situations are unusual in my practice. our practices and include, but are not necessarily limited to: ▪ If I we know or have reasonable cause reason to suspect that a child under 18 years of age or a mentally retarded, developmentally disabled, or physically impaired child under 21 years of age has been suffered or may be subjected to faces a threat of suffering any physical or mental wound, injury, disability, or condition of a nature that reasonably indicates abuse or neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglectof the child, the law requires that I or allows us to file a report with Tennessee’s Department of Children’s Servicesthe appropriate government agency, usually the Public Children Services Agency. Once such a report is filed, I we may be required to provide additional information. ▪ If I we have reasonable cause to suspect believe that an elderly or vulnerable adult, including mentally retarded and developmentally disabled adult presents a like- lihood adults of suffering serious physical harm and all ages, is being abused, neglected, or exploited, or is in need a condition, which is the result of protective servicesabuse, neglect, or exploitation, the law requires that I or allows us to file a report with Adult Protective Servicesof such belief to the appropriate governmental agency. Once such a report is filed, I we may be required to provide additional information. ▪ If I we know or have reasonable cause to believe that a patient or client has been the victim of domestic violence, we must note that knowledge or belief and the basis for it is necessary to disclose information to protect against in the patient’s or client’s records. ▪ If we believe that a patient presents a clear and substantial risk of imminent serious harm being inflicted by the client on to him/her- self herself or another personsomeone else, I including the possibility that he or she may be required cause the death of another, and we believe that disclosure of certain information may serve to take protective action. These actions protect that individual, then we may includehave to disclose that information to the appropriate public authorities, and/or initiating hospitalization and/or contacting the potential victim, and/or the police professional workers, and/or the client’s familyfamily of the client and/or take other appropriate steps to prevent the harm from happening. If such a situation arises, I we will make every effort to fully discuss it with you before taking any action and I we will limit my our disclosure to what is necessary, if we believe that is an appropriate and a safe thing to do. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records The laws governing confidentiality can be quite complex, and we are not attorneys. In situations where specific advice is required, formal legal advice may be needed and you are consenting to us consulting with our attorney to obtain that advice. PROFESSIONAL RECORDS You should be aware that, pursuant to HIPAA, I we keep Protected Health Information (PHI) about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I we receive from other providers, re- ports reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure is reasonably likely to endanger you and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harm, you You may examine and/or receive a copy of your Clinical Record, Record if you request it in writingwriting and the request is signed by you and dated not more than 60 days from the date it is submitted. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I we recommend that you initially review them in my our presence, or have them forwarded to another mental health professional so you can discuss the contents. [We are sometimes willing to conduct this review meeting without charge.] In most circumstances, I am allowed Ohio law allows us to charge a copying fee of 35 $1 per page for the first ten pages, 50 cents per page (for pages 11 through 50, and 20 cents per page for certain other expenses). The exceptions to this policy are contained pages in the attached Notice Form. If I refuse your request excess of fifty, plus $15 fee for access to your Clinical Recordsrecords search, you have a right of review, which I will discuss with you upon requestplus postage. In addition, I we also keep a set of Psychotherapy Notes. These Notes are for my our own use and are designed to assist me us in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client patient to clientpatient, they can include the con- tents contents of our conversations, my our analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me us that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentially.] These Psychotherapy Notes are kept separate from your Clinical Record. Your While insurance companies can request and receive a copy of your Clinical Record, they cannot receive a copy of your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your writtensigned, signed written Authorization. Insurance companies cannot require your authorization Authorization as a condition of coverage nor penalize you in any way for your refusal to provide itan Authorization. Patient Rights You may examine and/or receive a copy of your Psychotherapy Notes after filling out the appropriate Authorization form with us. Please turn to the next page 3 PATIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your Clinical Records PHI and disclosures of protected health information. These rights include:include requesting that we amend your record; requesting restrictions on what information from your Clinical Record or Psychotherapy Notes is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized and that are disclosed for treatment, payment or health care operations; determining the location to which protected information disclosures are sent; having any complaints you make about our policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and our privacy policies and procedures. We are happy to discuss any of these rights with you. In some instances, there may be exceptions or qualifications to these rights that we will discuss with you when you go to exercise your rights. MINORS & PARENTS Patients under 18 years of age who are not emancipated and their parents should be aware that the law allows parents to examine their child’s treatment records. One exception to this is that under, Ohio law, children between 14 and 18 may independently consent to and receive up to 6 sessions of psychotherapy (provided within a 30-day period) and no information about those sessions can be disclosed to anyone without the child’s agreement under most circumstances. While privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, parental involvement is also essential to successful treatment. For children 14 and over, it is our policy to request an agreement between our patient and his/her parents allowing us to share general information about the progress of the child’s treatment and his/her attendance at scheduled sessions. We will also provide parents with a summary of their child’s treatment when it is complete. Any other communication will require the child’s Authorization, unless we feel that the child is in danger or is a danger to someone else, in which case, we will notify the parents of my concern or follow the law if that requires some other type of reporting. Before giving parents any information, we will discuss the matter with the child, if possible, and do our best to handle any objections he/she may have. If the parent(s) agree(s) to abide by this agreement, then the information involving the child will be protected to the extent mentioned above. If there are two parents with custodial rights, then we will require that both parents sign the Agreement.
Appears in 1 contract
Samples: www.spectrum-psych.com
Meetings. I normally conduct an evaluation that will last from 1-2 During the first few sessions. During this time, we can both decide if I am the best person to provide the services that you need in order to meet your treatment goals. If therapy has psychotherapy is begun, I will usually schedule at least one 45-minute ses- sion session (one appointment hour of 45 minutes duration) per week at a time we agree on, although some sessions may be longer or more frequent. Once an appointment hour is scheduled, you will be expected to pay for it un- less unless you provide 24-48 hours advanced advance notice of cancellationcancellation [unless we both agree that you were unable to attend due to circumstances beyond your control]. It is important to note that insurance companies do not provide reimbursement for cancelled sessions. Professional Fees You will be responsible for payment in full for any missed sessions. [If it is possible, I will try to find another time to reschedule the appointment.] PROFESSIONAL FEES My hourly fee varies depending on services and durationfor an initial evaluation is $325; this session is one hour long. The fee for each subsequent 45-minute session is $225. In addition to weekly ap- pointmentsappointments, I charge this amount for other professional services you may need. How- ever, though I will break down the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services include report writing, telephone conversations lasting longer than 10-10 minutes, Skype appoint- ments or check-ins, consulting with other professionals with your permission, prepar- ing preparation of records or treatment summaries, and the time spent performing any other ser- vices service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Be- cause [Because of the difficulty of legal involvement, I charge $500 450 per hour for preparation and attendance at any legal proceedings. Contacting Me proceeding.] CONTACTING ME Due to my work schedule, I am often not immediately available by telephone. While I am usually in my office four days a weekbetween 8 AM and 6:00 PM, I probably will not answer the phone when I am with a clientpatient. When I am unavailable, my telephone is answered by voicemail that I monitor frequently. I will make every effort to return your call by on the end of my business day, with the exception of weekends and holidayssame day you make it. If you are difficult to reach, please inform me of some times when you will be available. If you are unable to reach me and you feel that you can’t wait for me to return your call, contact your family physician, physician or the nearest emergency room and ask for the psychologist or psychiatrist on call, or call 911. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client patient and a therapistpsychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, ad- xxxxx advanced consent. Your signature on this Agreement provides consent for those activities, as follows: • I may occasionally find it helpful to consult other health and mental health profes- sionals professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my clientpatient. The other professionals are also legally bound to keep informa- tion the information confidential. If you don’t object, I will not tell you about these consultations un- less unless I feel that it is important to our work together. I will note all consultations in your Clinical RecordRecord (which is called “PHI” in my Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information). • I also find it useful to communicate with colleagues in written form, in professional journals and books. You have the option of signing or not signing a separate form that gives permission to use material from our work in an appropriately disguised form so as to protect your anonymity and confidentiality. • Disclosures required by health insurers or to collect overdue fees are discussed else- where elsewhere in this Agreement. • If a patient threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her, or to contact family members or others who can help provide protection. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: • If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the social workerpsychologist-client patient privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. • If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. • If a client patient files a complaint or lawsuit against me, I may disclose relevant information regarding that client patient in order to defend myself. • If I am being compensated for providing treatment to you as a client files result of your having filed a worker’s compensation claim, I must, upon appropriate request, pro- vide a copy of the client’s record to the Labor and Industrial Commission or the Work- ers’ Compensation Division, or the client’s employerprovide information necessary for utilization review purposes. There are some situations in which I am legally obligated to take actions, which I be- lieve believe are necessary to attempt to protect others from harm and I may have to reveal some information about a clientpatient’s treatment. These situations are unusual in my practice. § If I have reasonable cause to suspect that a child has been or may be subjected to abuse or neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglect, the law requires that I file a report with Tennessee’s Department of Children’s Services. Once such a report is filed, I may be required to provide additional information. If I have reasonable cause to suspect that an elderly or disabled adult presents a like- lihood of suffering serious physical harm and is in need of protective services, the law requires that I file a report with Adult Child Protective Services. Once such a report is filed, I may be required to provide additional information. § If I believe that have reasonable cause to suspect the “criminal abuse” of an adult patient, I must report it to the police. Once such a report is necessary to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by the client on him/her- self or another personfiled, I may be required to provide additional information. § If a patient communicates a threat of physical violence against a reasonably identifiable third person and the patient has the apparent intent and ability to carry out that threat in the foreseeable future, I may have to disclose information in order to take protective action. These actions may includeinclude notifying the potential victim (or, if the victim is a minor, his/her parents and the county Department of Social Services) and contacting the police, and/or initiating seeking hospitalization and/or contacting for the potential victim, and/or the police and/or the client’s familypatient. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records You should The laws governing confidentiality can be aware thatquite complex, pursuant to HIPAAand I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. PROFESSIONAL RECORDS The laws and standards of my profession require that I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrierRecords. Except in the unusual circumstance where circumstances that disclosure is reasonably likely to would physically endanger you and/or others or when makes reference to another individual person (unless such other than another person is a health care provider) is referenced and I believe disclosing that information puts the access is reasonably likely to cause substantial harm to such other person at risk of substantial harmor where information has been supplied to me confidentially by others, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, presence or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of 35 cents $.10 per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Formpage. If I refuse your request for access to your Clinical Recordsrecords, you have a right of reviewreview (except for information supplied to me confidentially by others), which I will discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents of our conversations, my analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentially.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights PATIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include:include requesting that I amend your record; requesting restrictions on what information from your Clinical Records is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights with you. COUPLES AND FAMILY TREATMENT In couples and family therapy, or when different family members are seen individually, even over a period of time, confidentiality and privilege do not apply between the couple or among family members, unless otherwise agreed upon. When the work involves a couple, unless the session is explicitly agreed upon as an individual session, I will not meet with the couple individually if one of the members of the couple cannot attend the scheduled session. The cancellation policy as described above applies in this situation. Likewise, a couples/family session does not begin until all members of the couple/family arrive for the session. MINORS & PARENTS Patients under 18 years of age who are not emancipated and their parents should be aware that the law may allow parents to examine their child’s treatment records. They should also be aware that patients over 14 can consent to (and control access to information about) their own treatment, although that treatment cannot extend beyond 12 sessions or 4 months. While privacy in psychotherapy is very important, particularly with teenagers, parental involvement is also essential to successful treatment. Therefore, it is usually my policy to request an agreement from any patient between 14 and 18 and his/her parents allowing me to share general information with parents about the progress of treatment and the child’s attendance at scheduled sessions. I will also provide parents with a summary of their child’s treatment when it is complete. Any other communication will require the child’s authorization, unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have. Parents of children over the age of 18 who are responsible for paying for the treatment of their child will have access to information regarding payment of fees, but will not have access to any other confidential information without the written authorization of the child. BILLING AND PAYMENTS You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless. Payment schedules for other professional services will be agreed to when they are requested. [In circumstances of unusual financial hardship, I may be willing to negotiate a fee adjustment or payment installment plan.] If your account has not been paid for more than 60 days and arrangements for payment have not been agreed on, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or attorney or going to small claims court which will require me to disclose otherwise confidential information. In most collection situations, the only information I release regarding a patient’s treatment is the name, the nature of services provided, and amount due. [If such legal action is necessary, its costs will be included in the claim.] INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide reasonable assistance in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. It is important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, I will be willing to call the company on your behalf. Due to the rising costs of health care, insurance benefits have become increasingly more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in short-term therapy, some patients feel they need more services after insurance benefits end. You should be aware that I do not participate as an “in network provider” with any insurance plans. Should you elect to submit your statements from me to your insurance company for reimbursement, they will require that I provide a clinical diagnosis. They may subsequently request that I provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, I will speak with you prior to the release of any information, and I will always make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request. Should you not feel comfortable with your insurance company having this information about you, you may elect not to submit your claims for reimbursement. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your sessions. YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS AND ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPAA NOTICE FORM DESCRIBED ABOVE. ___________________________________________________ _______________________ Signature Date ___________________________________________________ (Print Name)
Appears in 1 contract
Samples: Services Agreement
Meetings. I normally conduct an evaluation that will last from 1-2 two to four sessions. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If therapy has psychotherapy is begun, I will usually schedule a session of one 45-minute ses- sion per week appointment hour of 45 to 50 minutes duration at a time we agree on, although some . The frequency and duration for these sessions may will be longer or more frequentdiscussed with your input. Once an appointment hour is scheduled, you will be expected to pay for it un- less unless you provide 24-24 hours advanced advance notice of cancellation. Please refer to the Cancellation Policy. It is important to note that insurance companies do not provide reimbursement for cancelled sessions. Professional Fees If it is possible, I will try to find another time to reschedule the appointment. PROFESSIONAL FEES My hourly fee varies depending on services is $175 for the initial session and duration$150 for an individual session. In addition to weekly ap- pointments, I charge this amount for other professional services you may needA family session is $150. How- ever, I will break down the hourly cost if I work for periods of less than one hourA half session is $75; a group therapy session is $75 per group member. Note that these additional services are not covered by insuranceCONTACTING ME My phone number is 000-000-0000. Other services include report writing, telephone conversations lasting longer than 10-minutes, Skype appoint- ments or check-ins, consulting with other professionals with your permission, prepar- ing of records or treatment summaries, and the time spent performing any other ser- vices you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Be- cause of the difficulty of legal involvement, I charge $500 per hour for preparation and attendance at any legal proceedings. Contacting Me Due to my work schedule, I am often not immediately available by telephone. While because I am usually in my office four days a weeksession, I probably will not answer the phone when I am with a client. I will make every effort to return your call by the end or it is outside of my business day, with the exception of weekends and holidayswork hours. You may leave a message on my voicemail. If you are difficult have an emergency or become suicidal you must call 911 or go immediately to reachthe emergency room. KW Counseling Services, please inform me of some times when you will be availableLLC is an outpatient private practice and not set up for emergency response. If you are unable to reach me and you feel that you can’t wait for me to return your call, contact your family physician, the nearest emergency room and ask for the psychologist or psychiatrist on call, or call 911. If I will be unavailable for an extended time, I will provide you with the name of a colleague contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client and a therapistmental health professional. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form that meets certain legal requirements imposed by HIPAAHIPAA and/or Iowa law. There are other situations that require only that you provide writtenHowever, ad- xxxxx consent. Your signature on this Agreement provides consent for those activitiesin the following situations, as followsno authorization is required: • I may occasionally find it helpful to consult other health and mental health profes- sionals professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my client. The other professionals are also legally bound to keep informa- tion the information confidential. If you don’t do not object, I will not tell you about these consultations un- less unless I feel that it is important to our out work together. I will note all consultations in your Clinical RecordRecord (which is called “PHI” in my Notice of Psychotherapist’s Policies and Practices to Protect the Privacy of Your Health Information). • I have contracts with other services, including billing and record keeping. As required by HIPAA, I have a formal business associate contract with these businesses, in which they promise to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I can provide you with the names of these organizations and/or a blank copy of this contract. • Disclosures required by health insurers or to collect overdue fees are discussed else- where elsewhere in this Agreement. There are some situations where • If a client threatens to harm himself/herself, I am permitted may be obligated to seek hospitalization for him/her or required to disclose information without either your consent contact family members or Authorization: others who can help provide protection. • If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatmentthe professional services I provided, such information is protected by the social workerpsychotherapist-client privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. • If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. • If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client in order to defend myself. • If a client files a worker’s 's compensation claim, I must, upon appropriate request, pro- vide a copy of provide any information concerning the client’s record employee's physical or mental condition relative to the Labor and Industrial Commission or the Work- ers’ Compensation Division, or the client’s employerclaim. There are some situations in which I am legally obligated to take actions, which I be- lieve believe are necessary to attempt to protect others from harm and I may have to reveal some information about a client’s 's treatment. These situations are unusual in my practice. • If I have reasonable cause to believe that a child I have provided professional services to has been abused or if I suspect that a child dependent adult has been or may be subjected to abuse or neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglectabused, the law requires that I file a report with Tennessee’s the appropriate government agency, usually the Department of Children’s Human Services. Once such a report is filed, I may be required to provide additional information. • If I have reasonable cause to suspect that a client communicates an elderly or disabled adult presents a like- lihood imminent threat of suffering serious physical harm and is in need of protective services, the law requires that I file a report with Adult Protective Services. Once such a report is filedto an identifiable victim, I may be required to provide additional information. If I believe that it is necessary to disclose information in order to protect against take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the client. • If a clear and substantial risk client communicates an imminent threat of imminent serious physical harm being inflicted by the client on to him/her- self or another personherself, I may be required to disclose information in order to take protective actionactions. These actions may include, and/or include initiating hospitalization and/or or contacting the potential victim, and/or the police and/or the client’s familyfamily members or others who can assist in providing protection. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records The laws governing confidentiality can be quite complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. PROFESSIONAL RECORDS You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure circumstances that involve danger to yourself and others or makes reference to another person (unless-such other person is a health care provider) and I believe that access is reasonably likely to endanger you and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the cause substantial harm to such other person at risk of substantial harmor where information has been supplied to me by others confidentially, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of 35 cents $1.00 per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Records, you have a right of reviewreview except for information supplied to me confidentially by others, which I will discuss with you upon request. In addition, I may also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also may include in- formation information from others provided to me confidentially.] . These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights CLIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include:include requesting that I amend your record; requesting restrictions on what information from your Clinical Records is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights with you. MINORS AND PARENTS Clients under eighteen years of age who are not emancipated and their parents should be aware that the law may allow parents to examine their child's treatment records. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, I will not share detailed information with parents about their child’s psychotherapy. The exception would be if the minor is participating in something unhealthy or participating in something that is a threat to their safety or the safety of others.
Appears in 1 contract
Samples: kevinwillsoncounseling.com
Meetings. I normally conduct an evaluation that will last from 1-2 1 to 4 sessions. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If therapy has psychotherapy is begun, I will usually schedule one 4550-minute ses- sion session (one appointment hour of 50 minutes duration) per week at a time we agree on, although some sessions may be longer or more frequent. Once an appointment hour is scheduledI understand that occasionally, circumstances beyond your control may arise which would prevent you from attending a scheduled appointment. For this reason, I allow each client one free missed session (i.e., less than 24 hours cancellation notice) per year. You will be expected to pay for it un- less you provide any other sessions that are cancelled within the 24-hours advanced notice of cancellationhour cancellation period. It is important to note that insurance companies do not provide reimbursement for cancelled sessions, so you would be expected to pay the entire fee, not just the co-insurance amount you might normally pay. Professional Fees If it is possible, I will try to find another time to reschedule the appointment. However, you would still be responsible for payment for the missed appointment. In a few circumstances, I may work out different financial policies with you. If so, I will discuss this with you before instituting the new policy. PROFESSIONAL FEES My hourly fee varies depending on services and durationis $120.00. In addition to weekly ap- pointmentsappointments, I charge this amount for other professional services you may need. How- ever, though I will break down the hourly cost if I work for periods of less than one hour. Note that these additional Examples of other services are not covered by insurance. Other services might include report writing, telephone conversations lasting longer than 10-10 minutes, Skype appoint- ments or check-ins, consulting with other professionals with your permission, prepar- ing preparation of records or treatment summaries, and the time spent performing any other ser- vices service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Be- cause Because of the difficulty of legal involvement, I charge $500 300.00 per hour for preparation and attendance at any legal proceedingsproceeding. Contacting Me CONTACTING ME Due to my work schedule, I am often not immediately available by telephone. While My telephone (000- 000-0000) is answered by a confidential voice mail that I monitor frequently. Unless I am usually in my office four days a weekout of town, I probably will not answer return calls throughout the phone when I am with day, including evenings and weekends. Even though you may have to wait a client. few hours to hear from me, I will make every effort to return your call by on the end of my business day, with same day you make it unless your call comes in very late in the exception of weekends and holidaysevening. If you are difficult to reach, please inform me of some times when you will be available. If you are unable to reach me and you feel that you can’t wait for me to return your call, please contact your family physician, physician or the nearest emergency room and ask for the psychologist or psychiatrist on call, or call 911mental health crisis center. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client and a therapistpsychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, ad- xxxxx advance consent. Your signature on this Agreement provides consent for those activities, as follows: • I may occasionally find it helpful to consult other health and mental health profes- sionals professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my client. The other professionals are also legally bound to keep informa- tion the information confidential. If you don’t object, I will not tell you about these consultations un- less unless I feel that it is important to our work together. I will note all consultations in your Clinical RecordRecord (which is called “PHI” in my Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information). • Disclosures required by health insurers or to collect overdue fees are discussed else- where elsewhere in this Agreement. • If a client threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her or to contact family members or others who can help provide protection. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: • If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatmentmy professional services, such information is protected by the social workerpsychologist-client patient privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. • If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. • If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client in order to defend myself. • If a client files a worker’s compensation claim, and I am providing treatment related to the claim, I must, upon appropriate request, pro- vide a copy furnish copies of the client’s record to the Labor all medical reports and Industrial Commission or the Work- ers’ Compensation Division, or the client’s employerbills. There are some situations in which I am legally obligated to take actions, which I be- lieve believe are necessary to attempt to protect others from harm and I may have to reveal some information about a client’s treatment. These situations are very unusual in my practice. ▪ If I have reasonable cause reason to suspect believe that a child has been or may be subjected to abuse or neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglectabused, the law requires that I file a report with Tennessee’s the appropriate governmental agency, usually the Department of Children’s ServicesHuman Resources. Once such a report is filed, I may be required to provide additional information. ▪ If I have reasonable cause to suspect believe that an elderly or a disabled adult presents or elder person has had a like- lihood physical injury or injuries inflicted upon such disabled adult or elder person, other than by accidental means, or has been neglected or exploited, I must report to an agency designated by the Department of suffering serious physical harm and is in need of protective services, the law requires that I file a report with Adult Protective ServicesHuman Resources. Once such a report is filed, I may be required to provide additional information. ▪ If I believe determine that it is necessary a client presents a serious danger of violence to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by the client on him/her- self or another personanother, I may be required to take protective actionactions. These actions may include, and/or initiating hospitalization and/or contacting include notifying the potential victim, and/or contacting the police police, and/or seeking hospitalization for the client’s family. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records You should The laws governing confidentiality can be aware thatquite complex, pursuant to HIPAAand I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. PROFESSIONAL RECORDS The laws and standards of my profession require that I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure circumstances that involve danger to yourself and others or makes reference to another person (unless such other person is a health care provider) and I believe that access is reasonably likely to endanger you and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the cause substantial harm to such other person at risk of substantial harmor where information has been supplied to me confidentially by others, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge My fee for copying a copying fee of 35 cents Clinical Record is $1.00 per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Formpage. If I need to refuse your request for access to your Clinical Recordsrecords, you have a right of reviewreview (except for information provided to me confidentially by others), which I will discuss with you upon request. In addition, I may also keep a set of Psychotherapy NotesNotes on your case. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents generally consist of rather cryptic notes to myself about our conversations, my analysis of those conversations, and how they impact your therapywork that would not be very meaningful to others. They may also contain particularly sensitive information that you may or others reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentially.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorizationauthorization. I’ve never been asked to release copies of my Psychotherapy Notes, and in most cases, would refuse to do so unless mandated by law, so this information remains highly protected and confidential. Insurance companies cannot require your authorization you to authorize me to release my Psychotherapy Notes as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights CLIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your Clinical Records Record and disclosures of protected health information. These rights include:include requesting that I amend your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights with you. MINORS & PARENTS Clients under 18 years of age who are not emancipated and their parents should be aware that the law allows parents to examine their child’s treatment records unless I believe that doing so would endanger the child or we agree otherwise. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is my policy to request an agreement from parents that they consent to give up their access to their child’s records. If they agree, during treatment, I will provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. Any other communication will require the child’s Authorization, unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have. BILLING AND PAYMENTS You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. In circumstances of unusual financial hardship, I may be willing to negotiate a fee adjustment or payment installment plan. Although this has never become necessary in my practice, if your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This could involve hiring a collection agency or going through small claims court which would require me to disclose otherwise confidential information. In most collection situations, the only information I release regarding a client’s treatment is his/her name, the nature of services provided, and the amount due. If such legal action becomes necessary, its costs may be included in the claim. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in short-term therapy, some clients feel that they need more services after insurance benefits end. You should also be aware that your contract with your health insurance company requires that I provide it with information relevant to the services that I provide to you. I am required to provide a clinical diagnosis. Sometimes I am required to provide additional clinical information such as treatment plans or summaries, or, in rare cases, copies of your entire Clinical Record. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information database. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier.
Appears in 1 contract
Samples: susanlitton.com
Meetings. I normally conduct an evaluation that will last from 1-1 to 2 sessions. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If therapy has begun, I will usually generally schedule one 45-45 minute ses- sion per week sessions at a time regular intervals that we agree on, although some sessions may be longer longer, shorter, or more frequentfrequent depending upon your treatment plan. Once an appointment hour is scheduled, you will be expected to pay for it un- less unless you provide 24-24 hours advanced advance notice of cancellation, unless we both agree that you were unable to attend due to circumstances beyond your control. It is important to note that insurance companies do not provide reimbursement for cancelled sessions. Professional Fees If it is possible, I will try to find another time to reschedule the appointment. PROFESSIONAL FEES My hourly fee varies depending on services and durationfor a typical 50-minute session is $115. In addition to weekly ap- pointmentsregular appointments, I charge this amount for other professional services you may need. How- ever, though I will break down the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services include professional report preparation and writing, telephone conversations and e-mails lasting longer than 10-5 minutes, Skype appoint- ments or check-ins, consulting with other professionals with your permission, prepar- ing preparation of records or treatment summaries, and the time spent performing any other ser- vices service you may request of me. Beyond a 50-minute session, should your session run over the specified time, I will bill you in increments of 15 minutes based upon my session rate ($28.75/per 15-minute increments) Fees for other types of treatment services such as a 90-minute sessions are available at your request. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Be- cause of the difficulty of legal involvement, I charge $500 175 per hour in advance for preparation and attendance at any legal proceedings. Contacting Me CONTACTING ME Due to my work and travel schedule, I am often usually not immediately available by telephone. While When I am usually in unavailable, my office four days telephone is answered by a week, confidential voice mail (770-946-2312) that I probably will not answer the phone when I am with a clientmonitor frequently. I will make every effort to return your call by on the end of my business daysame day you make it, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. If you are unable to reach me and you feel that you can’t cannot wait for me to return your call, please contact your family physician, physician or the nearest emergency room and ask for the psychologist or psychiatrist on call, or call 911. If I will be unavailable for an extended time, I will provide you with a means to reach me or the name of a colleague to contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client patient and a therapist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form form that meets certain legal requirements imposed by HIPAAHIPPA. There are other situations that require only that you provide written, ad- xxxxx advance consent. Your signature on this Agreement provides consent for those activities, activities as follows: • I may occasionally find it helpful to consult other health and mental health profes- sionals professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my clientpatient. The other professionals are also legally bound to keep informa- tion the information confidential. If you don’t object, I will not tell you about these consultations un- less unless I feel that it is important to our work together. I will note all consultations in your Clinical RecordRecord (which is called “PHI” in my Notice of Physicians Policies and Practices to Protect the Privacy of Your Health Information). • Disclosures required by health insurers or to collect overdue fees are discussed else- where elsewhere in this Agreement. • If you threaten to harm yourself or others, I may be obligated to seek hospitalization for you or to contact family members or others who can help provide support. There are some situations where I am permitted or required to disclose information without either your consent or Authorizationauthorization: • If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatmentmy professional services, such information is protected by the social workerphysician-client patient privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. • If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. • If a client files you file a complaint or lawsuit against me, I may disclose relevant information regarding that client you in order to defend myself. Such a complaint or lawsuit automatically terminates our psychiatrist-patient relationship. • If a client files you file a worker’s compensation claim, and I am providing treatmentrelated to the claim, I must, upon appropriate request, pro- vide a copy furnish copies of the client’s record to the Labor all medical reports and Industrial Commission or the Work- ers’ Compensation Division, or the client’s employerbills. There are some • Some situations may occur in which I am legally obligated to take actions, which I be- lieve believe are necessary to attempt to protect yourself and/or others from harm harm, and I may have to reveal some information about a client’s your treatment. These situations are very unusual in my practice. • If I have reasonable cause reason to suspect believe that a child has been or may be subjected to abuse or neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglectabused, the law requires that I file a report with Tennessee’s the appropriate governmental agency, usually the Department of Children’s ServicesHuman Resources. Once such a report is filed, I may be required to provide additional information. • If I have reasonable cause to suspect believe that an elderly or a disabled adult presents or elder person has had a like- lihood physical injury or injuries inflicted upon such disabled adult or elder person, other than by accidental means, or has been neglected or exploited, I must report to an agency designated by the Department of suffering serious physical harm and is in need of protective services, the law requires that I file a report with Adult Protective ServicesHuman Resources. Once such a report is filed, I may be required to provide toprovide additional information. • If I believe determine that it is necessary you present a serious danger of violence to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by the client on him/her- self or another personanother, I may be required to take protective actionactions. These actions may include, and/or initiating hospitalization and/or contacting include notifying the potential victim, and/or contacting the police police, and/or the client’s familyseeking hospitalization for you. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records The laws governing confidentiality can be quite complex. In situations where specific advice is required, formal legal advice may be needed. PROFESSIONAL RECORDS You should be aware that, pursuant to HIPAAHIPPA, I keep Protected Health Information (PHI) about you in two sets of professional records. One set of PHI constitutes your you Clinical Record. It includes information about your reasons for seeking therapytreatment, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards toward those goals, your medical and social history, your treatment history, any past treatment treatment/medical records that I receive from other providersprovider(s), re- ports reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure circumstances that involve danger to yourself or others or that make reference to another person (unless such other person is a health care provider) and I believe that access is reasonably likely to endanger you and/or others or when another individual (cause substantial harm to such other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harmpersons, you or your legal representative may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstancessituations, I am allowed to charge a copying fee of 35 cents $0.25 per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Recordsrecords, you have a right of reviewreview (except for information provided to me confidentially by others), which I will discuss with you upon requestbelow. In addition, I also keep a set of Psychotherapy Notes. These Notes notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client patient to clientpatient, they can include the con- tents contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal supplied to me that is not required to be included in your Clinical Recordconfidentially by others. [They also include in- formation from others provided to me confidentially.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorizationauthorization. Insurance companies cannot require your authorization as a condition of coverage nor or penalize you in any way for your refusal to provide it. Patient Rights HIPAA All PHI (Clinical Records and Psychotherapy Notes) is secured in a locked location to which only I have access. I also keep a transcribed telephone log of your calls and document the calls and their content in your chart. Any e-mails you send to me are initially housed on a secure network that is on a password protected computer to which only I have access. Once I receive your e-mail, I print it and place it in your Clinical Record while simultaneously deleting the original electronic version. PATIENT RIGHTS HIPPA provides you with several new or expanded rights with regard to your Clinical Records Record and disclosures of protected health information. These rights include:include requesting that I amend your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and, the right to a paper copy of this Agreement, the attached Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights with you. MINORS AND PARENTS For patients under 18 years of age who are not emancipated, their parents should be aware that the law allows parents to examine their child’s treatment records unless I believe that doing so would endanger the child or we agree otherwise. Because privacy is psychotherapeutic treatment is often crucial to successful progress, particularly with teenagers, it is generally my policy to request an agreement from parents that they consent to give up their access to their child’s records. If they agree, during treatment, I will provide them only with general information about the progress of the child’s treatment, and his or her attendance at scheduled sessions. I will also provide parents with a summary of their child’s treatment when it is complete. Any other communication will require the child’s authorization unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have. BILLING AND PAYMENTS You will be expected to pay for each session at the time it is held. In general, I do not bill for services. Payment schedules for other professional services will be agreed to when they are requested. If your account has not been paid for more than 60 days and arrangements forpayment have not been agreed upon, I charge an additional 1.5% per month (18% APR) for all overdue balances. I also reserve the option of using legal means to secure the payment. This may involve utilizing a collection agency or going through small claims court which will require me to disclose other wise confidential information to you. In most collection situations, the only information I release regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due. If such legal action is necessary, its costs will be included in the claim. Acceptable payments methods include Visa, MasterCard, American Express, and Discover credit and debit cards as well as cash. There is a $35 returned check fee. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. However, you (not your insurance company) are ultimately responsible for full payment of fees. Heavenly Therapeutic Services, LLC and X. Xxxxxxx Xxxxxxx are considered out-of-network providers for some insurances. Please check with us and/or your insurance company for further inquiry. I will provide you with the appropriate documentation so that you may file any necessary claims for reimbursement yourself.Payment is expected at the time of service and if your insurance company denies your claim, you are still responsible for the full self-pay rate. If you anticipate submitting information to your insurance company, it is very important hat you find out exactly which mental health services your insurance company covers. If you decide to submit claims for reimbursement to your insurance company, you should be aware that your contract with your health insurance company requires that I provide the company with information relevant to the services that I provide to you. Sometimes I am required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a database. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases the information may become part of a national databank. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your insurance carrier. YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS AND ALSO THAT IT SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPPA NOTICE FORM DESCRIBED ABOVE. Patient Name (Print) Date Signature of Patient/Guardian Signature of Therapist
Appears in 1 contract
Samples: Patient Services Agreement
Meetings. I normally conduct an evaluation that will last from 1-2 to 4 sessions. During this time, we can both decide if I am the best person to provide the services that you need in order to meet your treatment goals. If therapy has psychotherapy is begun, I will usually schedule one session (one appointment hour of 45-minute ses- sion 50 minutes duration) per week at a time we agree on, although some sessions may be longer or more frequent. Once an appointment hour is scheduled, you will be expected to pay for it un- less unless you provide 24-48 hours advanced advance notice of cancellation. It is important to note that insurance companies do not provide reimbursement for cancelled sessions. Professional Fees PROFESSIONAL FEES My hourly fee varies depending on services and durationis $275.00. In addition to weekly ap- pointmentsappointments, I charge this amount for other professional services you may need. How- ever, though I will break down the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services include report writing, telephone conversations lasting longer than 10-10 minutes, Skype appoint- ments or check-ins, consulting with other professionals with your permission, prepar- ing preparation of records or treatment summaries, and the time spent performing any other ser- vices professional service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Be- cause of the difficulty of legal involvement, I charge $500 per hour for preparation and attendance at any legal proceedings. Contacting Me CONTACTING ME Due to my work schedule, I am often not immediately available by telephone. While When I am usually in unavailable, my office four days a week, telephone is answered by voice mail that I probably will not answer the phone when I am with a clientmonitor frequently. I will make every effort to return your call by on the end of my business daysame day you make it, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. If you have Restricted Number Blocking I will not be able to reach you as quickly. If you are unable to reach me and you feel that you can’t n't wait for me to return your call, contact your family physician, physician or the nearest emergency room and ask for the psychologist or psychiatrist on call, or call 911. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client patient and a therapistpsychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form form that meets certain legal requirements imposed by state law and/or HIPAA. There However, there are other some situations that require only that you provide written, ad- xxxxx consent. Your signature on this Agreement provides where I am permitted or required to disclose information without either your consent for those activities, as followsor Authorization: I may occasionally find it helpful to consult other health and mental health profes- sionals professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my clientpatient. The other professionals are also legally bound to keep informa- tion the information confidential. If you don’t n't object, I will not tell you about these consultations un- less unless I feel that it is important to our work together. I will note all consultations in your Clinical RecordRecord (which is called "PHI" in my Notice of Psychologist's Policies and Practices to Protect the Privacy of Your Health Information). I also have contracts with other mental health service providers. As required by HIPAA, I have a formal business associate contract with this/these businesses, in which it/they promise to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I can provide you with the names of these organizations and/or a blank copy of this contract. Disclosures required by health insurers or to collect overdue fees are discussed else- where elsewhere in this Agreement. There are some situations where If a patient threatens to harm himself/herself, I am permitted may be obligated to seek hospitalization for him/her, or required to disclose information without either your consent contact family members or Authorization: others who can help provide protection. If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatmentabout the professional services that I have provided you and/or the records thereof, such information is protected by the social workerpsychologist-client patient privilege law. I cannot provide any information without your (or your legal legally-appointed representative’s's) written authorization, or a court order, or compulsory process (a subpoena) or discovery request from another party to the court proceeding where that party has given you proper notice (when required) has stated valid legal grounds for obtaining PHI, and I do not have grounds for objecting under state law (or you have instructed me not to object). If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. If a government agency is requesting the information for health oversight activitiesactivities pursuant to their legal authority, I may be required to provide it for them. If a client patient files a complaint or lawsuit against me, I may disclose relevant information regarding that client patient in order to defend myself. If a client patient files a worker’s 's compensation claim, I must, upon appropriate request, pro- vide a copy of the client’s record disclose information relevant to the Labor and Industrial Commission or claimant's condition, to the Work- ers’ Compensation Division, or the client’s employerworker's compensation insurer. There are some situations in which I am legally obligated to take actions, which I be- lieve believe are necessary to attempt to protect others from harm and I may have to reveal some information about a client’s patient's treatment. These situations are unusual in my practice. If I have reasonable cause to knowledge of a child under 18 or I reasonably suspect that a child under 18 that I have observed has been or may be subjected to abuse or neglect or observe a the victim of child being subjected to conditions or circumstances that would reasonably result in abuse or neglect, the law requires that I file a report with Tennessee’s Department of Children’s Servicesthe appropriate governmental agency, usually the county welfare department. I also may make a report if I know or reasonably suspect that mental suffering has been inflicted upon a child or that his or her emotional well being is endangered in any other way (other than physical or sexual abuse, or neglect). Once such a report is filed, I may be required to provide additional information. If I observe or have reasonable cause knowledge of an incident that reasonably appears to suspect be physical abuse, abandonment, abduction, isolation, financial abuse or neglect of an elder or dependent adult, or if an elder or dependent adult credibly reports that he or she has experienced behavior including an elderly act or disabled adult presents a like- lihood of suffering serious omission constituting physical harm and is in need of protective servicesabuse, abandonment, abduction, isolation, financial abuse, or neglect, or reasonably suspects that abuse, the law requires that I file a report with Adult Protective Servicesto the appropriate government agency. Once such a report is filed, I may be required to provide additional information. If a patient communicates a serious threat of physical violence against an identifiable victim, I must take protective actions, including notifying the potential victim and contacting the police. I may also seek hospitalization of the patient, or contact others who can assist in protecting the victim. If I have reasonable cause to believe that it the patient is necessary in such mental or emotional condition as to disclose information be dangerous to protect against a clear and substantial risk of imminent serious harm being inflicted by the client on him/her- self him or another personherself, I may be required obligated to take protective action. These actions may include, and/or initiating including seeking hospitalization and/or or contacting the potential victim, and/or the police and/or the client’s familyfamily members or others who can help provide protection. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records You should The laws governing confidentiality can be aware thatquite complex, pursuant to HIPAAand I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. PROFESSIONAL RECORDS The laws and standards of my profession require that I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where circumstances that disclosure is reasonably likely to would physically endanger you and/or others or when makes reference to another individual person (unless such other than another person is a health care provider) is referenced and I believe disclosing that information puts the access is reasonably likely to cause substantial harm to such other person at risk of substantial harmor where information has been supplied to me confidentially by others, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, [I am allowed sometimes willing to charge conduct this review meeting without charge.] There will be a copying fee of 35 25 cents per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Formpage. If I refuse your request for access to your Clinical Recordsrecords, you have a right of review, (except for information supplied to me confidentially by others) which I will discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents of our conversations, my analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentially.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights PATIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include:include requesting that I amend your record; requesting restrictions on what information from your Clinical Records is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights with you. MINORS & PARENTS Patients under 18 years of age who are not emancipated can consent to psychological services subject to the involvement of their parents or guardian if the psychologist determines that their involvement would be inappropriate. A patient over age 12 may consent to psychological services if he or she is mature enough to participate intelligently in such services, if the minor patient either would present a danger of serious physical or mental harm to him or herself or others, or is the alleged victim of incest or child abuse. In addition, patients over age 12 may consent to alcohol and drug treatment in some circumstances. However, unemancipated patients under 18 years of age and their parents should be aware that the law may allow parents to examine their child's treatment records unless I determine that access would have a detrimental effect on my professional relationship with the patient, or to his/her physical safety or psychological well-being. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, and parental involvement, is also essential, it is usually my policy to request an agreement with minors [over age 12] and their parents about access to information. This agreement provides that during treatment, I will provide parents with only with general information about the progress of the treatment, and the patient's attendance at scheduled sessions. I will also provide parents with a summary of their child's treatment when it is complete. Any other communication will require the child's Authorization, unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have. BILLING AND PAYMENTS You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. In circumstances of unusual financial hardship, I may be willing to negotiate a fee adjustment or payment installment plan. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require me to disclose otherwise confidential information. In most collection situations, the only information I release regarding a patient's treatment is his/her name, the nature of services provided, and the amount due. If such legal action is necessary, its costs will be included in the claim. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, I will be willing to call the company on your behalf Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. "Managed Health Care" plans such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person's usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in short-term therapy, some patients feel that they need more services after insurance benefits end. You should also be aware that your contract with your health insurance company requires that I provide it with information relevant to the services that I provide to you. I am required to provide a clinical diagnosis. Sometimes I am required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. Before I can disclose this information, both you and I must receive a written notification from the insurer stating what they are requesting, why they are requesting it, how long it will be kept and what will be done with the information when they are finished with it. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your sessions. It is important to remember that you always have the right to pay for my services yourself to avoid the problems described above. YOUR SIGNATURE BELOW SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPAA NOTICE FORM. _______________________________________ _______________________ Client Date ___________________________________ _____________________ Parent/Legal Representative Date
Appears in 1 contract
Samples: Services Agreement
Meetings. I normally conduct an evaluation that will last from 1-2 During the initial sessions. During this time, we can both decide if I am the best person to provide the services that you need in order to meet your treatment goals. If therapy has begun, I will usually schedule one 45-minute ses- sion session per week at a time we agree on, although some sessions may be longer or more frequent. Once an appointment hour is scheduled, you will be expected to pay for it un- less unless you provide 24-24 hours advanced advance notice of cancellation. It is important to note that insurance companies do If I can fill the scheduled time, you will not provide reimbursement be charged for cancelled the sessions. Professional Fees PROFESSIONAL FEES My hourly fee varies depending on services and durationfor an individual psychotherapy session is $175.00. The hourly fee for a couples therapy session is $200. In addition to weekly ap- pointmentsappointments, I charge this amount for the applicable hourly fee or other professional services you may need. How- ever, though I will break down the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services include report writing, telephone conversations lasting longer than 10-5 minutes, Skype appoint- ments or check-ins, consulting with other professionals with your permission, prepar- ing preparation of records or treatment summaries, case management and the time spent performing any other ser- vices service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Be- cause Because of the difficulty of legal involvement, I charge $500 400 per hour for preparation and attendance at any legal proceedingsproceeding. Contacting Me Due For clients using their insurance to my work schedulecover the outpatient (office) services, your co-payment will be due at the beginning of each session. Once an appointment hour is scheduled, you will be expected to pay for it unless you provide 24 hours advance notice of cancellation. If I am often not immediately available by telephone. While I am usually in my office four days a weekcan fill the scheduled time, I probably you will not answer be charged for the phone when sessions. You will be asked to pay for my full session if you miss a session without 24 hours advanced notice as missed sessions cannot be billed to your insurance. CONTACTING ME My telephone is answered by a voice mail service that I am with a clientcheck frequently; text messages are treated the same as voice mail messages. I will make every effort to return your call calls within 24 hours or by the end of my next business day, with but cannot guarantee the exception of weekends and holidayscalls will be returned immediately. Please refrain from texting personal information and/or clinical information that is better suited for therapy sessions. Text messages should be limited to reminder texts regarding appointment times. If you are difficult to reach, please inform me of some times when you will be available. If you are unable to reach me I am unavailable and you feel that have an emergency, you can’t wait for me to return your callshould call 911, contact your family physician, the nearest emergency room and ask for the psychologist or psychiatrist on calltelephone a crisis line, or call 911proceed to a psychiatric emergency facility. For emergency/crisis team services call: Los Angeles (000) 000-0000 or Ventura County (000) 000-0000. If I will be unavailable for an extended time, I will provide let you with the name know well in advance of a colleague contact, if necessarymy scheduled absence. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client and a therapist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form form that meets certain legal requirements imposed by state law and/or HIPAA. There But, there are other some situations that require only that you provide written, ad- xxxxx consent. Your signature on this Agreement provides where I am permitted or required to disclose information without either your consent for those activities, as followsor Authorization: • I may occasionally find it helpful to consult other health and mental health profes- sionals professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my clientpatient. The other professionals are also legally bound to keep informa- tion the information confidential. If you don’t object, I will not tell you about these consultations un- less unless I feel that it is important to our work together. I will note all consultations in your Clinical Record. • Disclosures required by health insurers or to collect overdue fees are discussed else- where elsewhere in this Agreement. There are some situations where • If a patient threatens to harm himself/herself, I am permitted may be obligated to seek hospitalization for him/her, and/or to contact family members or required to disclose information without either your consent or Authorization: others who can help provide protection. • If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatmentabout the professional services that I have provided you and/or the records thereof, such information is protected by the social workertherapist-client patient privilege law. I cannot provide any information without your (or your legal legally-appointed representative’s) written authorization, or a court order, or compulsory process (a subpoena) or discovery request from another party to the court proceeding where that party has given you proper notice (when required) has stated valid legal grounds for obtaining PHI, and I do not have grounds for objecting under state law (or you have instructed me not to object). If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. • If a government agency is requesting the information for health oversight activitiesactivities pursuant to their legal authority, I may be required to provide it for them. • If a client patient files a complaint or lawsuit against me, I may disclose relevant information regarding that client patient in order to defend myself. • If a client patient files a worker’s compensation claimclaim that involves their mental health, I must, upon appropriate request, pro- vide a copy of the client’s record disclose information relevant to the Labor and Industrial Commission or claimant's condition, to the Work- ers’ Compensation Division, or the clientpatient’s employer. There are some situations in which I am legally obligated to take actions, which I be- lieve believe are necessary to attempt to protect others from harm and I may have to reveal some information about a clientpatient’s treatment. These situations are unusual in my practice. practice and are described below: • If I have reasonable cause to knowledge of a child under 18, or I reasonably suspect that a child under 18 that I have observed has been or may be subjected to abuse or neglect or observe a the victim of child being subjected to conditions or circumstances that would reasonably result in abuse or neglect, the law requires that I file a report with Tennessee’s Department of Children’s Servicesthe appropriate governmental agency, usually the county welfare department. • I also may make a report if I know or reasonably suspect that mental suffering has been inflicted upon a child or that his or her emotional well being is endangered in any other way (other than physical or sexual abuse, or neglect). Once such a report is filed, I may be required to provide additional information. • If I observe or have reasonable cause knowledge of an incident that reasonably appears to suspect be physical abuse, abandonment, abduction, isolation, financial abuse or neglect of an elder or dependent adult, or if an elder or dependent adult credibly reports that he or she has experienced behavior including an elderly act or disabled adult presents a like- lihood of suffering serious omission constituting physical harm and is in need of protective servicesabuse, abandonment, abduction, isolation, financial abuse, or neglect, or reasonably suspects that abuse, the law requires that I file a report with Adult Protective Servicesto the appropriate government agency. Once such a report is filed, I may be required to provide additional information. • If a patient or a patient's family member communicate that the patient poses a serious threat of physical violence against an identifiable victim, I must take protective actions, including notifying the potential victim and contacting the police. I may also seek hospitalization of the patient, or contact others who can assist in protecting the victim. • If I have reasonable cause to believe that it the patient is necessary in such mental or emotional condition as to disclose information be dangerous to protect against a clear and substantial risk of imminent serious harm being inflicted by the client on him/her- self him or another personherself, I may be required obligated to take protective action. These actions may include, and/or initiating hospitalization including seeking hospitalization, contacting the police, contacting the crisis team and/or contacting the potential victim, and/or the police and/or the client’s familyfamily members or others who can help provide protection. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records The laws governing confidentiality can be quite complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. PROFESSIONAL RECORDS You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets of professional records. One set This constitutes your Clinical Record. It includes information Information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where circumstances in that disclosure is reasonably likely to would physically endanger you and/or others or when makes reference to another individual person (unless such other than another person is a health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harm), you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of 35 cents per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Records, you have a right of reviewreview (except for information supplied to me confidentially by others), which I will discuss with you upon request. In additionShould Client request a copy of Therapist's records, I also keep such a set of Psychotherapy Notesrequest must be made in writing. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents of our conversations, my analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentially.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights PATIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include:include requesting that I amend your record; requesting restrictions on what information from your Clinical Records is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights with you. BILLING AND PAYMENTS You will be expected to pay for each session at the time of treatment, unless we agree otherwise. I accept Cash, Checks and Credit Cards. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require me to disclose otherwise confidential information. In most collection situations, the only information I release regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due. If such legal action is necessary, its costs will be included in the claim. INSURANCE REIMBURSEMENT I am not contracted with all insurance companies, however I can provide you with a summary of the services that you received and pay for called a “super bill”. You may submit this to your insurance company and may be able to get reimbursement based on your insurance, plan and benefits. Please contact your insurance company directly to verify what if at all would be the amount that you would be reimbursed. I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, I will be willing to call the company on your behalf. You should also be aware that insurance company may require that I provide it with information relevant to the services that I provide to you. I am required to provide a clinical diagnosis. Sometimes I am required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. Before I can disclose this information, both you and I must receive a written notification from the insurer stating what they are requesting, why they are requesting it, how long it will be kept and what will be done with the information when they are finished with it. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. By signing this Agreement, you agree that I can provide requested information to your carrier. YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS AND ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPAA NOTICE FORM DESCRIBED ABOVE. Signature Date Name of Client
Appears in 1 contract
Samples: Therapist Client Services Agreement
Meetings. I normally conduct an evaluation that will last from 1-2 1 to 3 sessions. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If therapy has psychotherapy is begun, I will usually schedule one 45-50- minute ses- sion session (one appointment hour of 50 minutes duration) per week at a time we agree on, although some sessions may be longer or more frequent. Once an appointment PROFESSIONAL FEES My fees are as follows: Initial 90 minute visit is $250.00; Individual Therapy 50 minute therapeutic hour fee is scheduled$160.00; and, you will be expected to pay for it un- less you provide 24-hours advanced notice of cancellation. It Family Therapy 50 minute session is important to note that insurance companies do not provide reimbursement for cancelled sessions. Professional Fees My hourly fee varies depending on services and duration. In addition to weekly ap- pointments, I charge this amount for other professional services you may need. How- ever, I will break down the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurance$160.00. Other services include report writing, telephone conversations lasting longer than 10-minutes, Skype appoint- ments or check-ins, consulting with other professionals with your permission, prepar- ing preparation of records or treatment summaries, and the time spent performing any other ser- vices service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Be- cause of the difficulty of legal involvement, I charge $500 250.00 per hour for preparation and attendance at any legal proceedingsproceeding. Contacting Me Due Please be advised there will be periodic increases. Should you have any questions regarding fee changes, please feel free to my work schedulediscuss them with me. CANCELLATIONS Your appointment time is reserved exclusively for you. Please help us serve you better by keeping scheduled appointments. Unless cancelled at least 24 hours in advance, I am often you will be charged for the missed appointment/late cancellation at the rate of a normal office visit. It is important to note that insurance companies do not immediately available by telephoneprovide reimbursement for cancelled sessions. Please accept responsibility for keeping your appointments as WE DO NOT CALL YOU OR MAIL YOU A REMINDER. CONTACTING ME / EMERGENCIES While I am usually in my office four days a weekMonday through Thursday, I probably will do not answer the phone when I am with a clientpatient. When I am unavailable, my telephone is answered by an auto-attendant voice mail that I monitor frequently. I will make every effort to return your call by on the end of my business day, with the exception of weekends and holidayssame day you make it. If you are difficult to reach, please inform me of some times when you will be available. If you are unable to reach me and you feel that you can’t wait for me to return your call, contact your family physician, the nearest emergency room and ask for the psychologist or psychiatrist on call, or call 911. [If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary.] For psychological emergencies after hours, call 911 or go to the nearest hospital. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client patient and a therapistpsychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, ad- xxxxx advance consent. Your signature on this Agreement Agreeme nt provides consent for those activities, as follows: • I may occasionally find it helpful to consult other health and mental health profes- sionals professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my clientpatient. The other professionals are also legally bound to keep informa- tion the information confidential. If you don’t object, I will not tell you about these consultations un- less unless I feel that it is important to our work together. . • You should be aware that I will note all consultations practice in a shared office space environment with other mental health professionals and that I contract with independent business associates to handle the paperwork of my daily business operations. In most cases, I need to share protected information with these individuals for both clinical and administrative purposes, such as scheduling, billing and quality assurance. All of these mental health professionals and business associates are bound by the same rules of confidentiality and have been given training about protecting your Clinical Recordprivacy and have agreed not to release any information outside of this practice without permission. As required by HIPAA, I have a formal business associate contract with these businesses, in which they promise to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I can provide you with the names of these organizations and/or a blank copy of this contract. • Disclosures required by health insurers or to collect overdue fees are discussed else- where elsewhere in this Agreement. • Licensed Psychological Associates are required by NC statute to receive supervision for providing psychological services. As a level III Psychological Associate, Xx. Xxxxx Xxxxxx will be discussing your PHI during supervision with Xx. Xxxxx Xxxxxxx, PhD on a once per month basis. • If I believe that a patient presents an imminent danger to his/her health or safety, I may be obligated to seek hospitalization for him/her, or to contact family members or others who can help provide protection. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: • If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatmentthe professional services that I provided you, such information is protected by the social workerpsychologist-client patient privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. • If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. • If a client patient files a complaint or lawsuit against me, I may disclose relevant information regarding that client patient in order to defend myself. • If a client patient files a worker’s compensation claim, and my services are being compensated through workers compensation benefits, I must, upon appropriate request, pro- vide provide a copy of the clientpatient’s record to the Labor and Industrial Commission patient’s employer or the Work- ers’ Compensation Division, or the client’s employerNorth Carolina Industrial Commission. There are some situations in which I am legally obligated to take actions, which I be- lieve believe are necessary to attempt to protect others from harm and I may have to reveal some information about a clientpatient’s treatment. These situations are unusual in my practice. • If I have reasonable cause to suspect that a child has been under 18 is abused or may be subjected neglected, or if I have reasonable cause to abuse or neglect or observe believe that a child being subjected to conditions or circumstances that would reasonably result disabled adult is in abuse or neglectneed of protective services, the law requires that I file a report with Tennessee’s Department the County Director of Children’s Social Services. Once such a report is filed, I may be required to provide additional information. • If I have reasonable cause believe that a patient presents an imminent danger to suspect that an elderly or disabled adult presents a like- lihood the health and safety of suffering serious physical harm and is in need of protective services, the law requires that I file a report with Adult Protective Services. Once such a report is filedanother, I may be required to provide additional information. If I believe that it is necessary to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by the client on him/her- self or another person, I may be required in order to take protective action. These actions may includeactions, and/or including initiating hospitalization and/or contacting hospitalization, warning the potential victim, if identifiable, and/or calling the police and/or the client’s familypolice. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records You should The laws governing confidentiality can be aware thatquite complex, pursuant to HIPAAand I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. PROFESSIONAL RECORDS / COMPLETION OF FORMS The laws and standards of my profession require that I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in unusual circumstances that involve danger to yourself and/or others or the unusual circumstance where disclosure record makes reference to another person (unless such other person is a health care provider) and I believe that access is reasonably likely to endanger you and/or others or when another individual (cause substantial harm to such other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harmpers on, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying processing fee of 35 cents $50.00 per page request for medical records and $10.00 to complete forms (and for certain other expenses)up to 2 pages) to schools, insurance companies, disability services, etc. The exceptions to this policy are contained in A SEPARATE CONSENT TO RELEASE MEDICAL RECORDS form must be executed by the attached Notice Formpatient before we can release these records. If I refuse your request for access to your Clinical Recordsrecords, you have a right of review, which I will discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents of our conversations, my analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentially.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights PATIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include:include requesting that I amend your record; requesting restrictions on what information from your Clinical Records is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and my privacy policies and procedures. I would be happy to discuss any of these rights with you.
Appears in 1 contract
Samples: Patient Services Agreement
Meetings. I We normally conduct an evaluation that will last from 1-2 to 4 sessions. During this time, we both can decide if I am KCC is the best person place to provide the services you need in order to meet your treatment goals. If therapy has psychotherapy is begun, I we will usually schedule one 45-minute ses- sion appointment hour of 45 minutes duration per week or every other week at a time we agree on, although some sessions may be longer or more frequent. Once an appointment hour is scheduled, you will be expected to pay for it un- less unless you provide 24-a minimum of 24 hours advanced advance notice of cancellation. It The sole exception to this policy is important cancellation due to note that insurance companies do not provide reimbursement severely inclement weather. PROFESSIONAL FEES KCC’s fee per 50 minute session is $110 for cancelled sessions. Professional Fees My hourly fee varies depending on services individual and duration$140 for couples and families. In addition to weekly ap- pointmentsappointments, I we charge this amount for other professional services you may need. How- ever, I though we will break down the hourly cost if I work prorate for periods of less than one hour. Note that these additional services are not covered by insurance45 minutes. Other services include report writing, telephone conversations lasting longer than 10-minutes, Skype appoint- ments or check-insconversations, consulting with other professionals with your permission, prepar- ing preparation of records or treatment summaries, and the time spent performing any other ser- vices service you may request of merequest. If you become involved in legal proceedings that require my our participation, you will be expected to pay for all of my our professional time, including preparation and transportation costs, even if I am we are called to testify by another party. Be- cause CONTACTING US Due to the nature of the difficulty of legal involvementwork, I charge $500 per hour for preparation and attendance at any legal proceedings. Contacting Me Due to my work schedule, I am we are often not immediately available by telephone, email or text message. While I am usually in my office four days a week, I probably will not answer the phone when I am with a client. I KCC will make every effort to return your call by the end communication promptly, but is not able to guarantee immediate response outside of my business day, with the exception of weekends and holidayssession. If you are difficult to reach, please inform me of some times when you will be available. If In emergencies if you are unable to reach me us and you feel that you can’t wait for me us to return your call, contact your family physician, physician or the nearest emergency room and ask for the psychologist or psychiatrist on call, or call 911. If I we will be unavailable for an extended time, I we will provide you with the name of a colleague to contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client patient and a therapistpsychologist/psychotherapist. In most situations, I KCC can only release information about your treatment to others if you sign a written Authorization Form authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, ad- xxxxx advance consent. Your signature on this Agreement provides consent for those activities, as follows: I • We may occasionally find it helpful to consult other health and mental health profes- sionals professionals about a case. During a consultation, I we make every effort to avoid revealing the identity of my our client. The other professionals are also legally bound to keep informa- tion the information confidential. If you don’t object, I we will not tell you about these consultations un- less I unless we feel that it is important to our work together. I will note all consultations in your Clinical Record• We also have contracts with business associates who provide additional services such as legal and accounting services to our practice. Disclosures As required by health insurers HIPAA, we have a formal business associate contract with these businesses, in which they promise to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, we can provide you with the names of these organizations and/or a blank copy of this contract. • If a patient threatens to harm himself/herself, we may be obligated to seek hospitalization for him/her, or to collect overdue fees are discussed else- where in this Agreementcontact family members or others who can help provide protection. There are some situations where I am we are permitted or required to disclose information without either your consent or Authorization: • If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatmentour professional services, such information is protected by the social workerpsychotherapist-client patient privilege law. I We cannot provide any information without your (or your legal representative’s) written authorization, or a court order, or a subpoena of which you have been officially notified and failed to inform us that you are opposing. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me us to disclose information. • If a government agency is requesting the information for health oversight activities, I we may be required to provide it for them. them • If a client patient files a complaint or lawsuit against meus, I we may disclose relevant information regarding that client patient in order to defend myself. If a client files a worker’s compensation claim, I must, upon appropriate request, pro- vide a copy of the client’s record to the Labor and Industrial Commission or the Work- ers’ Compensation Division, or the client’s employerourselves. There are some situations in which I am we are legally obligated to take actions, which I be- lieve we believe are necessary to attempt to protect others from harm and I we may have to reveal some information about a clientpatient’s treatment. These situations are unusual in my our practice. • If I we have reasonable cause reason to know or suspect that a child has been abused or may be subjected to neglected, or has been a victim of sexual abuse or neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglectby another child, the law requires that I we file a report with Tennessee’s the Department of Children’s Servicesfor Children and Families. Once such a report is filed, I we may be required to provide additional information. • If I have reasonable cause to suspect we believe that an elderly or disabled adult a patient presents a like- lihood of suffering serious physical harm and is in need of protective servicesrisk to a person or his/her family, the law requires that I file a report with Adult Protective Services. Once such a report is filed, I may be required to provide additional information. If I believe that it is necessary to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by the client on him/her- self or another person, I we may be required to take protective action. These actions may includeincluding warning the potential victim(s), and/or initiating hospitalization and/or contacting the potential victimpolice, and/or or seeking hospitalization of the police and/or patient. • If we have reason to know or suspect that an adult with a disability or over the client’s familyage of 60 has been abused or is no longer able to care for him/herself we must report that information to the Disabled Persons Protection Commission. If such a situation arises, I KCC will make every effort to fully discuss it with you before taking any action and I we will limit my our disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records You should The laws governing confidentiality can be aware thatquite complex, pursuant to HIPAAand we are not attorneys. In situations where specific advice is required, I formal legal advice may be needed. PROFESSIONAL RECORDS The laws and standards of our profession require that we keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure is reasonably likely to endanger you and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harm, you You may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I we recommend that you initially review them in my our presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of 35 cents per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Records, you have a right of review, which I will discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents of our conversations, my analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentially.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights PATIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your Clinical Records Record and disclosures of protected health information. These rights include:include requesting that we amend your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about our policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and our privacy policies and procedures. We are happy to discuss any of these rights with you. MINORS & PARENTS Patients under 18 years of age who are not emancipated and their parents/legal guardians should be aware that the law may allow parents/guardians to examine their child’s treatment records. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is sometimes our policy to request an agreement from parents/legal guardians that they consent to give up their access to their child’s records. If they agree, during treatment, we will provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. Any other communication will require the child’s Authorization, unless we feel that the child is in danger or is a danger to someone else, in which case, we will notify the parents/legal guardians of our concern. Before giving parents any information, we will discuss the matter with the child, if possible, and do our best to handle any objections he/she may have. BILLING AND PAYMENTS You will be expected to pay for each session at the time it is held, unless we agree otherwise. Payment must be in the form or cash or check, and payment schedules for other professional services will be agreed to when they are requested. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, we have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require us to disclose otherwise confidential information. In most collection situations, the only information we release regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due. If such legal action is necessary, its costs will be included in the claim.
Appears in 1 contract
Meetings. I normally conduct an evaluation that will last from 1-2 to 4 sessions. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If therapy has psychotherapy is begun, I will usually schedule one 4550-minute ses- sion session (one appointment hour of 50 minutes’ duration) per week at a time we agree on, although some sessions may be longer or more frequent. Once an appointment hour is scheduled, you will be expected to pay for it un- less unless you provide 24-hours advanced 24 hours’ advance notice of cancellationcancellation unless we both agree that you were unable to attend due to circumstances beyond your control. It is important to note that insurance companies do not provide reimbursement for cancelled sessions. Professional Fees If it is possible, I will try to find another time to reschedule the appointment. PROFESSIONAL FEES My hourly fee varies depending on services and durationis $150. My fee for the initial interview is $185. In addition to weekly ap- pointmentsappointments, I charge this amount $150 per hour for other professional services you may need. How- ever, including psychological assessment (i.e. testing), though I will break down the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services include report writing, telephone conversations lasting longer than 10-5 minutes, Skype appoint- ments or check-ins, consulting with other professionals with your permission, prepar- ing preparation of records or treatment summaries, and the time spent performing any other ser- vices service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Be- cause Because of the difficulty of legal involvement, I charge $500 300 per hour for preparation and attendance at any legal proceedingsproceeding. Contacting Me CONTACTING ME Due to my work schedule, I am often not immediately available by telephone. While I am usually in my office four days a weekbetween 1 PM and 6 PM, I probably will not answer the phone when I am with a clientpatient. When I am unavailable, my telephone is answered by voice mail that I monitor frequently. I will make every effort to return your call by on the end of my business daysame day you make it, with the exception of weekends and holidays. If you leave a voice mail message be sure to include your telephone number. If you are difficult to reach, please inform me of some times when you will be available. If you are unable to reach me and you feel that you can’t wait for me to return your call, contact your family physician, physician or the nearest emergency room and ask for the psychologist or psychiatrist on call, or call 911. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client patient and a therapistpsychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form form that meets certain legal requirements imposed by HIPAAHIPAA and/or Indiana law. There are other situations that require only that you provide writtenHowever, ad- xxxxx consent. Your signature on this Agreement provides consent for those activitiesin the following situations, as followsno authorization is required: I may occasionally find it helpful to consult other health and mental health profes- sionals professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my clientpatient. The other professionals are also legally bound to keep informa- tion the information confidential. If you don’t object, I will not tell you about these consultations un- less unless I feel that it is important to our work together. I will note all consultations in your Clinical RecordRecord (which is called “PHI” in my Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information). I also have a contract with TherapyNotes, as my electronic medical records (EMR) provider, as well as with other providers as needed. As required by HIPAA, I have a formal business associate contract with these businesses, in which they promise to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I can provide you with the names of these organizations and/or a blank copy of this contract. Disclosures required by health insurers or to collect overdue fees are discussed else- where elsewhere in this Agreement. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatmentthe professional services I provided to you, such information is protected by the social workerpsychologist-client patient privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. I may be required to provide information to a coroner or medical examiner, in the performance of that individual’s duties. If a client patient files a complaint or lawsuit against me, I may disclose relevant information regarding that client patient in order to defend myself. If a client files a worker’s compensation claim, I must, upon appropriate request, pro- vide a copy of the client’s record to the Labor and Industrial Commission or the Work- ers’ Compensation Division, or the client’s employer. There are some situations in which I am legally obligated to take actions, which I be- lieve believe are necessary to attempt to protect others from harm and I may have to reveal some information about a clientpatient’s treatment. These situations are unusual in my practice. If I have reasonable cause reason to suspect believe that a child has been or may be subjected to abuse or neglect or observe is a victim of child being subjected to conditions or circumstances that would reasonably result in abuse or neglect, the law requires that I file a report with Tennessee’s Department of Children’s Servicesthe appropriate government agency, usually the local child protection service. Once such a report is filed, I may be required to provide additional information. If I have reasonable cause reason to suspect believe that someone is an elderly or disabled adult presents a like- lihood of suffering serious physical harm and is in need of protective servicesendangered adult, the law requires that I file a report with Adult Protective Servicesthe appropriate government agency, usually the adult protective services unit. Once such a report is filed, I may be required to provide additional information. If I believe a patient communicates an actual threat of physical violence against an identifiable victim, or evidences conduct or makes statements indicating imminent danger that it is necessary the patient will use physical violence or other means to disclose information cause serious personal injury to protect against a clear and substantial risk of imminent serious harm being inflicted by the client on him/her- self or another personothers, I may be required to disclose information in order to take protective actionactions. These actions may include, and/or initiating hospitalization and/or contacting include notifying the potential victim, and/or contacting the police and/or police, or seeking hospitalization for the client’s familypatient. If a patient communicates an imminent threat of serious physical harm to him/herself, I may be required to disclose information in order to take protective actions. These actions may include initiating hospitalization or contacting family members or others who can assist in providing protection. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records The laws governing confidentiality can be quite complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. PROFESSIONAL RECORDS You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure is reasonably likely circumstances that involve danger to endanger you and/or others or when another individual (other than another health care provider) is referenced yourself and I believe disclosing that information puts the other person at risk of substantial harmothers, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of 35 cents $1.50 per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Records, you have a right of review, which I will discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They can also include in- formation information from others provided to me confidentially.] . These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights PATIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include:include requesting that I amend your record; requesting restrictions on what information from your Clinical Records is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights with you. MINORS & PARENTS Patients under 18 years of age who are not emancipated and their parents should be aware that the law may allow parents to examine their child’s treatment records. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is sometimes my policy to request an agreement from parents that they consent to give up their access to their child’s records. If they agree, during treatment, I will provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. I will also provide parents with a summary of their child’s treatment when it is complete. Any other communication will require the child’s Authorization, unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have. BILLING AND PAYMENTS You will be expected to pay for each session at the time it is held, unless we agree otherwise. Payment schedules for other professional services will be agreed to when they are requested. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require me to disclose otherwise confidential information. In most collection situations, the only information I release regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due. If such legal action is necessary, its costs will be included in the claim. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will provide you with whatever assistance I can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, I will be willing to call the company on your behalf. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in short- term therapy, some patients feel that they need more services after insurance benefits end. Some managed- care plans will not allow me to provide services to you once your benefits end. If this is the case, I will do my best to find another provider who will help you continue your psychotherapy. You should also be aware that your contract with your health insurance company requires that I provide it with information relevant to the services that I provide to you. I am required to provide a clinical diagnosis. Sometimes I am required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your sessions. It is important to remember that you always have the right to pay for my services yourself to avoid the problems described above [unless prohibited by contract]. YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THE INFORMATION IN THIS AGREEMENT AND AGREE TO ABIDE BY ITS TERMS DURING OUR PROFESSIONAL RELATIONSHIP AND ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPAA NOTICE FORM DESCRIBED ABOVE. Printed Name Signature
Appears in 1 contract
Meetings. I We normally conduct an evaluation that will last from 1-2 1 to 4 sessions. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If therapy has psychotherapy is begun, I the psychologist will usually schedule one 4550-minute ses- sion session (one appointment hour of 50 minutes duration) per week or every two weeks at a time we agree on, although some sessions (especially testing sessions or the first diagnostic interview) may be longer or more frequent. Once an appointment hour is scheduled, you will be expected to pay for it un- less unless you provide 24-at least 24 hours advanced advance notice of cancellation. It is important to note that insurance companies do not provide reimbursement for cancelled sessions. Professional Fees My You may be required to provide a credit card number for billing for missed or late-cancelled appointments. PROFESSIONAL FEES The hourly fee varies depending is currently based on services $250.00 for psychotherapy and durationcounseling and $300.00 for evaluations. In addition This typically translates to weekly ap- pointments, I charge this amount $190.00 for other professional services you may needa typical 50-minute in-person or tele-conferenced therapy session. How- ever, I Assessments of intellectual abilities are typically $500.00. We will break down the hourly cost to 15-minute increments if I we work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services include report writing, telephone conversations consultations lasting longer than 10-7 minutes, Skype appoint- ments or check-ins, consulting with other professionals with your permission, prepar- ing preparation of records or treatment summaries, and the time spent performing any other ser- vices service you may request of meme or my staff. If you become involved in legal proceedings that require my our participation, you will be expected to pay for all of my professional time, including preparation and transportation time and costs, even if I am we are called to testify by another party. Be- cause Because of the difficulty of difficulties associated with legal involvement, I we charge $500 450.00 per hour for preparation and attendance at any legal proceedingsproceeding and will require a prepaid retainer. Contacting Me CONTACTING US Due to my our work schedule, I am we are often not immediately available by telephone. While I am usually in my our office four days a weekbetween 9 AM and 6 PM on Monday through Thursday, I probably will not answer the phone when I am with a clientpatient. I When we are unavailable, our telephone is answered by voice mail that we monitor frequently. We will make every effort to return your call by on the end of my business daysame day you make it, with the exception of weekends and holidays. If you are difficult to reach, please inform me us of some times when you will be available. If you are unable to reach me us and you feel that you can’t wait for me to return your call, contact your family physician, the Seattle Crisis Clinic (206/461-3222), or the nearest emergency room and ask for the psychologist or psychiatrist mental health professional on call, or call 911. If I we will be unavailable for an extended time, I we will provide you with the name of a colleague contact, if necessaryon the voicemail message. You Please feel free to contact that professional in any emergencies. They will provide what assistance they can and may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality The law protects the privacy of all communications between a client and a therapist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, ad- xxxxx consent. Your signature on this Agreement provides consent for those activities, as follows: I may occasionally find it helpful to consult other health and mental health profes- sionals about a case. During consultation, I make every effort to avoid revealing the identity of my client. The other professionals are also legally bound to keep informa- tion confidential. If you don’t object, I will not tell you about these consultations un- less I feel that it is important to our work together. I will note all consultations in your Clinical Record. Disclosures required by health insurers or to collect overdue fees are discussed else- where in this Agreement. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the social worker-client privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. If a government agency is requesting have the information for health oversight activities, I may be required to provide it for them. If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client in order to defend myself. If a client files a worker’s compensation claim, I must, upon appropriate request, pro- vide a copy of the client’s record to the Labor and Industrial Commission or the Work- ers’ Compensation Division, or the client’s employer. There are some situations in which I am legally obligated to take actions, which I be- lieve are necessary to attempt to protect others from harm and I may have to reveal some information about a client’s treatment. These situations are unusual contact me directly in my practice. If I have reasonable cause to suspect that a child has been or may be subjected to abuse or neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglect, the law requires that I file a report with Tennessee’s Department of Children’s Services. Once such a report is filed, I may be required to provide additional information. If I have reasonable cause to suspect that an elderly or disabled adult presents a like- lihood of suffering serious physical harm and is in need of protective services, the law requires that I file a report with Adult Protective Services. Once such a report is filed, I may be required to provide additional information. If I believe that it is necessary to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by the client on him/her- self or another person, I may be required to take protective action. These actions may include, and/or initiating hospitalization and/or contacting the potential victim, and/or the police and/or the client’s family. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure is reasonably likely to endanger you and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harm, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of 35 cents per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Records, you have a right of review, which I will discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents of our conversations, my analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentiallyabsence.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include:
Appears in 1 contract
Meetings. I normally conduct an evaluation that will last from 1-2 sessions. During this timeAfter your initial consultation, we both decide if I am the best person to provide the services you need in order to meet your treatment goals. If therapy has begunpsychotherapy is indicated, I will usually schedule one 45-minute ses- sion session (one appointment hour of 45 minutes duration) per week at a time we agree on, although some sessions may be longer or more frequentthis can vary in duration and frequency. Once an appointment hour is scheduled, you will be expected to pay for it un- less unless you provide 24-48 hours advanced advance notice of cancellation. It is important to note that insurance companies do not provide reimbursement for cancelled sessionslate cancellations or missed scheduled appointments. Professional Fees PROFESSIONAL FEES My hourly fee varies depending on services and duration. schedule is as follows: • Initial Consultation/Evaluation $175 • Individual Sessions $135 • Family/Couples Sessions $135 • Group Therapy Sessions $75 • Psychological Testing (per hour) from $175 • Psychological Testing Materials Fee $75 • Other In addition to weekly ap- pointmentsappointments, I charge this amount from $175 per hour for other professional services you may need. How- ever, though I will break down the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services include report writing, telephone conversations lasting longer than 10-10 minutes, Skype appoint- ments or check-ins, consulting with other professionals with your permission, prepar- ing preparation of records or treatment summaries, and the time spent performing any other ser- vices service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Be- cause Because of the difficulty intricacies of legal involvementlegal/forensic work, I charge my fees begin at $500 250 per hour for preparation preparation, travel and attendance at any legal proceedingsproceeding. Contacting Me CONTACTING ME Due to my work scheduleschedule and the fact that I generally do not interrupt sessions with patients to take phone calls, I am often not immediately available by telephone. While When I am usually in unavailable, my office four days a week, telephone is answered by voice mail that I probably will not answer the phone when I am with a clientmonitor frequently. I will make every effort to return your call by on the end of my business daysame day you make it, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. My colleagues/office- mates, Drs Xxxxxx Xxxxxxx-Xxxxx, Xxxxxx Xxxxxx, Xxxxxx Xxxxx and Xxxxx Xxxxxxx and I often share on-call coverage for our practices. If you are unable to reach me and you feel that you can’t cannot wait for me to a return your call, you can contact your family physician, one of us by following the instructions on my voicemail and/or you can contact the nearest emergency room and ask for the psychologist or psychiatrist on call, or call 911. If I will be unavailable for an extended time, I will provide you with the name of a colleague contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality The law protects the privacy of all communications between a client and a therapist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, ad- xxxxx consent. Your signature on this Agreement provides consent for those activities, as follows: I may occasionally find it helpful to consult other health and mental health profes- sionals about a case. During consultation, I make every effort to avoid revealing the identity of my client. The other professionals are also legally bound to keep informa- tion confidential. If you don’t object, I will not tell you about these consultations un- less I feel that it is important to our work together. I will note all consultations in your Clinical Record. Disclosures required by health insurers or to collect overdue fees are discussed else- where in this Agreement. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the social worker-client privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client in order to defend myself. If a client files a worker’s compensation claim, I must, upon appropriate request, pro- vide a copy of the client’s record to the Labor and Industrial Commission or the Work- ers’ Compensation Division, or the client’s employer. There are some situations in which I am legally obligated to take actions, which I be- lieve are necessary to attempt to protect others from harm and I may have to reveal some information about a client’s treatment. These situations are unusual in my practice. If I have reasonable cause to suspect that a child has been or may be subjected to abuse or neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglect, the law requires that I file a report with Tennessee’s Department of Children’s Services. Once such a report is filed, I may be required to provide additional information. If I have reasonable cause to suspect that an elderly or disabled adult presents a like- lihood of suffering serious physical harm and is in need of protective services, the law requires that I file a report with Adult Protective Services. Once such a report is filed, I may be required to provide additional information. If I believe that it is necessary to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by the client on him/her- self or another person, I may be required to take protective action. These actions may include, and/or initiating hospitalization and/or contacting the potential victim, and/or the police and/or the client’s family. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure is reasonably likely to endanger you and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harm, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of 35 cents per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Records, you have a right of review, which I will discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents of our conversations, my analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentiallycrisis service.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include:
Appears in 1 contract
Samples: Summary of Agreement
Meetings. I We normally conduct an evaluation that will last from 1-2 to 4 sessions. During this time, we both can decide if I am our practice is the best person place to provide the services you need in order to meet your treatment goals. If therapy has psychotherapy is begun, I we will usually schedule one 45-minute ses- sion appointment hour of 45 minutes duration per week or every other week at a time we agree on, although some sessions may be longer or more frequent. Once an appointment hour is scheduled, you will be expected to pay for it un- less unless you provide 24-a minimum of 24 hours advanced advance notice of cancellation. The sole exception to this policy is cancellation due to severely inclement weather. It is important to note that insurance companies do not provide reimbursement for cancelled canceled sessions. Professional Fees My PROFESSIONAL FEES Our hourly fee varies depending on services is $250 for the initial evaluation and duration$150 for 45 minute appointments thereafter. In addition to weekly ap- pointmentsappointments, I we charge this amount for other professional services you may need. How- ever, I though we will break down the hourly cost if I work prorate for periods of less than one hour. Note that these additional services are not covered by insurance45 minutes. Other services include report writing, telephone conversations lasting longer than 10-minutes, Skype appoint- ments or check-insconversations, consulting with other professionals with your permission, prepar- ing preparation of records or treatment summaries, and the time spent performing any other ser- vices service you may request of meus. If you become involved in legal proceedings that require my our participation, you will be expected to pay for all of my our professional time, including preparation and transportation costs, even if I am we are called to testify by another party. Be- cause Because of the difficulty of legal involvement, I we charge $500 300 per hour for preparation and attendance at any legal proceedingsproceeding. Contacting Me CONTACTING US Due to my our work scheduleschedules, I am we are often not immediately available by telephone. While I am usually There is a receptionist answering the telephone Monday through Friday between the hours of 9:00am and 5:00pm. However, when we are in my office four days a weekthe office, I probably will we do not answer the accept phone calls when I am we are in session with a client. I When we are unavailable and the receptionist is not in the office, the telephone is answered by voice mail. We will make every effort to return your call by on the end of my business daysame day you make it, with the exception of weekends and holidays. If you are difficult to reach, please inform me us of some times when you will be available. In emergencies, you may bypass the voice mail system to leave a message with the answering service and they will attempt to reach us on your behalf. If you are unable to reach me us and you feel that you can’t wait for me us to return your call, contact your family physician, physician or the nearest emergency room and ask for the psychologist or psychiatrist on call, or call 911. If I we will be unavailable for an extended time, I we will provide you with the name of a colleague to contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client patient and a therapistpsychologist/psychotherapist. In most situations, I we can only release information about your treatment to others if you sign a written Authorization Form authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, ad- xxxxx advance consent. Your signature on this Agreement provides consent for those activities, as follows: I You should be aware that we practice as a group of mental health professionals and that we employ administrative staff. In most cases, we need to share protected information with these individuals for both clinical and administrative purposes, such as scheduling, billing and quality assurance. All of the mental health professionals are bound by the same rules of confidentiality. All staff members have been given training about protecting your privacy and have agreed not to release any information outside of the practice without the permission of a professional staff member. We may occasionally find it helpful to consult other health and mental health profes- sionals professionals about a case. During a consultation, I we make every effort to avoid revealing the identity of my our client. The other professionals are also legally bound to keep informa- tion the information confidential. If you don’t object, I we will not tell you about these consultations un- less I unless we feel that it is important to our work together. I will note all consultations We also have contracts with business associates who provide additional services such as legal and accounting services to our practice. As required by HIPAA, we have a formal business associate contract with these businesses, in your Clinical Recordwhich they promise to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, we can provide you with the names of these organizations and/or a blank copy of this contract. Disclosures required by health insurers or to collect overdue fees are discussed else- where elsewhere in this Agreement. If a patient threatens to harm himself/herself, we may be obligated to seek hospitalization for him/her, or to contact family members or others who can help provide protection. There are some situations where I am we are permitted or required to disclose information without either your consent or Authorization: If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatmentour professional services, such information is protected by the social workerpsychotherapist-client patient privilege law. I We cannot provide any information without your (or your legal representative’s) written authorization, or a court order, or a subpoena of which you have been officially notified and failed to inform us that you are opposing. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me us to disclose information. If a government agency is requesting the information for health oversight activities, I we may be required to provide it for them. If a client patient files a complaint or lawsuit against meus, I we may disclose relevant information regarding that client patient in order to defend myselfourselves. If a client patient files a worker’s compensation claim, I information that is directly related to that claim must, upon appropriate request, pro- vide a copy of the client’s record be provided to the Labor and Industrial Commission or the Work- ersWorkers’ Compensation Division, or the client’s employerCommission. There are some situations in which I am we are legally obligated to take actions, which I be- lieve we believe are necessary to attempt to protect others from harm and I we may have to reveal some information about a clientpatient’s treatment. These situations are unusual in my our practice. If I we have reasonable cause reason to know or suspect that a child has been abused or may be subjected to neglected, or has been a victim of sexual abuse or neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglectby another child, the law requires that I we file a report with Tennessee’s the Department of for Children’s Services, Youth and Families. Once such a report is filed, I we may be required to provide additional information. If I have reasonable cause to suspect we believe that an elderly or disabled adult a patient presents a like- lihood of suffering serious physical harm and is in need of protective servicesrisk to a person or his/her family, the law requires that I file a report with Adult Protective Services. Once such a report is filed, I may be required to provide additional information. If I believe that it is necessary to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by the client on him/her- self or another person, I we may be required to take protective action. These actions may includeincluding warning the potential victim(s), and/or initiating hospitalization and/or contacting the potential victimpolice, and/or or seeking hospitalization of the police and/or patient. If we have reason to know or suspect that an adult over the client’s familyage of 60 has been abused or is no longer able to care for him/herself we must report that information to the Division of Elderly Affairs, Protective Services Unit. If such a situation arises, I we will make every effort to fully discuss it with you before taking any action and I we will limit my our disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records You should The laws governing confidentiality can be aware thatquite complex, pursuant to HIPAAand we are not attorneys. In situations where specific advice is required, I formal legal advice may be needed. PROFESSIONAL RECORDS The laws and standards of our profession require that we keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure is reasonably likely to endanger you and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harm, you You may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I we recommend that you initially review them in my our presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of 35 cents per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Records, you have a right of review, which I will discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents of our conversations, my analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentially.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights PATIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your Clinical Records Record and disclosures of protected health information. These rights include:include requesting that we amend your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about our policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and our privacy policies and procedures. We are happy to discuss any of these rights with you. MINORS & PARENTS Patients under 18 years of age who are not emancipated and their parents/legal guardians should be aware that the law may allow parents/guardians to examine their child’s treatment records. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is sometimes our policy to request an agreement from parents/legal guardians that they consent to give up their access to their child’s records. If they agree, during treatment, we will provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. Any other communication will require the child’s Authorization, unless we feel that the child is in danger or is a danger to someone else, in which case, we will notify the parents/legal guardians of our concern. Before giving parents any information, we will discuss the matter with the child, if possible, and do our best to handle any objections he/she may have. You should also be aware that it is our office policy to notify both parents that a minor child is receiving treatment at this office. BILLING AND PAYMENTS You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, we have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require us to disclose otherwise confidential information. In most collection situations, the only information we release regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due. If such legal action is necessary, its costs will be included in the claim. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. We will fill out forms and provide you with whatever assistance we can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of our fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, we will provide you with whatever information we can based on our experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, we will be willing to call the company on your behalf. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in short-term therapy, some patients feel that they need more services after insurance benefits end. You should also be aware that your contract with your health insurance company requires that we provide it with information relevant to the services that we provide to you. We are required to provide a clinical diagnosis. Sometimes we are required to provide additional clinical information such as treatment plans or summaries, or copies of your entire clinical record. In such situations, we will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, we have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. We will provide you with a copy of any report we submit, if you request it. By signing this Agreement, you agree that we can provide requested information to your carrier. We may provide them with this information via mail, fax, or telephone. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your sessions. It is important to remember that you always have the right to pay for our services yourself to avoid the problems described above. YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ AND UNDERSTAND THIS AGREEMENT AND AGREE TO ITS TERMS AND ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPAA NOTICE FORM DESCRIBED ABOVE. Name (print) Signature Date
Appears in 1 contract
Samples: Patient Services Agreement
Meetings. I normally conduct an evaluation that will last from 1-2 to 6 sessions. This evaluation may also include the use of psychological testing. During this time, we can both decide if I am the best person to provide the services that you need in order to meet your treatment goals. If therapy has psychotherapy is begun, I will usually schedule one 4560-minute ses- sion session (one appointment hour of 60 minutes duration) per week at a time we agree on, although some sessions may be longer or more frequent. Once an appointment hour is scheduled, you will be expected to pay for it un- less unless you provide 24-24 hours advanced advance notice of cancellationcancellation [unless we both agree that you were unable to attend due to circumstances beyond your control]. It is important to note that insurance companies do not provide reimbursement for cancelled sessions. Professional Fees PROFESSIONAL FEES My hourly fee varies depending on services and durationis $120.00. In addition to weekly ap- pointmentsappointments, I charge this amount for other professional services you may need. How- ever, though I will break down the hourly cost if I work for periods of less than one hour. Note that these additional Other services may include but are not covered by insurance. Other services include limited to report writing, review of psychological testing results, correspondence with and/or other contacts with insurance companies, telephone conversations lasting longer than 10-5 minutes, Skype appoint- ments or check-ins, consulting with other professionals with your permission, prepar- ing preparation of records or treatment summaries, and the time spent performing any other ser- vices service you may request of me. Psychological testing will be charged at a flat rate that will be discussed and priced to you prior to the test administration. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Be- cause Because of the difficulty of legal involvement, I charge $500 200.00 per hour for preparation and attendance at any legal proceedingsproceeding. Contacting Me CONTACTING ME Due to my work schedule, I am often not immediately available by telephone. While I am usually in my office four days a weekbetween 9 AM and 5 PM, I probably will not answer the phone when I am with a clientpatient. When I am unavailable, my telephone is answered by an answering machine that I monitor frequently. I will make every effort to return your call by on the end of my business daysame day you make it, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. If In emergencies, if you are unable to reach me (000-000-0000) and you feel that you can’t wait for me to return your call, contact your family physician, physician or the nearest emergency room and ask for the psychologist or and/or psychiatrist on call, or call 911. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client patient and a therapistpsychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, ad- xxxxx advance consent. Your signature on this Agreement provides consent for those activities, as follows: • I may occasionally find it helpful to consult other health and mental health profes- sionals professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my clientpatient. The other professionals are also legally bound to keep informa- tion the information confidential. If you don’t object, I will not tell you about these consultations un- less unless I feel that it is important to our work together. I will note all consultations in your Clinical RecordRecord (which is called “PHI” in my Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information). • If I enter into contracts with any businesses that involve your PHI, I will have a formal business associate contract with these businesses, as required by HIPAA, in which they promise to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I can provide you with the names of these organizations and/or a blank copy of this contract. • Disclosures required by health insurers or to collect overdue fees are discussed else- where elsewhere in this Agreement. • If a patient threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her, or to contact family members or others who can help provide protection. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: • If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the social workerpsychologist-client patient privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. • If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. • If a client patient files a complaint or lawsuit against me, I may disclose relevant information regarding that client patient in order to defend myself. • If a client patient files a worker’s compensation claim, I must, upon appropriate request, pro- vide a copy of the client’s record provide relevant information, to the Labor and Industrial Commission or appropriate parties, including the Work- ers’ Compensation Division, or the clientpatient’s employer, the worker’s compensation insurer. There are some situations in which I am legally obligated to take actions, which I be- lieve believe are necessary to attempt to protect others from harm and I may have to reveal some information about a clientpatient’s treatment. These situations are unusual in my practice. ▪ If I know or have reasonable cause to suspect believe that a child has been child, spouse, or may be subjected to abuse vulnerable adult is neglected or neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglectabused, the law requires that I file a report with Tennessee’s Department of the appropriate governmental agency, usually the Cabinet for Families and Children’s Services. Once such a report is filed, I may be required to provide additional information. ▪ If I have reasonable cause to suspect that a patient communicates an elderly or disabled adult presents a like- lihood actual threat of suffering serious physical harm and is in need of protective services, the law requires that I file a report with Adult Protective Services. Once such a report is filed, I may be required to provide additional information. If I believe that it is necessary to disclose information to protect violence against a clear and substantial risk clearly identified or reasonably identifiable victim or a threat of imminent serious harm being inflicted by the client on him/her- self or another persona specific violent act, I may be required to take protective actionactions. These actions may include, and/or initiating hospitalization and/or contacting include notifying the potential victim, and/or contacting the police and/or police, or seeking hospitalization for the client’s familypatient. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records You should The laws governing confidentiality can be aware thatquite complex, pursuant to HIPAAand I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. PROFESSIONAL RECORDS The laws and standards of my profession require that I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where circumstances that that disclosure is reasonably likely to would physically endanger you and/or others or when makes reference to another individual person (unless such other than another person is a health care provider) is referenced and I believe disclosing that information puts the access is reasonably likely to cause substantial harm to such other person at risk of substantial harmperson, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstancesYou are entitled to a free copy of your records. However, I am allowed to charge a copying fee of 35 cents $1 per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form) for any subsequent copies. If I refuse your request for access to your Clinical Recordsrecords, you have a right of review, which I will discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents of our conversations, my analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentially.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights PATIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include:include requesting that I amend your record; requesting restrictions on what information from your Clinical Records is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights with you. MINORS & PARENTS Patients under 16 years of age who are not emancipated and their parents should be aware that the law may allow parents to examine their child’s treatment records. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is sometimes my policy to request an agreement from parents that they consent to give up their access to their child’s records. If they agree, during treatment, I will provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. I will also provide parents with a summary of their child’s treatment when it is complete. Any other communication will require the child’s Authorization, unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have. BILLING AND PAYMENTS You will be expected to pay for each session at the time it is held, unless we agree otherwise. Payment schedules for other professional services will be agreed to when they are requested. In circumstances of unusual financial hardship, I may be willing to negotiate a payment installment plan. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require me to disclose otherwise confidential information. In most collection situations, the only information I release regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due. If such legal action is necessary, its costs will be included in the claim. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, I will be willing to call the company on your behalf. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in short-term therapy, some patients feel that they need more services after insurance benefits end. You should also be aware that your contract with your health insurance company requires that I provide it with information relevant to the services that I provide to you. I am required to provide a clinical diagnosis. Sometimes I am required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your sessions. It is important to remember that you always have the right to pay for my services yourself to avoid the problems described above [unless prohibited by contract]. YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS AND ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPAA NOTICE FORM DESCRIBED ABOVE. Patient Signature Date
Appears in 1 contract
Samples: Patient Services Agreement
Meetings. I normally conduct The initial evaluation typically lasts about one hour. The testing session can vary depending on the age of the person being evaluated and on the reason you are seeking help, but the session typically ranges between 1 and 5 hours. Please provide 24 hours notice if you are unable to keep an evaluation that will last from 1-2 sessions. During this time, we both decide if I am the best person to provide the services you need in order to meet your treatment goalsappointment. If therapy has beguntwo appointments are missed prior to the feedback session, I will usually schedule one 45it may 55 Jonesboro Street XxXxxxxxx, Georgia 30253 Office: 000-minute ses- sion per week at 000-0000 Fax: 000-000-0000 Email: xxxxxxxxx@xxxxx.xxx necessitate you being placed on a time we agree on, although some sessions waiting list for future appointments. You may also be longer or more frequentcharged for missed appointments. Once an appointment hour is scheduled, you will be expected to pay for it un- less you provide 24-hours advanced notice of cancellation. It is important to note that insurance companies do not provide reimbursement for cancelled sessions. Professional Fees PROFESSIONAL FEES My hourly fee varies depending on services is $180 for the initial evaluation session, $180 for testing sessions, and duration$180.00 for follow-up therapy or feedback sessions. In addition to weekly ap- pointmentsthe appointments, I charge this amount for other professional services you may need. How- ever, though I will break down the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services include report writing, telephone conversations lasting longer than 10-15 minutes, Skype appoint- ments or check-ins, consulting with other professionals with your permission, prepar- ing preparation of records or treatment summaries, and the time spent performing any other ser- vices service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Be- cause Because of the difficulty of legal involvement, I charge $500 per hour 900 for preparation a half day and $1800 for a full day attendance at any legal proceedingsproceeding. Contacting Me Transportation costs are billed at $120 per hour, portal to portal. CONTACTING ME Due to my work schedule, I am often not immediately available by telephone. While I am usually not in my the office four days a week, I probably will not answer the phone when every day. When I am with a clientunavailable, my telephone is answered by voice mail that I monitor frequently. I will make every effort to return your call by on the end of my business daysame day you make it, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. If you are unable to reach me and you feel that you can’t wait for me to return your call, contact your family physician, physician or the nearest emergency room and ask for the psychologist or psychiatrist on call, or call 911. If I will be unavailable for an extended time, I will provide you with the name of a colleague contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality The law protects the privacy of all communications between a client and a therapist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, ad- xxxxx consent. Your signature on this Agreement provides consent for those activities, as follows: I may occasionally find it helpful to consult other health and mental health profes- sionals about a case. During consultation, I make every effort to avoid revealing the identity of my client. The other professionals are also legally bound to keep informa- tion confidential. If you don’t object, I will not tell you about these consultations un- less I feel that it is important to our work together. I will note all consultations in your Clinical Record. Disclosures required by health insurers or to collect overdue fees are discussed else- where in this Agreement. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the social worker-client privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client in order to defend myself. If a client files a worker’s compensation claim, I must, upon appropriate request, pro- vide a copy of the client’s record to the Labor and Industrial Commission or the Work- ers’ Compensation Division, or the client’s employer. There are some situations in which I am legally obligated to take actions, which I be- lieve are necessary to attempt to protect others from harm and I may have to reveal some information about a client’s treatment. These situations are unusual in my practice. If I have reasonable cause to suspect that a child has been or may be subjected to abuse or neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglect, the law requires that I file a report with Tennessee’s Department of Children’s Services. Once such a report is filed, I may be required to provide additional information. If I have reasonable cause to suspect that an elderly or disabled adult presents a like- lihood of suffering serious physical harm and is in need of protective services, the law requires that I file a report with Adult Protective Services. Once such a report is filed, I may be required to provide additional information. If I believe that it is necessary to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by the client on him/her- self or another person, I may be required to take protective action. These actions may include, and/or initiating hospitalization and/or contacting the potential victim, and/or the police and/or the client’s family. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure is reasonably likely to endanger you and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harm, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of 35 cents per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Records, you have a right of review, which I will discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents of our conversations, my analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentially.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include:
Appears in 1 contract
Meetings. I normally conduct an evaluation that will last from 1-2 An interview to discuss concerns, problems, issues and background information usually occurs in the first one or two sessions. During this time, we can both decide if I am the best person to provide the services that you need in order to meet your treatment goals. If therapy has begun, I will A treatment hour is usually schedule one 45-minute ses- sion per week at a time we agree on, although some sessions may be longer or more frequent55 minutes duration. Once an appointment hour is scheduled, you will be expected to pay for it un- less unless you provide 24-24 hours advanced advance notice of cancellationcancellation [unless an agreement is reached that you were unable to attend due to circumstances beyond your control]. It is important to note that insurance Insurance companies do not provide reimbursement for cancelled sessions. Professional Fees PROFESSIONAL FEES My hourly fee varies depending on services and duration. In addition to weekly ap- pointments, I charge this amount for other professional services you may need. How- ever, I will break down the hourly cost if I work for periods of less than one hour. Note that these additional services fees are not covered by insurance. as follows: Initial Consult $140.00 Counseling: $120.00 Other charged services include report writing, telephone conversations lasting longer than 10-10 minutes, Skype appoint- ments or check-ins, consulting with other professionals with your permission, prepar- ing preparation of records or treatment summaries, and the time spent performing any other ser- vices service you may request of merequest. The charges for these services will be similar to my hourly charges, prorated for the time invested. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my the professional time, including preparation and transportation costs, even if I am when called to testify by another party. Be- cause Because of the difficulty of legal involvement, I charge $500 250.00 per hour for preparation testimony given in court or through a deposition and attendance at any legal proceedings$100.00 per hour for travel time. Contacting Me Due CONTACTING ME My office hours vary by the day of the week , but I am generally in Monday through Friday, 9:30 a.m. to my work schedule, 5:00 p.m. I am often not immediately available by telephone. While telephone as I am usually in my office four days a week, I probably will not answer the phone when I am with a clientpatient. I My telephone is answered by my voicemail. Every effort will make every effort be made to return your call by on the end of my business daysame day you made it, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. If you are unable to reach me and you feel that you can’t cannot wait for me to a return your call, contact your family physician, physician or the nearest hospital’s emergency room and ask for the psychologist or psychiatrist on call, or call 911. If I A more convenient means of communication will be unavailable for an extended time, I via encrypted email through my scheduling and billing program – Xxxxxxxxxxxxxxxxxx.xxx – which you have likely already accessed. Email will provide you with the name of a colleague contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx allow us to communicate with me. Limits of Confidentiality The law protects the privacy of all communications between a client and a therapist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, ad- xxxxx consent. Your signature on this Agreement provides consent for those activities, as follows: I may occasionally find it helpful to consult other health and mental health profes- sionals about a case. During consultation, I make every effort to avoid revealing the identity of my client. The other professionals are also legally bound to keep informa- tion confidential. If you don’t object, I will not tell you about these consultations un- less I feel that it is important to our work together. I will note all consultations in your Clinical Record. Disclosures required by health insurers or to collect overdue fees are discussed else- where in this Agreement. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the social worker-client privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client in order to defend myself. If a client files a worker’s compensation claim, I must, upon appropriate request, pro- vide a copy of the client’s record to the Labor and Industrial Commission or the Work- ers’ Compensation Division, or the client’s employer. There are some situations in which I am legally obligated to take actions, which I be- lieve are necessary to attempt to protect others from harm and I may have to reveal some information about a client’s treatment. These situations are unusual in my practice. If I have reasonable cause to suspect that a child has been or may be subjected to abuse or neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglect, the law requires that I file a report with Tennessee’s Department of Children’s Services. Once such a report is filed, I may be required to provide additional information. If I have reasonable cause to suspect that an elderly or disabled adult presents a like- lihood of suffering serious physical harm and is in need of protective services, the law requires that I file a report with Adult Protective Services. Once such a report is filed, I may be required to provide additional information. If I believe that it is necessary to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by the client on him/her- self or another person, I may be required to take protective action. These actions may include, and/or initiating hospitalization and/or contacting the potential victim, and/or the police and/or the client’s family. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure is reasonably likely to endanger you and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harm, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of 35 cents per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Records, you have a right of review, which I will discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents of our conversations, my analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentially.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include:in
Appears in 1 contract
Samples: Patient Services Agreement
Meetings. Our first few sessions will involve evaluation of your needs. By the end of the evaluation, I normally conduct an evaluation that will last from 1-2 sessionsbe able to offer you some first impressions of what our work will include if you decide to continue with therapy. During You should evaluate this information along with your own opinions of whether you feel comfortable working with me. Therapy involves a large commitment of time, we both decide if I am money, and energy, so you should be very careful about the best person to provide the services therapist you need in order to meet your treatment goalsselect. If therapy has you have any questions, please feel free to ask them as they arise. If psychotherapy is begun, I will usually schedule one 45-minute ses- sion session (one appointment hour of 50 minutes duration for an individual and 75 minutes for a couple) per week at a time we agree on, although some sessions this may be longer or more frequentvary. Once an appointment hour is scheduled, you will be expected to pay for it un- less unless you provide 24-24 hours advanced advance notice of cancellationcancellation (unless we both agree that you were unable to attend due to circumstances beyond your control). It is important to note that insurance companies do not provide reimbursement for cancelled unused sessions. Professional Fees PROFESSIONAL FEES My hourly general individual fee varies depending on services and durationis $125 for a 50 minute session (the initial assessment is $150), couples’ therapy is $175 for a 75 minute session. For consultations, I charge $150 per hour. In addition to weekly ap- pointmentsappointments, I charge this amount these amounts for other professional services you may need. How- everperformed on your behalf, though I will break down pro-rate the hourly cost if I work fee in 15 minute increments for periods of less than then one hour. Note that these additional services are not covered by insurance. Other Examples of other services include report writing, frequent or lengthy telephone conversations lasting longer than 10-minutes, Skype appoint- ments or check-insconversations, consulting with other professionals with your permission, prepar- ing and preparation of records or treatment summaries, and . My preference is not to become involved in any legal matter. It usually interferes with the time spent performing any other ser- vices you may request of metherapeutic relationship which is essential for successful change. I recommend hiring another therapist who specializes in legal work yet is not in active therapy with you. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Be- cause I will not agree to court appearance unless we have discussed the matter thoroughly and both agree that such appearance will not interfere with the treatment relationship and that I will be able to participate in the legal proceedings without unreasonable bias. Because of the complexity and difficulty of legal involvement, I charge my fee, in advance, is $500 200.00 per hour for preparation and attendance at involvement in any legal proceedingswork. Contacting Me CONTACTING ME Due to my work schedule, I am often not immediately available by telephone. While When I am usually in unavailable, my office four days a week, telephone is answered by confidential voice mail that I probably will not answer the phone when I am with a clientmonitor frequently. I will make every effort to return your call by on the end of my business daysame day you make it, with the exception of weekends weekends, holidays, and holidaysvacations. Nighttime calls will usually be returned the next day. If you are difficult to reachfind yourself in an urgent situation, please inform me make a judgment about the prudence of some times when you will be available. If you are unable to reach me and you feel that you can’t wait waiting for me to return my call versus calling your call, contact your family primary care physician, the nearest emergency room and ask for the psychologist or psychiatrist on call911, or call 911or visit your local hospital emergency room. If I am away for more than a day, my voicemail message will be unavailable for an extended time, indicate that and state when I will provide you with the name of a colleague contact, if necessaryreturn. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client patient and a therapistpsychotherapist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, ad- xxxxx consent. Your signature on this Agreement provides consent for those activities, as follows: I may occasionally find it helpful to consult other health and mental health profes- sionals about a case. During consultation, I make every effort to avoid revealing the identity of my client. The other professionals are also legally bound to keep informa- tion confidential. If you don’t object, I will not tell you about these consultations un- less I feel that it is important to our work together. I will note all consultations in your Clinical Record. Disclosures required by health insurers or to collect overdue fees are discussed else- where in this Agreementform. There are some situations where I am permitted or required to disclose information without either your consent or Authorization. Please see the attached “Notice of Policies and Practices to Protect the Privacy of Your Health Information” for more information. A summary is provided below: I may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my client. If a client threatens to harm himself/ herself, I may be obligated to seek hospitalization for him/her, or to contact family members or others who can help provide protection. If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the social workercounselor-client patient privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. If I am required to comply if a government agency is requesting the requests information for health oversight activities, I may be required to provide it for them. If a client patient files a complaint or lawsuit against me, I may disclose relevant information regarding that client patient in order to defend myself. If a client files a worker’s compensation claim, I must, upon appropriate request, pro- vide a copy of the client’s record to the Labor and Industrial Commission or the Work- ers’ Compensation Division, or the client’s employer. There are some situations in which I am legally obligated to take actionsaction, such as making a report to a protective agency or warning a potential victim, which I be- lieve are believe is necessary to attempt to protect others from harm harm, and I may have to reveal some thereby revealing information about a clientpatient’s treatment. These situations are unusual in my practice. If I have reasonable cause to suspect that a child has been or may be subjected to abuse or neglect or observe suffered harm as a result of child being subjected to conditions or circumstances that would reasonably result in abuse or neglect. If I have reasonable cause to believe a vulnerable adult suffers from abandonment, the law requires that I file exploitation, abuse, neglect, or self-neglect; or a report with Tennessee’s Department disabled person has been abused. If a client communicates an immediate threat of Children’s Services. Once such a report is filedserious harm to an identifiable victim, I may be required to provide additional information. If I have reasonable cause to suspect that an elderly or disabled adult presents a like- lihood of suffering serious physical harm and is in need of protective services, the law requires that I file a report with Adult Protective Services. Once such a report is filed, I may be required to provide additional information. If I believe that it is necessary to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by the client on him/her- self or another person, I may be required to take protective action. These actions may include, and/or initiating hospitalization and/or contacting notify the potential victim, and/or the police and/or contact police, or seek hospitalization for the client’s family. If any such a situation arises, I will make every effort to fully discuss it with you fully before taking any action action, and I will try to limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records You should The laws governing confidentiality can be aware thatquite complex, pursuant to HIPAAand I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. PROFESSIONAL RECORDS The law and standards of my profession require that I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, If you provide a description of the ways in which your problem impacts your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure is reasonably likely to endanger you and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harmwritten request, you may have the right to examine and/or receive a copy of your Clinical Record, if you request it in writingrecords. Because these are professional records, they can sometimes be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, presence or have them forwarded to another mental health professional so you to review with you. There may be a charge for reproducing records or for the time required to review them with you. BILLING AND PAYMENTS Payment can discuss be with check, cash, or credit card. You will be expected to pay for each session at the contentstime it is held, unless we agree otherwise. In most circumstancesI do not file insurance for you. However, I am allowed to charge a copying fee of 35 cents per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Records, you have a right of review, which I will discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing provide you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents of our conversations, my analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information a statement that you may reveal forward to me that is your insurance company if you so desire. If you use your insurance, as the insured, you are ultimately responsible for determining what services are covered and to what degree. If, for some reason, your account has not required been paid for 90 days or more and arrangements for payment have not been agreed upon, late payment feels of 1.5% per month will be charged, and I have the option of using legal means to secure payment. This may involve hiring a collection agency (in which case, a 30% delinquency fee will be added to your balance) or going through small claims court (in which case, legal costs will be included in your Clinical Record. [They also include in- formation from others provided to me confidentially.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health informationthe claim). These rights include:situations are rare, and require disclosure of otherwise confidential information (usually just name, the nature of services provided, and amount due). Please do not let this happen; I would much rather communicate and find some solution to overdue accounts. *********** Your signature below indicates that you have read this agreement and agree to its terms and also serves as an acknowledgement that you have received the HIPAA notice form titled “Notice of Policies and Practices to Protect the Privacy of Your Health Information.” Signature of Client or Representative Date Printed Name Name of Client (if different) If the authorization is signed by a personal representative
Appears in 1 contract
Samples: tcirner.com
Meetings. I normally conduct an initial evaluation that will last from 1-2 sessionsduring the first session. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If therapy has psychotherapy is begun, I will usually schedule one sessions on a 45-50-minute ses- sion per week basis at a time we agree on, although some sessions may be longer or more frequentfrequency agreed upon by us. Once an appointment hour is scheduled, you will be expected to pay for it un- less unless you provide 24-24 hours advanced advance notice of cancellationcancellation [unless we both agree that you were unable to attend due to circumstances beyond your control]. It is important to note that insurance companies do not provide reimbursement for cancelled sessionsor missed sessions and therefore cannot be billed. Professional Fees Therefore, you will be responsible for the full fee of $160.00. PROFESSIONAL FEES My hourly fee varies depending on services and durationis $160. In addition to weekly ap- pointments, I charge this amount for other professional services you may need. How- ever, though I will break down the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services include report writing, telephone conversations lasting longer than 10-minutes, Skype appoint- ments or check-insconversations, consulting with other professionals with your permission, prepar- ing preparation of records or treatment summaries, and the time spent performing any other ser- vices service you may request of me. I cannot charge these services to your insurance. Therefore, you will be personally responsible for payment of these services. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Be- cause [Because of the difficulty of legal involvement, I charge $500 160 per hour for preparation and attendance at any legal proceedings. Contacting Me proceeding.] CONTACTING ME Due to my work schedule, I am often not immediately available by telephone. While I am usually in my office four days a weekbetween 9 AM and 5 PM, I probably will not answer the phone when I am with a client. When I am unavailable, my telephone is answered by voice mail. I check my messages once a day and will make every effort to return your call by the end of my business daywithin 24 hours, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. If you are unable to reach me and you feel that you can’t wait for me to return your call, contact your family physician, physician or the nearest emergency room and ask for the psychologist or psychiatrist on call, or call 911. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client patient and a therapistpsychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, ad- xxxxx advance consent. Your signature on this Agreement provides consent for those activities, as follows: • I may occasionally find it helpful to consult other health and mental health profes- sionals professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my clientpatient. The other professionals are also legally bound to keep informa- tion the information confidential. If you don’t object, I will not tell you about these consultations un- less unless I feel that it is important to our work together. I will note all consultations in your Clinical Record. • Disclosures required by health insurers or to collect overdue fees are discussed else- where elsewhere in this Agreement. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: • If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the social workerpsychologist-client patient privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. • If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. • If a client patient files a complaint or lawsuit against me, I may disclose relevant information regarding that client patient in order to defend myself. • If a client patient files a worker’s compensation claim, I must, upon appropriate request, pro- vide provide appropriate information, including a copy of the clientpatient’s record record, to the Labor and Industrial Commission patient’s employer, the insurer or the Work- ers’ Compensation Division, or the clientDepartment of Worker’s employerCompensation. There are some situations in which I am legally obligated to take actions, which I be- lieve believe are necessary to attempt to protect others from harm and I may have to reveal some information about a clientpatient’s treatment. These situations are unusual in my practice. If I have reasonable cause to suspect believe that a child has been under age 18 is suffering physical or may be subjected emotional injury resulting from abuse inflicted upon him or her which causes harm or substantial risk of harm to abuse the child's health or welfare (including sexual abuse), or from neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglect(including malnutrition), the law requires that I file a report with Tennessee’s the Department of Children’s Social Services. Once such a report is filed, I may be required to provide additional information. If I have reasonable cause reason to suspect that believe an elderly or disabled adult presents a like- lihood of handicapped individual is suffering serious physical harm and is in need of protective servicesfrom abuse, the law requires that I file a report with Adult Protective Servicesto the Department of Elder Affairs. Once such a report is filed, I may be required to provide additional information. If I believe that it is necessary a patient communicates an immediate threat of serious physical harm to disclose information an identifiable victim or if a patient has a history of violence and the apparent intent and ability to protect against a clear and substantial risk of imminent serious harm being inflicted by carry out the client on him/her- self or another personthreat, I may be required to take protective actionactions. These actions may include, and/or initiating hospitalization and/or contacting include notifying the potential victim, contacting the police, and/or seeking hospitalization for the police and/or the client’s familypatient. If a patient threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her, or to contact family members or others who can help provide protection. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records The laws governing confidentiality can be quite complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. PROFESSIONAL RECORDS You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets a set of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure is reasonably likely to endanger you and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harm, you You may examine and/or receive a copy of your Clinical Record, Record if you request it in writingwriting unless I believe that access would endanger you. In those situations, you have a right to a summary and to have your record sent to another mental health provider or your attorney. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstancessituations, I am allowed to charge a copying fee of 35 cents $.20 per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. .) If I refuse your request for access to your Clinical Recordsrecords, you have a right of review, which I will discuss with you upon your request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents of our conversations, my analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentially.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights PATIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your Clinical Records Record and disclosures of protected health information. These rights include:include requesting that I amend your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, and my privacy policies and procedures. I am happy to discuss any of these rights with you. BILLING AND PAYMENTS You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. [In circumstances of unusual financial hardship, I may be willing to negotiate a fee adjustment or payment installment plan.] If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require me to disclose otherwise confidential information. In most collection situations, the only information I release regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due. [If such legal action is necessary, its costs will be included in the claim.] INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, I will be willing to call the company on your behalf. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in short-term therapy, some patients feel that they need more services after insurance benefits end. You should also be aware that your contract with your health insurance company requires that I provide it with information relevant to the services that I provide to you. I am required to provide a clinical diagnosis. Sometimes I am required to provide additional clinical information such as treatment plans or summaries, or copies of your entire clinical record. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your sessions. It is important to remember that you always have the right to pay for my services yourself to avoid the problems described above. Xxxxxxx Xxxxxxxx, Psy.D. Licensed Psychologist PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENT SIGNATURE PAGE Welcome to my practice. This document (the Agreement) contains important information about my professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations. The law requires that I obtain your signature acknowledging that I have provided you with this information at the end of this session. Although these documents are long and sometimes complex, it is very important that you read them carefully before our next session. We can discuss any questions you have about the procedures at that time. When you sign this document, it will also represent an agreement between us. You may revoke this Agreement in writing at any time. That revocation will be binding on me unless I have taken action in reliance on it; if there are obligations imposed on me by your health insurer in order to process or substantiate claims made under your policy; or if you have not satisfied any financial obligations you have incurred. YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THE AGREEMENT AND AGREE TO ITS TERMS AND ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPAA NOTICE FORM DESCRIBED ABOVE.
Appears in 1 contract
Samples: Services Agreement
Meetings. I normally conduct an evaluation that will last from 1-2 lasts for approximately two sessions. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If therapy has is begun, I will usually schedule one 45-50 minute ses- sion session per week or every two weeks at a time we agree on, although some sessions may be longer or more frequentupon. Once an appointment hour is scheduled, you will be expected to pay for it un- less unless you provide 24-hours advanced advance notice of cancellationcancellation or unless we both agree that you are unable to attend due to circumstances beyond your control. It is important to note that insurance companies do not provide reimbursement for cancelled sessionscanceled sessions and I cannot xxxx them or no-show fees. Professional Fees Therapeutic assessments are procedures that are usually requested by another professional who you are working with or may be a procedure that we agree is an appropriate undertaking prior to therapy. Therapeutic assessments are highly useful for diagnostic clarity and for understanding important psychological dynamics that underlie potential problems. PROFESSIONAL FEES: The fee for the initial diagnostic consultation and clinical interview is $200.00. My regular hourly fee varies depending on services and durationfees for a 50 – minute to 60-minute individual psychotherapy session is $125.00, 20-minute to 30-minute is $100.00. In addition to weekly ap- pointmentsappointments, I charge this amount for other professional services you may need. How- ever, though I will break down breakdown the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services include report writing, telephone conversations lasting longer than 10-minutes, Skype appoint- ments or check-insconversations, consulting with other professionals with on your permissionbehalf, prepar- ing preparation of records or treatment summaries, and the time spent performing any other ser- vices you may request service required of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, time including preparation and transportation costs, cost even if I am called to testify by another party. Be- cause of the difficulty of legal involvement, I charge $500 per hour 215.00, accrued in 15 minute intervals for preparation and attendance at any legal proceedingsproceeding. Contacting Me CONTACTING ME: Due to my work schedule, I am often not immediately available by telephone. While I am usually in my the office four days a weekMonday through Friday, I probably most likely will not answer the be unable to accept phone calls when I am with a clientpatient. When I am unavailable, my telephone is answered by an answering machine. I will make every effort to return your call by on the end of my business day, same day or following day with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. If you are unable to reach me and you feel that you can’t cannot wait for me to return your call, you may contact your family physician, go to the nearest emergency room and ask for the psychologist or psychiatrist on callroom, or call 911contact your local emergency mental health community organization. If I will be unavailable for an extended timeIn Steuben, I will provide you with the name of a colleague contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality 000-000-0000, and in Allegany County, contact 000-000-000 LIMITS OF CONFIDENTIALITY: The law protects the privacy of all communications between a client patient and a therapistpsychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form authorization form that meets certain legal requirements imposed by HIPAAHIPPA. There are other situations that require only that you provide written, ad- xxxxx written advance consent. Your signature on this Agreement agreement provides consent for those activities, activities as follows: I may occasionally find it helpful to consult other health and mental health profes- sionals about a case. During consultation, I make every effort to avoid revealing the identity of my client. The other professionals are also legally bound to keep informa- tion confidential. If you don’t object, I will not tell you about these consultations un- less I feel that it is important to our work together. I will note all consultations in your Clinical Record. Disclosures required by health insurers or to collect overdue fees are discussed else- where in this Agreement. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the social worker-client privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client in order to defend myself. If a client files a worker’s compensation claim, I must, upon appropriate request, pro- vide a copy of the client’s record to the Labor and Industrial Commission or the Work- ers’ Compensation Division, or the client’s employer. There are some situations in which I am legally obligated to take actions, which I be- lieve are necessary to attempt to protect others from harm and I may have to reveal some information about a client’s treatment. These situations are unusual in my practice. If I have reasonable cause to suspect that a child has been or may be subjected to abuse or neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglect, the law requires that I file a report with Tennessee’s Department of Children’s Services. Once such a report is filed, I may be required to provide additional information. If I have reasonable cause to suspect that an elderly or disabled adult presents a like- lihood of suffering serious physical harm and is in need of protective services, the law requires that I file a report with Adult Protective Services. Once such a report is filed, I may be required to provide additional information. If I believe that it is necessary to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by the client on him/her- self or another person, I may be required to take protective action. These actions may include, and/or initiating hospitalization and/or contacting the potential victim, and/or the police and/or the client’s family. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure is reasonably likely to endanger you and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harm, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of 35 cents per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Records, you have a right of review, which I will discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents of our conversations, my analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentially.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include:
Appears in 1 contract
Samples: irp-cdn.multiscreensite.com
Meetings. I normally conduct an evaluation that will last from 1-2 to 3 sessions. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If therapy has psychotherapy is begun, I will usually schedule one 4550-minute ses- sion session (one appointment hour of 50 minutes duration) per week at a time we agree on, although some sessions may be longer or more frequent. Once an appointment hour is scheduled, you will be expected to pay for it un- less unless you provide 24-24 hours advanced advance notice of cancellationcancellation (unless we both agree that you were unable to attend due to circumstances beyond your control). It is important to note that insurance companies do not provide reimbursement for cancelled sessions. Professional Fees If possible, I will try to find another time to reschedule the appointment. PROFESSIONAL FEES My hourly fee varies depending on services is $110 for diagnostic interviews, $150 per hour for psychological testing (including neuropsychological testing, psychoeducational evaluation, etc.) and duration$90 for therapy sessions. In addition to weekly ap- pointmentsappointments, I charge this amount for other professional services you may need. How- ever, though I will break down the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services include report writing, telephone conversations lasting longer than 10-15 minutes, Skype appoint- ments or check-ins, consulting with other professionals with your permission, prepar- ing preparation of records or treatment summaries, and the time spent performing any other ser- vices service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Be- cause Because of the difficulty of legal involvement, I charge $500 180 per hour for preparation and attendance at any legal proceedingsproceeding. Contacting Me Patients who are unable to pay my full hourly fee may be eligible for a fee reduction at my discretion. CONTACTING ME Due to my work schedule, I am often not immediately available by telephone. While I am usually in my office four days a weekbetween 9 AM and 5 PM Monday through Friday, I probably will not answer the phone when I am with a clientpatient. When I am unavailable, my phone is answered by confidential voice mail that I monitor frequently. I will make every effort to return your call by on the end of my business daysame day you make it, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. If you are unable to reach me and you feel that you can’t wait for me to return your call, contact your family physician, physician or the nearest emergency room and ask for the psychologist or psychiatrist on call, or call 911. If I will be unavailable for an extended time, I will provide you with the name of a colleague contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality The law protects the privacy of all communications between a client and a therapist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, ad- xxxxx consent. Your signature on this Agreement provides consent for those activities, as follows: I may occasionally find it helpful to consult other health and mental health profes- sionals about a case. During consultation, I make every effort to avoid revealing the identity of my client. The other professionals are also legally bound to keep informa- tion confidential. If you don’t object, I will not tell you about these consultations un- less I feel that it is important to our work together. I will note all consultations in your Clinical Record. Disclosures required by health insurers or to collect overdue fees are discussed else- where in this Agreement. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the social worker-client privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client in order to defend myself. If a client files a worker’s compensation claim, I must, upon appropriate request, pro- vide a copy of the client’s record to the Labor and Industrial Commission or the Work- ers’ Compensation Division, or the client’s employer. There are some situations in which I am legally obligated to take actions, which I be- lieve are necessary to attempt to protect others from harm and I may have to reveal some information about a client’s treatment. These situations are unusual in my practice. If I have reasonable cause to suspect that a child has been or may be subjected to abuse or neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglect, the law requires that I file a report with Tennessee’s Department of Children’s Services. Once such a report is filed, I may be required to provide additional information. If I have reasonable cause to suspect that an elderly or disabled adult presents a like- lihood of suffering serious physical harm and is in need of protective services, the law requires that I file a report with Adult Protective Services. Once such a report is filed, I may be required to provide additional information. If I believe that it is necessary to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by the client on him/her- self or another person, I may be required to take protective action. These actions may include, and/or initiating hospitalization and/or contacting the potential victim, and/or the police and/or the client’s family. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure is reasonably likely to endanger you and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harm, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of 35 cents per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Records, you have a right of review, which I will discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents of our conversations, my analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentially.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include:
Appears in 1 contract
Samples: Patient Services Agreement
Meetings. I normally conduct an evaluation that will last from 1-2 sessionsA therapy session lasts 50 minutes. During this time, we both decide if I am Within a reasonable period of time after the best person to provide the services you need in order to meet your treatment goals. If therapy has beguninitiation of treatment, I will usually schedule one 45-minute ses- sion per week at a time we agree ondiscuss with you my working understanding of the problem, although some sessions may be longer treatment plan, therapeutic objectives, and view of the possible outcomes of treatment. If you have any unanswered questions about any of the procedures used in the course of your therapy, their possible risks, my expertise in employing them, or more frequentabout the treatment plan, please bring this up with me. Once an appointment hour is scheduled, you will be expected to pay for it un- less unless you provide 24-24 hours advanced advance notice of cancellation, unless we both agree that you were unable to attend due to circumstances beyond your control. It is important to note that insurance companies do not provide reimbursement for cancelled canceled sessions. Professional Fees PROFESSIONAL FEES My hourly fee varies depending on services and durationis $185. In addition to weekly ap- pointmentsappointments, I charge this amount for other professional services you may need. How- ever, though I will break down the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services include report writing, telephone conversations lasting longer than 10-15 minutes, Skype appoint- ments or check-ins, consulting with other professionals with your permission, prepar- ing preparation of records or treatment summaries, and the time spent performing any other ser- vices service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Be- cause [Because of the difficulty of legal involvement, I charge $500 350 per hour for preparation and attendance at any legal proceedingsproceeding.] CONTACTING ME The best way to reach me is on my mobile phone at 000-000-0000. Contacting Me Due to my work schedule, I am often not immediately available by telephone. While I am usually in my office four days a week, I probably will not answer the phone when I am with a client. I will make This voice mail is checked several times every effort to return your call by the end of my business day, 24 hours with the exception of weekends and holidays. If You can typically expect a return telephone call within 24 hours. In the event of a life- threatening situation you are difficult advised to reachcall 911 immediately. When I am on vacation, please inform me of some times when you will be available. If you are unable to reach me and you feel that you can’t wait for me to return your call, contact your family physician, the nearest emergency room and ask for the psychologist or psychiatrist on call, or call 911. If I will make arrangements for another licensed mental health professional to be unavailable for an extended timeavailable if needed, I and will provide you with the name of a colleague contact, if necessaryappropriate contact information. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications communication between a client and a therapistpsychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, ad- xxxxx advance consent. Your signature on this Agreement provides consent for those activities, as follows: I may occasionally find it helpful to consult other health and mental health profes- sionals about a case. During consultation, I make every effort to avoid revealing the identity of my client. The other professionals are also legally bound to keep informa- tion confidential. If you don’t object, I will not tell you about these consultations un- less I feel that it is important to our work together. I will note all consultations in your Clinical Record. Disclosures required by health insurers or to collect overdue fees are discussed else- where in this Agreement. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the social worker-client privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client in order to defend myself. If a client files a worker’s compensation claim, I must, upon appropriate request, pro- vide a copy of the client’s record to the Labor and Industrial Commission or the Work- ers’ Compensation Division, or the client’s employer. There are some situations in which I am legally obligated to take actions, which I be- lieve are necessary to attempt to protect others from harm and I may have to reveal some information about a client’s treatment. These situations are unusual in my practice. If I have reasonable cause to suspect that a child has been or may be subjected to abuse or neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglect, the law requires that I file a report with Tennessee’s Department of Children’s Services. Once such a report is filed, I may be required to provide additional information. If I have reasonable cause to suspect that an elderly or disabled adult presents a like- lihood of suffering serious physical harm and is in need of protective services, the law requires that I file a report with Adult Protective Services. Once such a report is filed, I may be required to provide additional information. If I believe that it is necessary to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by the client on him/her- self or another person, I may be required to take protective action. These actions may include, and/or initiating hospitalization and/or contacting the potential victim, and/or the police and/or the client’s family. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure is reasonably likely to endanger you and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harm, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of 35 cents per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Records, you have a right of review, which I will discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents of our conversations, my analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentially.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include:
Appears in 1 contract
Samples: www.drlizbias.com
Meetings. I normally conduct an evaluation that will last from 12-2 4 sessions. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If therapy has psychotherapy is begun, I will usually schedule one 45-50 minute ses- sion session (one appointment hour of 50 minute duration) per week at a time we agree on, although some sessions may be longer or more frequent. Once an appointment hour is scheduled, you will be expected to pay for it un- less unless you provide 24-hours advanced 48 hour advance notice of cancellation. It is important to note that insurance companies do not provide reimbursement for cancelled sessions. Professional Fees My hourly fee varies depending on services You normally will be the one who decides therapy will end, with three exceptions. If we have contracted for a specific short-time piece of work, we will finish therapy at the end of that contract. If I am not able to help you because of the kind of problem you have or because my training and duration. In addition to weekly ap- pointmentsskills are, I charge this amount for other professional services you may need. How- everin my judgment, not appropriate, I will break down the hourly cost if I work for periods inform you of less than one hour. Note that these additional services are not covered by insurance. Other services include report writing, telephone conversations lasting longer than 10-minutes, Skype appoint- ments or check-ins, consulting with other professionals with this fact and refer you to another therapist who may meet your permission, prepar- ing of records or treatment summaries, and the time spent performing any other ser- vices you may request of meneeds. If you become involved in legal proceedings that require my participationdo violence to, you will be expected to pay for all of my professional timethreaten, including preparation and transportation costsverbally or physically, even if I am called to testify by another party. Be- cause of or harass myself, or the difficulty of legal involvementoffice, I charge $500 per hour reserve the right to terminate you unilaterally and immediately from treatment. If I terminate you from therapy, I will offer you referrals to other sources of care, but cannot guarantee that they will accept you for preparation and attendance at any legal proceedingstherapy. Contacting Me Due to my work schedulework, I am often not immediately available by telephone. While I am usually can be in my Silverton office four between 10 am to 8 p.m. Monday and Thursday and 10 am - 4 p.m. on Saturday, and other days a weekin Canby, I probably will not let my answering machine answer my calls. I monitor my calls throughout the phone when I am with a clientday. I will make every effort usually return your call in a few hours and/or on the same day with the exception of Sundays and holidays. In the event of an emergency related to your treatment with me, during the hours of 10 am to 5 p.m. Monday-Saturday call my answering machine at 000-000-0000 and please identify in your message that your call is urgent. If you feel you cannot wait for me to return your call by the end of or there is a delay in my business day, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. If you are unable to reach me and you feel that you can’t wait for me ability to return your call, contact your family physician, primary care physician or the nearest emergency room and ask for to speak with a mental health professional. In an emergency involving immediate risk to someone’s safety or well-being, clients agree to go to the psychologist or psychiatrist on call, nearest hospital emergency room or call 911911 without waiting for me to return the call. If I will be am unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality The law protects the privacy of all communications between a client and a therapist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, ad- xxxxx consent. Your signature on this Agreement provides consent for those activities, as follows: I may occasionally find it helpful to consult other health and mental health profes- sionals about a case. During consultation, I make every effort to avoid revealing the identity of my client. The other professionals are also legally bound to keep informa- tion confidential. If you don’t object, I will not tell you about these consultations un- less I feel that it is important to our work together. I will note all consultations in your Clinical Record. Disclosures required by health insurers or to collect overdue fees are discussed else- where in this Agreement. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the social worker-client privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. Legal Proceeding / Court Involvement If you are involved in or contemplating litigationanticipate being involved in legal or court proceedings, please notify me as soon as possible. It is important for me to understand how, if at all, your involvement in these proceedings might affect our work together. It is also important for you should consult to know that I will not be a party to any legal proceedings involving current or former clients. My goal is to support my clients to achieve therapy goals, not to address legal issues that require an adversarial approach. Clients entering treatment are agreeing to not involve me in legal/court proceedings or attempt to obtain records of treatment for legal/court proceedings. This prevents misuse of your treatment for legal objectives. In the event you require my testimony or involvement in non-adversarial aspects of legal/court proceedings I will do so only with your attorney to determine whether a court would consent. I will be likely to order me unable to disclose any information pertaining to other family members or parties involved in treatment without their specific consent to disclose this information. If a government agency is requesting the information for health oversight activitiesA fee schedule will be applied, I may be required to provide it for them. If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client in order to defend myself. If a client files a worker’s compensation claim, I must, upon appropriate request, pro- vide a copy of the client’s record to the Labor and Industrial Commission or the Work- ers’ Compensation Division, or the client’s employer. There are some situations in which I am legally obligated to take actions, which I be- lieve are necessary to attempt to protect others from harm and I may have to reveal some information about a client’s treatment. These situations are unusual in my practice. If I have reasonable cause to suspect that a child has been or may be subjected to abuse or neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglect, the law requires that I file a report with Tennessee’s Department of Children’s Services. Once such a report is filed, I may be required to provide additional information. If I have reasonable cause to suspect that an elderly or disabled adult presents a like- lihood of suffering serious physical harm and is in need of protective services, the law requires that I file a report with Adult Protective Services. Once such a report is filed, I may be required to provide additional information. If I believe that it is necessary to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by the client on him/her- self or another person, I may be required to take protective action. These actions may include, and/or initiating hospitalization and/or contacting the potential victim, and/or the police and/or the client’s family. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. as outlined under Professional Records You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure is reasonably likely to endanger you and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harm, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of 35 cents per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Records, you have a right of review, which I will discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents of our conversations, my analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentiallyFees.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include:
Appears in 1 contract
Samples: Client Services Agreement
Meetings. I normally conduct an evaluation that will last from 1-generally schedule family or couples’ sessions for 1.5- 2 sessions. During this timehours, we both decide if I am the best person to provide the services you need in order to meet your treatment goals. If therapy has begun, I will usually schedule one 45-minute ses- sion per every week at a time we agree on, although some sessions may be longer or more frequentevery other week. Once an appointment hour is scheduled, you will be expected to pay for it un- less unless you provide 24-48 hours advanced advance notice of cancellationcancellation [unless we both agree that you were unable to attend due to circumstances beyond your control]. It is important For Monday appointments, please cancel on Thursday prior to note that insurance companies do not provide reimbursement for cancelled sessionsthe time of the appointment. Professional Fees For example, if you have a 2PM appointment on Monday, a cancellation can be accepted (without fee) no later than 1:58PM on Thursday. PROFESSIONAL FEES My hourly fee varies depending on services and durationis $250, so a session of 1.5 hours will cost $375. In addition to weekly ap- pointmentsappointments, I charge this amount the hourly fee for other professional services you may need. How- ever, though I will break down the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services include report writing, telephone conversations or emails lasting longer than 10-10 minutes, Skype appoint- ments or check-ins, consulting with other professionals with your permission, prepar- ing preparation of records or treatment summaries, and the time spent performing any other ser- vices service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Be- cause Person(s) responsible for paying (indicate name and % of the difficulty of legal involvement, I charge $500 per hour for preparation and attendance at any legal proceedings. Contacting Me fee): CLIENT NAME(S): CONTACTING ME Due to my work schedule, I am often not immediately available by telephonetelephone or email. While I am usually in my office four days a weekroughly between 9 AM and 7 PM, I probably will not answer the phone when I am with a clientpatient. When I am unavailable, my telephone is answered by private voice mail, that my assistant and I monitor frequently. I will make every effort to return your call by as quickly as possible. Note that I am not in the end office on Fridays, and there may be the possibility of my business day, with the exception of delay on weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. [In emergencies, you can leave an urgent message on the office line or write an email with “Urgent” in the message line.] If you are unable to reach me and feel that, you feel that you can’t cannot wait for me to return your call, contact your family physician, “911” or go to the nearest emergency room and ask for the psychologist or psychiatrist on call, or call 911. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. I do get a lot of emails daily, so please feel free to re-send if you do not hear back within 24 hours during the work week. RECORDING SESSIONS There is to be no recording of sessions, either video or audio by any of the parties in the room without all parties agreeing. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx agree to communicate with merefrain from taping by signing this agreement. Limits of Confidentiality LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client patient and a therapistpsychologist. The patient in this case is a family, and all communications are privileged between all family members and myself. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form authorization form that meets certain legal requirements imposed by state law and/or HIPAA. There are other situations that require only that you provide writtenNevertheless, ad- xxxxx consent. Your signature on this Agreement provides consent for those activities, as follows: I may occasionally find it helpful to consult other health and mental health profes- sionals about a case. During consultation, I make every effort to avoid revealing the identity of my client. The other professionals are also legally bound to keep informa- tion confidential. If you don’t object, I will not tell you about these consultations un- less I feel that it is important to our work together. I will note all consultations in your Clinical Record. Disclosures required by health insurers or to collect overdue fees are discussed else- where in this Agreement. There there are some situations where I am permitted or required to disclose information without either your consent or Authorization: If you are involved in • I may occasionally find it helpful to consult other health and mental health professionals about a court proceeding and case. During a request is made for information concerning your diagnosis and treatment, such information is protected by the social worker-client privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. If a government agency is requesting the information for health oversight activitiesconsultation, I may be required to provide it for them. If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client in order to defend myself. If a client files a worker’s compensation claim, I must, upon appropriate request, pro- vide a copy of the client’s record to the Labor and Industrial Commission or the Work- ers’ Compensation Division, or the client’s employer. There are some situations in which I am legally obligated to take actions, which I be- lieve are necessary to attempt to protect others from harm and I may have to reveal some information about a client’s treatment. These situations are unusual in my practice. If I have reasonable cause to suspect that a child has been or may be subjected to abuse or neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglect, the law requires that I file a report with Tennessee’s Department of Children’s Services. Once such a report is filed, I may be required to provide additional information. If I have reasonable cause to suspect that an elderly or disabled adult presents a like- lihood of suffering serious physical harm and is in need of protective services, the law requires that I file a report with Adult Protective Services. Once such a report is filed, I may be required to provide additional information. If I believe that it is necessary to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by the client on him/her- self or another person, I may be required to take protective action. These actions may include, and/or initiating hospitalization and/or contacting the potential victim, and/or the police and/or the client’s family. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit avoid revealing the identity of my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure is reasonably likely to endanger you and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harm, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of 35 cents per page (and for certain other expenses)patient. The exceptions other professionals are also legally bound to this policy are contained in keep the attached Notice Form. If I refuse your request for access to your Clinical Records, you have a right of review, which I will discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents of our conversations, my analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentially.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include:CLIENT NAME(S):
Appears in 1 contract
Samples: Family Therapy Services Agreement
Meetings. I normally conduct an evaluation that will last from 1-1 to 2 sessions. During this time, we can both decide if I am the best person to provide the services that you need in order to meet your treatment goals. If therapy has psychotherapy is begun, I will usually schedule one 45-minute ses- sion full session (one appointment hour of 50 minutes duration) per week at a time we agree on, although some sessions may be longer or more frequent. Once an appointment hour is scheduled, you will be expected to pay for it un- less unless you provide 24-24 hours advanced (1 day) advance notice of cancellation, unless we both agree that you were unable to attend due to circumstances beyond your control (such as illness or an emergency). It is important to note that insurance companies do not provide reimbursement for cancelled sessions, so I will not provide a receipt for missed appointment charges. Professional Fees If it is possible, I will try to find another time to reschedule the appointment. PROFESSIONAL FEES My hourly full session (50-minute) fee varies depending on services is $295 and durationmy half session (25-minute) fee is $160. In addition to weekly ap- pointmentsappointments, I charge this amount for other professional services you may need. How- ever, though I will break down prorate the hourly cost if I work for periods of less other than one hour. Note that these additional services are not covered by insurance. Other services include report writing, telephone conversations and Skype conversations, lasting longer than 10-05 minutes, Skype appoint- ments or check-ins, consulting with other professionals with your permission, prepar- ing preparation of records or treatment summaries, and the time spent performing any other ser- vices service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Be- cause Because of the difficulty of legal involvement, I charge $500 per hour for preparation and attendance at any legal proceedingsproceeding. Contacting Me CONTACTING ME Due to my work schedule, I am often sometimes not immediately available by telephone. While I am usually in my office four days a weekavailable between 9 AM and 5 PM, I probably will not answer the phone when I am with a clientpatient. When I am unavailable, my telephone is answered by my confidential voice mail that I monitor frequently and no one else listens to. I will make every effort to return your call by on the end of my business daysame day you make it, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. If In emergencies, if you are unable to reach me and you feel that you can’t wait for me to return your call, contact your family physician, physician or the nearest emergency room and ask for the psychologist (or psychiatrist psychiatrist) on call, or call 911. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client patient and a therapistpsychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form form that meets certain legal requirements imposed by state law and/or HIPAA. There are other situations that require only that you provide writtenBut, ad- xxxxx consent. Your signature on this Agreement provides consent for those activities, as follows: I may occasionally find it helpful to consult other health and mental health profes- sionals about a case. During consultation, I make every effort to avoid revealing the identity of my client. The other professionals are also legally bound to keep informa- tion confidential. If you don’t object, I will not tell you about these consultations un- less I feel that it is important to our work together. I will note all consultations in your Clinical Record. Disclosures required by health insurers or to collect overdue fees are discussed else- where in this Agreement. There there are some situations where I am permitted or required to disclose information without either your consent or Authorization: If you are involved in I may occasionally find it helpful to consult other health and mental health professionals about a court proceeding and case. During a request is made for information concerning your diagnosis and treatment, such information is protected by the social worker-client privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. If a government agency is requesting the information for health oversight activitiesconsultation, I may be required to provide it for them. If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client in order to defend myself. If a client files a worker’s compensation claim, I must, upon appropriate request, pro- vide a copy of the client’s record to the Labor and Industrial Commission or the Work- ers’ Compensation Division, or the client’s employer. There are some situations in which I am legally obligated to take actions, which I be- lieve are necessary to attempt to protect others from harm and I may have to reveal some information about a client’s treatment. These situations are unusual in my practice. If I have reasonable cause to suspect that a child has been or may be subjected to abuse or neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglect, the law requires that I file a report with Tennessee’s Department of Children’s Services. Once such a report is filed, I may be required to provide additional information. If I have reasonable cause to suspect that an elderly or disabled adult presents a like- lihood of suffering serious physical harm and is in need of protective services, the law requires that I file a report with Adult Protective Services. Once such a report is filed, I may be required to provide additional information. If I believe that it is necessary to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by the client on him/her- self or another person, I may be required to take protective action. These actions may include, and/or initiating hospitalization and/or contacting the potential victim, and/or the police and/or the client’s family. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit avoid revealing the identity of my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure is reasonably likely to endanger you and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harm, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of 35 cents per page (and for certain other expenses)patient. The exceptions other professionals are also legally bound to this policy are contained in keep the attached Notice Form. If I refuse your request for access to your Clinical Records, you have a right of review, which I will discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents of our conversations, my analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentially.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include:
Appears in 1 contract
Samples: Patient Services Agreement
Meetings. I normally conduct an evaluation that will last from 1-2 to 4 sessions. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If therapy has psychotherapy is begun, I will usually schedule one 4550-minute ses- sion session (one appointment hour of 50 minutes duration) per week at a time we agree on, although some sessions may be longer longer, more frequent, or more less frequent. Once an appointment hour is scheduled, you will be expected to pay for it un- less unless you provide 24-48 hours advanced advance notice of cancellationcancellation [unless we both agree that you were unable to attend due to circumstances beyond your control]. It is important to note that insurance companies do not provide reimbursement for cancelled sessions. Professional Fees However, if I am able to adjust my client schedule (e.g.: move a wait-list client into your time slot), I will not enforce these terms. PROFESSIONAL FEES My hourly session fee varies depending on services is $175. A session is typically between 45 and duration55 minutes, but we will work together to attain the goal of 50 minute sessions. In addition to weekly ap- pointmentssessions, I charge this amount for other professional services you may need. How- ever, though I will break down the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services include report writing, telephone conversations lasting longer than 10-5 minutes, Skype appoint- ments or check-ins, consulting with other professionals with your permission, prepar- ing preparation of records or treatment summaries, and the time spent performing any other ser- vices service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Be- cause [Because of the difficulty of legal involvementinvolvement and lost income, I charge $500 per hour for preparation and attendance at any legal proceedings. Contacting Me proceeding.] CONTACTING ME Due to my work schedule, I am often not immediately available by telephone. While I am usually in my office four days a weekbetween 7:30 AM and 2:30 PM weekdays, I probably will not answer the phone when I am with a clientpatient. When I am unavailable, my telephone is answered by voice mail that I monitor frequently. I also frequently check my email. I will make every effort to return your call by on the end of my business daysame day you make it, with the exception of weekends and weekends, holidays, vacations, or illness. If you are difficult to reach, please inform me of some times when you will be available. If you are unable to reach me and you feel that you can’t wait for me to return your call, contact your family physician, the nearest emergency room and to ask for the on-call psychologist or psychiatrist on callpsychiatrist, or call 911. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client patient and a therapistpsychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, ad- xxxxx advance consent. Your signature on this Agreement provides consent for those activities, as follows: x I may occasionally find it helpful to consult other health and mental health profes- sionals professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my clientpatient. The other professionals are also legally bound to keep informa- tion the information confidential. If you don’t object, I will not tell you about these consultations un- less unless I feel that it is important to our work together. I will note all consultations in your Clinical RecordRecord (which is called “PHI” in my Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information). x You should be aware that I may employ administrative staff. In most cases, I need to share protected information with these individuals for both clinical and administrative purposes, such as scheduling, billing and quality assurance. All staff members will be given training about protecting your privacy and have agreed not to release any information outside of the practice without the permission of a professional staff member. x I also may have contracts with outside business associates. As required by HIPAA, I will have a formal business associate contract with this/these business(es), in which it/they promise to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I can provide you with the names of these organizations and/or a blank copy of this contract. x Disclosures required by health insurers or to collect overdue fees are discussed else- where elsewhere in this Agreement. x If a patient threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her or to contact family members or others who can help provide protection. x Mental Health care professionals are required to report admitted prenatal exposure to controlled substances that are potentially harmful. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: x If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatmentmy professional services, such information is protected by the social workerpsychologist-client patient privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. x If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. x If a client patient files a complaint or lawsuit against me, I may disclose relevant information regarding that client patient in order to defend myself. x If a client patient files a worker’s compensation claim, and I am providing treatment related to the claim, I must, upon appropriate request, pro- vide a copy furnish copies of the client’s record to the Labor all medical reports and Industrial Commission or the Work- ers’ Compensation Division, or the client’s employerbills. There are some situations in which I am legally obligated to take actions, which I be- lieve believe are necessary to attempt to protect others from harm and I may have to reveal some information about a clientpatient’s treatment. These situations are unusual in my practice. x If I have reasonable cause reason to suspect believe that a child has been or may be subjected to abuse or neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglectabused, the law requires that I file a report with Tennessee’s the appropriate governmental agency, usually the Department of Children’s ServicesHuman Resources. Once such a report is filed, I may be required to provide additional information. x If I have reasonable cause to suspect believe that an elderly or a disabled adult presents or elder person has had a like- lihood physical injury or injuries inflicted upon such disabled adult or elder person, other than by accidental means, or has been neglected or exploited, I must report to an agency designated by the Department of suffering serious physical harm and is in need of protective services, the law requires that I file a report with Adult Protective ServicesHuman Resources. Once such a report is filed, I may be required to provide additional information. x If I believe determine that it is necessary a patient presents a serious danger of violence to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by the client on him/her- self or another personanother, I may be required to take protective actionactions. These actions may include, and/or initiating hospitalization and/or contacting include notifying the potential victim, and/or contacting the police police, and/or seeking hospitalization for the client’s familypatient. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records The laws governing confidentiality can be quite complex, and I am not an attorney. Formal legal advice may be needed to obtain specific advice. PROFESSIONAL RECORDS You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure circumstances that involve danger to yourself or others or makes reference to another person (unless such other person is a health care provider) and I believe that access is reasonably likely to endanger you and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the cause substantial harm to such other person at risk of substantial harm, [or if information is supplied to me confidentially by others] you or your legal representative may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. [I am sometimes willing to conduct this review meeting without charge.] In most circumstancessituations, I am allowed to charge a copying fee of 35 cents $1.50 per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Recordsrecords, you have a right of review, review (except for information provided to me confidentially by others) which I will discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. Record [They also include in- formation from others provided and information supplied to me confidentially.] confidentially by others]. These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies companies, without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide refusing it. Patient Rights PATIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your Clinical Records Record and disclosures of protected health information. These rights include:include requesting that I amend your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights with you. MINORS & PARENTS Patients under 18 years of age who are not emancipated and their parents should be aware that the law allows parents to examine their child’s treatment records unless I believe that doing so would endanger the child or we agree otherwise. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is [sometimes] my policy to request an agreement from parents that they consent to give up their access to their child’s records. If they agree, during treatment, I will provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. I will also provide parents with a summary of their child’s treatment when it is complete. Any other communication will require the child’s Authorization, unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have. The child will be encouraged to share directly with parents. BILLING AND PAYMENTS You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. [In circumstances of unusual financial hardship, we may negotiate a fee adjustment or payment installment plan.] If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require me to disclose otherwise confidential information. In most collection situations, the only information I release regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due. [If such legal action is necessary, its costs will be included in the claim.] INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. It is very important that you find out exactly what mental health services your insurance covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, I will be willing to call the company on your behalf.
Appears in 1 contract
Samples: www.doctorheinsz.com
Meetings. I normally conduct an evaluation that typically meet with parent(s)/legal guardian and the son or daughter at the initial intake/consultation. At this meeting, I ask the family for detailed information about the problems the son or daughter has been experiencing. At the end of the session, I will last from 1-2 sessions. During this time, we both decide let the family know if I am think I can be helpful given the best person history they have provided. I ask parents/legal guardians to provide go home and talk with their son or daughter about the services you need in order meeting. I ask them to meet your treatment goalslet me know by phone or e-mail if they would like to schedule another appointment. If therapy has psychotherapy is begun, I will usually schedule one 45-55 minute ses- sion session (one appointment hour of 55 minutes duration) per week or at specified intervals at a time we agree on, although some sessions may be longer or more frequent. PROFESSIONAL FEES The fee for the initial intake/consultation is $215.00. Fees for subsequent 55 minute sessions are $175.00. I require keeping a credit card on file. This card will be charged on the date of service, unless you prefer to pay with cash or check at time of service. You will be provided a receipt for your records. Once an appointment hour is scheduled, you will be expected to pay for it un- less unless you provide 24-24 hours advanced advance notice of cancellation. It is important cancellation (unless we both agree that you were unable to note that insurance companies do not provide reimbursement for cancelled sessions. Professional Fees My hourly fee varies depending on services and duration. In addition attend due to weekly ap- pointments, I charge this amount for other professional services you may need. How- ever, I will break down the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services include report writing, telephone conversations lasting longer than 10-minutes, Skype appoint- ments or check-ins, consulting with other professionals with circumstances beyond your permission, prepar- ing of records or treatment summaries, and the time spent performing any other ser- vices you may request of me. control.) If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Be- cause Because of the difficulty of legal involvement, I charge $500 165.00 per hour for preparation and attendance at any legal proceedingsproceeding. Contacting Me This includes preparation, driving time, and all time spent in court. In addition, a charge of $75 per hour will be assessed by my assistant regarding any legal proceeding. CONTACTING ME Due to my work schedule, I am often not immediately available by telephone. While When I am usually in unavailable you may leave a message on my office four days a week, I probably will not answer the phone when I am with a clientvoice mail at 000-000-0000. I will make every effort to return your call by the end of my business day, with the exception of weekends and holidayswithin 24 hours. If you are difficult to reach, please inform me of some times when you will be available. If you are unable facing a life threatening emergency, you should go to reach me and you feel that you can’t wait for me to return your call, contact your family physician, the nearest emergency room and ask for the psychologist or psychiatrist mental health professional on call, or call 911. If I will be unavailable The phone number for an extended time, I will provide you with the name Suicide Center of a colleague contact, if necessaryNorth Texas is (000) 000-0000. You can also text “CONNECT” to 741741 anytime to reach trained, caring volunteers at the National Crisis Text Line. The National Suicide Prevention lifeline phone number is (000)000-0000. All email communication goes through my administrative assistant (xxxxxxxxx000@xxxxx.xxx) and should not be used to contact me in an emergency. E-mail, phone texts and similar forms of communication may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx be vulnerable to communicate with meunauthorized access which can compromise privacy and confidentiality. Limits Electronic means of Confidentiality communication are not fail-safe in terms of encryption and do not provide the same protection as face to face therapy sessions. Please do not use electronic communication to send sensitive information. LIMITS OF CONFIDENTIALITY The law protects the privacy of all communications between a client patient and a therapistpsychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, ad- xxxxx advance consent. Your signature on this Agreement provides consent for those activities, as follows: I may occasionally find it helpful to consult other health and mental health profes- sionals professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my clientpatient. The other professionals are also legally bound to keep informa- tion the information confidential. If you don’t n't object, I will not tell you about these consultations un- less unless I feel that it is important to our work together. I will note all consultations in your Clinical RecordRecord (which is called "PHI" in my Notice of Psychologist's Policies and Practices to Protect the Privacy of Your Health Information). Disclosures required by health insurers If a patient seriously threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her, or to collect overdue fees are discussed else- where in this Agreementcontact family members or others who can help provide protection. Texas law provides that a professional may disclose confidential information only to medical or law enforcement personnel if the professional determines that there is a probability of imminent physical injury by the patient to the patient or others, or there is a probability of immediate mental or emotional injury to the patient. There are some situations where I am permitted or required to disclose information without either your consent or Authorizationauthorization: If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the social worker-client privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. If a client patient files a complaint or lawsuit against me, I may disclose relevant information regarding that client patient in order to defend myself. If a client patient files a worker’s 's compensation claim, I must, upon appropriate request, pro- vide provide records relating to treatment or hospitalization for which compensation is being sought. If a copy of the client’s record patient fails to the Labor and Industrial Commission or the Work- ers’ Compensation Divisionpay for services I have rendered, or the client’s employerI may disclose relevant information in a suit seeking payment. There are some situations in which I am legally obligated to take actions, which I be- lieve believe are necessary to attempt to protect others from harm and I may have to reveal some information about a client’s patient's treatment. These situations are unusual in my practice. If I have reasonable cause to suspect believe that a child under 18 has been or may be subjected to abuse abused or neglected (including physical injury, substantial threat of harm, mental or emotional injury, or any kind of sexual contact or conduct), or that a child is a victim of a sexual offense, or that an elderly or disabled person is in a state of abuse, neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglectexploitation, the law requires that I file make a report with Tennessee’s to the appropriate governmental agency, usually the Department of Children’s Protective and Regulatory Services. Once such a report is filed, I may be required to provide additional information. If I have reasonable cause to suspect determine that an elderly or disabled adult presents there is a like- lihood of suffering serious probability that the patient will inflict imminent physical harm and is in need of protective services, the law requires that I file a report with Adult Protective Services. Once such a report is filed, I may be required to provide additional information. If I believe that it is necessary to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by the client injury on him/her- self herself, or another personanother, or that the patient will inflict imminent mental or emotional harm upon others, I may be required to take protective action. These actions may include, and/or initiating action by disclosing information to medical or law enforcement personnel or by securing hospitalization and/or contacting of the potential victim, and/or the police and/or the client’s familypatient. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and and, I will limit my disclosure to what is necessary. By signing this agreement, you authorize me to contact any person/entity in a position to prevent harm to the patient or a third party if I determine there is a probability of harm to the patient or a third party. In addition, I have an assistant, Xxx Xxxxxx, and part-time assistant Xxxxxx Xxxxxx who work in the office assisting with paper work and office duties. This work brings them into contact with PHI of the clients with whom I work. As employees working with a psychologist, they are bound by the same duties of confidentiality required of me. I have educated them about the requirement that they view only that portion of PHI required to complete administrative tasks included but not limited to correspondence (scheduling, sending copies of this document…) with a patient’s parents or patient by mail, telephone, or e-mail, filing, copying, and data entry of responses to questionnaires. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records You should The laws governing confidentiality can be aware thatquite complex and I am not an attorney. In situations where specific advice is required, pursuant to HIPAA, formal legal consultation may be needed. PROFESSIONAL RECORDS The laws and standards of my profession require that I keep Protected Health Information about you or your child in two sets of professional records. One set constitutes your Clinical Record. It , The Clinical Record includes information about you or your child's reasons for seeking therapy, a description of the ways in which your the problem impacts on you or your child's life, your the diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrierchild's school. Except in the unusual circumstance where disclosure is reasonably likely circumstances that involve danger to endanger you yourself and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harmothers, you may examine and/or receive a copy of your Clinical Record, Record if you request it in writing. You should be aware that pursuant to Texas law, psychological test data are not part of a patient's record. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of 35 cents $.50 per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Recordsrecords, you have a right of review, which I will discuss with you upon your request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents of our conversations, my analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentially.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights PATIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your Clinical Records Record and disclosures of protected health information. These rights include:include requesting that I amend your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and my privacy policies and procedures. MINORS & PARENTS Patients under 18 years of age who are not emancipated and their parents should be aware that the law may allow parents to examine their child's treatment records. However, if the treatment is for suicide prevention, chemical addiction or dependency, or sexual, physical or emotional abuse, the law provides that parents may not access their child's records. For children and adolescents, because privacy in psychotherapy is often critical in building rapport with the therapist which is crucial to successful progress, it is my policy to discuss the manner in which I will communicate with the son or daughter and the parents. This discussion will typically take place early on in therapy so that all parties are informed as to how we will work together.
Appears in 1 contract
Samples: Patient Services Agreement
Meetings. I normally conduct an evaluation that will last from 1-2 schedule weekly sessions. During this time, we both decide if I am the best person to provide the services you need in order to meet your treatment goals. If therapy has begun, I will usually schedule one 45-minute ses- sion per week at a This time we agree on, although some sessions may be longer or more frequentis set aside for you. Once an appointment hour time is scheduled, you will be expected to pay for it un- less unless you provide 24-24 hours advanced advance notice of cancellation. Notice must be provided by phone, text or voice mail message. It is important to note that insurance companies do not provide reimbursement for cancelled canceled sessions. Professional Fees My hourly fee varies depending on services and duration. In addition to weekly ap- pointments, I charge this amount for other professional services you may need. How- ever, I will break down the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services include report writing, telephone conversations lasting longer than 10-minutes, Skype appoint- ments or check-ins, consulting with other professionals with your permission, prepar- ing of records or treatment summaries, and the time spent performing any other ser- vices you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Be- cause of the difficulty of legal involvement, I charge $500 per hour for preparation and attendance at any legal proceedings. Contacting Me CONTACTING ME Due to my work schedule, I am often not immediately available by telephone. While I am usually in my office four days a week, I probably will do not answer the phone when I am with a client. When I will make every effort to return your call by am unavailable, you can reach my voice mail, which I monitor frequently during the end of my business day, with the exception of weekends and holidayswork week. If you are difficult to reach, please inform me of some times during the day and evening when you will be available. If you are unable to reach me and you feel that you can’t wait for me to return your call, contact your family physician, physician or the nearest emergency room and ask for the psychologist or psychiatrist on call, or call 911room. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. You may can also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with mecontact me by email, but I do not check this as frequently as voice mail. Limits of Confidentiality Email should not be used for urgent messages or appointment changes. LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client and a therapistpsychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, ad- xxxxx advance consent. Your signature on this Agreement provides consent for those activities, as follows: • I may occasionally find it helpful to consult other health and mental health profes- sionals professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my client. The other professionals are also legally bound to keep informa- tion the information confidential. If you don’t object, I will not tell you about these consultations un- less unless I feel that it is important to our work together. I will note all consultations in your Clinical Record. • Disclosures required by health insurers or to collect overdue fees are discussed else- where elsewhere in this Agreement. There Although unusual in my practice, there are some situations where I am permitted or required to disclose information without either your consent or Authorization: If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the social worker-client privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client in order to defend myself. If a client files a worker’s compensation claim, I must, upon appropriate request, pro- vide a copy of the client’s record to the Labor and Industrial Commission or the Work- ers’ Compensation Division, or the client’s employer. There are some situations in which I am legally obligated to take actions, which I be- lieve are necessary to attempt to protect others from harm and I may have to reveal some information about a client’s treatment. These situations are unusual discussed in my practice. If I have reasonable cause to suspect that a child has been or may be subjected to abuse or neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglect, the law requires that I file a report with Tennessee’s Department Notice of Children’s Services. Once such a report is filed, I may be required to provide additional information. If I have reasonable cause to suspect that an elderly or disabled adult presents a like- lihood of suffering serious physical harm and is in need of protective services, the law requires that I file a report with Adult Protective Services. Once such a report is filed, I may be required to provide additional information. If I believe that it is necessary to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by the client on him/her- self or another person, I may be required to take protective action. These actions may include, and/or initiating hospitalization and/or contacting the potential victim, and/or the police and/or the client’s familyPrivacy Practices. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets of professional records. One set constitutes your PROFESSIONAL RECORDS Your Clinical Record. It Record includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where circumstances that disclosure would physically endanger you and/or others, or makes reference to another person (other than a health care provider) and I believe that access is reasonably likely to endanger you and/or others or when another individual (cause substantial harm to such other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harmperson, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of 35 cents per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Records, you have a right of review, which I will discuss with you upon request. In addition, reques CLIENT RIGHT Client rights include requesting that I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents of our conversations, my analysis of those conversations, and how they impact amend your therapy. They also contain particularly sensitive record; requesting restrictions on what information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentially.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available Records is disclosed to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition others; requesting an accounting of coverage nor penalize you in any way for your refusal to provide it. Patient Rights HIPAA provides you with several new or expanded rights with regard to your Clinical Records and most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights with you. BILLING AND PAYMENTS You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Although I may bill insurance companies on your behalf, any portion not paid by such third parties is the client's responsibility to pay in full. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require me to disclose otherwise confidential information. These rights include:In most collection situations, the only information I release regarding a client’s treatment is his/her name, the nature of services provided, and the amount due. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will provide you with the assistance I can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. It is very important that you find out what mental health services your insurance policy covers. They often do not cover couples counseling.
Appears in 1 contract
Meetings. I normally conduct an evaluation that will last from 1-2 to 4 sessions. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If therapy has psychotherapy is begun, I will usually schedule one 4553-55 minute ses- sion session per week at a time we agree on, although some sessions may be longer or more frequent. Once an appointment hour is scheduled, you will be expected to pay for it un- less the full fee unless you provide 24-24 hours advanced advance notice of cancellation, regardless of the reason for the late cancelation. It is important to note that insurance companies do not provide reimbursement for cancelled sessions. Professional Fees While it may result in a late cancelation fee, you will not be seen if you are clearly ill or contagious. If it is possible, I will try to find another time to reschedule the appointment. PROFESSIONAL FEES My fee for the initial consultation is $250. My hourly fee varies depending on services and durationis $220. In addition to weekly ap- pointmentsappointments, I charge this amount for other professional services you may need. How- ever, though I will break down the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services include report writing, telephone conversations lasting longer than 10-5 minutes, Skype appoint- ments or check-ins, consulting with other professionals with your permission, prepar- ing preparation of records or treatment summaries, form completion (e.g., FMLA) and the time spent performing any other ser- vices service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Be- cause Because of the difficulty of legal involvement, I charge $500 400 per hour for preparation and attendance at any legal proceedingsproceeding. Contacting Me CONTACTING ME Due to my work schedule, I am often not immediately available by telephone. While I am usually in my office four days a weekbetween 8AM and 7 PM, I probably will not answer the phone when I am with a clientpatient. When I am unavailable, my telephone is answered by voice mail that I monitor frequently. I will make every effort to return your call by on the end of my business daysame day you make it, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. If you are unable to reach me and you feel that you can’t wait for me to return your call, contact your family physician, physician or the nearest emergency room and ask for the psychologist or psychiatrist on call, or call 911. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client patient and a therapistpsychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form form that meets certain legal requirements imposed by state law and/or HIPAA. There are other situations that require only that you provide written, ad- xxxxx consent. Your With your signature on this Agreement provides consent for those activitiesa proper Authorization form, as followsI may disclose information in the following situations: • I may occasionally find it helpful to consult other health and mental health profes- sionals professionals about a case. During consultationIf I consult with a professional who is not involved in your treatment, I make every effort to avoid revealing the identity of my clientyour identity. The other These professionals are also legally bound to keep informa- tion the information confidential. If you don’t object, I will not tell you about these consultations un- less unless I feel that it is important to our work together. I will note all consultations in your Clinical RecordRecord (which is called “PHI” in my Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information). • You should be aware that I practice with other mental health professionals and that I employ administrative staff. In most cases, I need to share protected information with these individuals for both clinical and administrative purposes, such as scheduling, billing, and quality assurance. All of the mental health professionals are bound by the same rules of confidentiality. All staff members have been given training about protecting your privacy and have agreed not to release any information outside of the practice without the permission of a professional staff member. • Disclosures required by health insurers or to collect overdue fees are discussed else- where elsewhere in this Agreement. • If you are involved in a court proceeding and a request is made for information concerning the professional services I provided you, such information is protected by the psychologist-patient privilege law. I cannot provide any information without 1) your written authorization; 2) you informing me that you are seeking a protective order against my compliance with a subpoena that has been properly served on me and of which you have been notified in a timely manner; or 3) a court order requiring the disclosure. If you are involved in or contemplating litigation, you should consult with your attorney about likely required court disclosures. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the social worker-client privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. • If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. • If a client patient files a complaint or lawsuit against me, I may disclose relevant information regarding that client patient in order to defend myself. • If a client patient files a worker’s compensation claim, and the services I am providing are relevant to the injury for which the claim was made, I must, upon appropriate request, pro- vide provide a copy of the clientpatient’s record to the patient’s employer and the state Department of Labor and Industrial Commission Industries (L&I) or the Work- ers’ federal Office of Worker’s Compensation Division, or the client’s employerPrograms (OWCP). There are some situations in which I am legally obligated to take actions, which I be- lieve believe are necessary to attempt to protect others from harm and I may have to reveal some information about a clientpatient’s treatment. These situations are unusual in my practice. ! If I have reasonable cause to suspect believe that a child has been or may be subjected to abuse or neglect or observe a child being subjected to conditions or circumstances that would reasonably result in suffered abuse or neglect, the law requires that I file a report with Tennessee’s the appropriate government agency, usually the Department of Children’s Social and Health Services. Once such a report is filed, I may be required to provide additional information. ! If I have reasonable cause to suspect believe that an elderly abandonment, abuse, financial exploitation, or disabled neglect of a vulnerable adult presents a like- lihood of suffering serious physical harm and is in need of protective serviceshas occurred, the law requires that I file a report with Adult Protective the appropriate government agency, usually the Department of Social and Health Services. Once such a report is filed, I may be required to provide additional information. • If I reasonably believe that it there is necessary an imminent danger to disclose information to protect against a clear and substantial risk the health or safety of imminent serious harm being inflicted by the client on him/her- self patient or another personany other individual, I may be required to take protective actionactions. These actions may include, and/or initiating hospitalization and/or contacting include notifying the potential victim, and/or contacting the police and/or police, seeking hospitalization for the client’s familypatient, or contacting family members or others who can help provide protection. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records You should The laws governing confidentiality can be aware thatquite complex, pursuant to HIPAAand I am not an attorney. In situations where specific advice is required, I keep Protected Health Information about you in two sets of professional recordsformal legal advice may be needed. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports ELECTRONIC MEDIA The confidentiality of any professional consultations, your billing records, and any reports that have been sent to anyoneform of communication through electronic media, including reports to your insurance carrier. Except in the unusual circumstance where disclosure is reasonably likely to endanger you and/or others or when another individual (other than another health care provider) is referenced text messages and I believe disclosing that information puts the other person at risk of substantial harm, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of 35 cents per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Records, you have a right of review, which I will discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents of our conversations, my analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentially.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and emails cannot be guaranteed. You are also advised that any email sent to anyone elseme via computer in a work-place environment is legally accessible by an employer. If you prefer to communicate via email or text messaging for issues regarding scheduling or cancellations, including insurance companies without your writtenI will do so. While I may try to return messages in a timely manner, signed Authorization. Insurance companies I cannot require your authorization guarantee immediate response and request that you do not use these methods of communication to discuss therapeutic content and/or request assistance for emergencies. I am ethically and legally obligated to maintain records of each time we meet, talk on the phone, or correspond via electronic communication such as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights HIPAA provides you with several new email or expanded rights with regard to your Clinical Records and disclosures of protected health informationtext messaging. These rights include:records may include a brief synopsis of the conversation along with any observations or plans for the next meeting. A judge can subpoena your records for a variety of reasons, and if this happens, I must comply.
Appears in 1 contract
Samples: Services Agreement
Meetings. I normally conduct an evaluation that will last from 1-2 to 4 sessions. During this time, we can both decide if I am your psychologist is the best person to provide the services you need in order to meet your treatment goals. If therapy has psychotherapy is begun, I we will usually schedule one 45-45- minute ses- sion session per week at a time we agree on, although some sessions may be longer or more frequent. Once an My policy is to require 24 business hours advance notice of cancellation. In the event of a missed appointment hour is scheduledor cancellation less-than 24 hours in-advance, you will be expected incur a missed-appointment fee equal to pay for it un- less you provide 24-hours advanced notice half of cancellationthe appointment fee. It is important to note that insurance companies do not provide reimbursement for cancelled sessions. Professional Fees PROFESSIONAL FEES My hourly session fee varies depending on services and durationis $145. In addition to weekly ap- pointmentsappointments, I charge this amount for other professional services you may need. How- ever, I though we will break down the hourly cost if I we work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services include report writing, letter writing, telephone conversations lasting longer than 10-10 minutes, Skype appoint- ments or check-ins, consulting with other professionals with your permission, prepar- ing preparation of records or treatment summaries, and the time spent performing any other ser- vices service you may request of meyour psychologist. If you become involved in legal proceedings that require my our participation, you will be expected to pay for all of my our professional time, including preparation and transportation costs, even if I am your psychologist is called to testify by another party. Be- cause Because of the difficulty of legal involvement, I charge $500 250 per hour for preparation preparation, travel and attendance at any legal proceedingsproceeding. Contacting Me Due to my work schedule, CONTACTING YOUR PSYCHOLOGIST I am often not immediately available by telephone. While I am usually in my office four days a week, I probably will not answer the phone when I am with a client. I will make every effort to return your call by on the end of my business daysame day you make it, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. If you are unable to reach me and you feel that you can’t n't wait for me to the return your call, contact your family physician, physician or the nearest emergency room and ask for the psychologist or psychiatrist on call. If you are experiencing a life-threatening emergency, or call 911. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client patient and a therapistpsychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, ad- xxxxx advance consent. Your signature on this Agreement provides consent for those activities, as follows: • I may occasionally find it helpful to consult other health and mental health profes- sionals professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my clientthe patient. The other professionals are also legally bound to keep informa- tion the information confidential. If you don’t n't object, I will not tell you about these consultations un- less unless I feel that it is important to our work together. I will note all consultations in your Clinical RecordRecord (which is called "PHI" in my Notice of Psychologist's Policies and Practices to Protect the Privacy of Your Health Information). • I also have a privacy contract with my accountants. As required by HIPAA, I have a formal business associate contract with them, in which they promise to maintain the confidentiality of data except as specifically allowed in the contract or otherwise required by law. If you wish, I can provide you with a blank copy of this contract. • Disclosures required by health insurers or to collect overdue fees are discussed else- where elsewhere in this Agreement. • If a patient seriously threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her, or to contact family members or others who can help provide protection. I may disclose confidential information only to medical or law enforcement personnel if I determines that there is a probability of imminent physical injury by the patient to the patient or others, or there is a probability of immediate mental or emotional injury to the patient. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: • If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the social workerpsychologist-client patient privilege law. I cannot provide any information without your (or your legal representative’s's) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me us to disclose information. • If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. • If a client patient files a complaint or lawsuit against meus, I may disclose relevant information regarding that client patient in order to defend myselfourselves. • If a client patient files a worker’s 's compensation claim, I must, upon appropriate request, pro- vide a copy of the client’s record provide records relating to the Labor and Industrial Commission treatment or the Work- ers’ Compensation Division, or the client’s employerhospitalization for which compensation is being sought. There are some situations in which I am legally obligated to take actions, which I be- lieve believe are necessary to attempt to protect others from harm harm, and I may have to reveal some information about a client’s patient's treatment. These situations are unusual in my practice. • If I have reasonable cause to suspect believe that a child under 18 has been or may be subjected to abuse abused or neglected (including physical injury, substantial threat of harm, mental or emotional injury, or any kind of sexual contact or conduct), or that a child is a victim of a sexual offense, or that an elderly or disabled person is in a state of abuse, neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglectexploitation, the law requires that I file your doctor makes a report with Tennessee’s to the appropriate governmental agency, usually the Department of Children’s Protective Services. Once such a report is filed, I may be required to provide additional information. • If I have reasonable cause to suspect determine that an elderly there is a probability that the patient will inflict imminent physical injury on another, or disabled adult presents a like- lihood of suffering serious physical that the patient will inflict imminent physical, mental or emotional harm and is in need of protective services, the law requires that I file a report with Adult Protective Services. Once such a report is filed, I may be required to provide additional information. If I believe that it is necessary to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by the client on upon him/her- self herself, or another personothers, I may be required to take protective action. These actions may include, and/or initiating action by disclosing information to medical or law enforcement personnel or by securing hospitalization and/or contacting of the potential victim, and/or the police and/or the client’s familypatient. If such a situation arises, I will make every effort to fully discuss it with you before taking any action action, and I we will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records The laws governing confidentiality can be quite complex. In situations where specific advice is required, formal legal advice may be needed. PROFESSIONAL RECORDS You should be aware that, pursuant to HIPAA, I we keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I we receive from other providers, re- ports reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure is reasonably likely circumstances that involve danger to endanger you and/or others or when another individual (other than another health care provider) is referenced yourself and I believe disclosing that information puts the other person at risk of substantial harmothers, you may examine and/or receive a copy of your Clinical Record, Record if you request it in writing. You should be aware that pursuant to Maryland law, psychological test data are not part of a patient's record. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I we recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am we are allowed to charge a copying fee of 35 cents $5 per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical RecordsRecord, you have a right of review, which I we will discuss with you upon your request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my your doctor’s own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents contents of our conversations, my your doctor’s analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me your psychologist that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentially.] These Psychotherapy Notes are kept separate from your Clinical Record. Your While insurance companies can request and receive a copy of your Clinical Record, they cannot receive a copy of your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your writtensigned, signed written Authorization. Insurance companies cannot require your authorization Authorization as a condition of coverage nor penalize you in any way for your refusal refusal. You may examine and/or receive a copy of your Psychotherapy Notes unless your doctor determines that release would be harmful to provide ityour physical, mental or emotional health. Patient Rights PATIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your Clinical Records Record and disclosures of protected health information. These rights include:include requesting that your doctor amend your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about our policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and our privacy policies and procedures. MINORS AND PARENTS A minor (i.e., a person under the age of 18) has the same capacity as an adult to consent to treatment for or advice about venereal disease [Md. Code Xxx., Health-Gen. II § 20-102(c)(1)-(5)] Without the consent of or over the express objection of a minor, the health care provider may, but need not, give a parent, guardian, or custodian of the minor or the spouse of the parent information about treatment needed by the minor or provided to the minor [Md. Code Xxx., Health-Gen. II § 20-102(f)] Any communication will require the child's Authorization, unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify the parents of the concern. Before giving parents any information, I will discuss the matter with the child, if possible, and will do my best to handle any objections he/she may have. BILLING AND PAYMENTS You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require us to disclose otherwise confidential information. In most collection situations, the only information we release regarding a patient's treatment is his/her name, the nature of services provided, and the amount due. If such legal action is necessary, its costs will be included in the claim. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance we can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company. You should also be aware that your contract with your health insurance company requires that we provide it with information relevant to the services provided to you. I am required to provide a clinical diagnosis. Sometimes I am required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. By signing this Agreement, you agree that we can provide requested information to your carrier. I LOOK FORWARD TO WORKING WITH YOU! CONSENT TO PSYCHOTHERAPY Your signature below indicates that you have read this Agreement and the Notice of Privacy Practices and agree to their terms. Date Signature of Patient or Personal Representative Date
Appears in 1 contract
Samples: Service Agreement
Meetings. I normally conduct an evaluation that will last from 1-2 to 4 sessions. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If therapy has begunpsychotherapy is started, I will usually schedule one 45-minute ses- sion session (one appointment hour of 45 minutes duration) per week at a time we agree on, although some sessions may be longer or more frequent. Once an appointment hour is scheduled, you will be expected to pay for it un- less unless you provide 24-hours advanced advance notice of cancellationcancellation the day before the appointment [unless we both agree that you were unable to attend due to circumstances beyond your control]. It is important to note that insurance companies do not provide reimbursement for cancelled sessions. Professional Fees PROFESSIONAL FEES My hourly fee varies depending on services fees are as follows: Initial Appointment $180, Individual Psychotherapy $150, Couples and durationFamily Therapy $155. In addition to weekly ap- pointmentsappointments, I charge this amount $180 for other professional services you may need. How- ever, though I will break down the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services include report writing, telephone conversations lasting longer than 10-10 minutes, Skype appoint- ments or check-ins, consulting with other professionals with your permission, prepar- ing preparation of records or treatment summaries, and the time spent performing any other ser- vices service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Be- cause Because of the difficulty of legal involvement, I charge $500 250 per hour for preparation and attendance at any legal proceedingsproceeding. Contacting Me CONTACTING ME Due to my work schedule, I am often not immediately available by telephone. While I am usually in my office four days a weekbetween 10 AM and 6:15 PM, I probably will not answer the phone when I am with a clientpatient. When I am unavailable, my telephone is answered by voice mail that I monitor frequently. I will make every effort to return your call by on the end of my business daysame day you make it, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. In emergencies, you can try me at 000-000-0000. If you are unable to reach me and you feel that you can’t wait for me to return your call, contact your family physician, physician or the nearest emergency room and ask for the psychologist or psychiatrist on call, or call 911. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with meEmails, texts and other messaging apps are not appropriate for discussion of clinical matters or emergencies. Limits of Confidentiality LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client patient and a therapistpsychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form form that meets certain legal requirements imposed by HIPAAHIPAA and/or Maryland law. There are other situations that require only that you provide writtenHowever, ad- xxxxx consent. Your signature on this Agreement provides consent for those activitiesin the following situations, as followsno authorization is required: • I may occasionally find it helpful to consult other health and mental health profes- sionals professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my clientpatient. The other professionals are also legally bound to keep informa- tion the information confidential. If you don’t object, I will not tell you about these consultations un- less unless I feel that it is important to our work together. I will note all consultations in your Clinical RecordRecord (which is called “PHI” in my Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information). • I also have a contract with Psychiatric Billing Services. As required by HIPAA, I have a formal business associate contract with this business, in which they promise to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I can provide you with the names of these organizations and/or a blank copy of this contract. • Disclosures required by health insurers or to collect overdue fees are discussed else- where elsewhere in this Agreement. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: • If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the social workerpsychologist-client patient privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. • If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. • If a client patient files a complaint or lawsuit against me, I may disclose relevant information regarding that client patient in order to defend myself. If a client files a worker’s compensation claim, I must, upon appropriate request, pro- vide a copy of the client’s record to the Labor and Industrial Commission or the Work- ers’ Compensation Division, or the client’s employer. There are some situations in which I am legally obligated to take actions, which I be- lieve believe are necessary to attempt to protect others from harm and I may have to reveal some information about a clientpatient’s treatment. These situations are unusual in my practice. ▪ If I have reasonable cause reason to suspect believe that a child or vulnerable adult has been or may be subjected to abuse or neglect neglect, or observe that a child being vulnerable adult has been subjected to conditions self-neglect, or circumstances that would reasonably result in abuse or neglectexploitation, the law requires that I file a report with Tennessee’s the appropriate government agency, usually the local office of the Department of Children’s Social Services. Once such a report is filed, I may be required to provide additional information. ▪ If I have reasonable cause know that a patient has a propensity for violence and the patient indicates that he/she has the intention to suspect that an elderly or disabled adult presents inflict imminent physical injury upon a like- lihood of suffering serious physical harm and is in need of protective services, the law requires that I file a report with Adult Protective Services. Once such a report is filed, I may be required to provide additional information. If I believe that it is necessary to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by the client on him/her- self or another personspecified victim(s), I may be required to take protective actionactions. These actions may includeinclude establishing and undertaking a treatment plan that is calculated to eliminate the possibility that the patient will carry out the threat, seeking hospitalization of the patient and/or informing the potential victim or the police about the threat. ▪ If I believes that that there is a imminent risk that a patient will inflict serious physical harm or death on him/herself, or that immediate disclosure is required to provide for the patient’s emergency health care needs, I may be required to take appropriate protective actions, including initiating hospitalization and/or contacting notifying family members or others who can protect the potential victim, and/or the police and/or the client’s familypatient. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records The laws governing confidentiality can be quite complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. PROFESSIONAL RECORDS You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where circumstances that disclosure is reasonably likely to endanger the life or physical safety of you and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harmperson, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of 35 cents $1.00 per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Records, you have a right of review, which I will discuss with you upon request. In addition, I may also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentially.] These Psychotherapy Notes are kept separate from your Clinical Record. Your While insurance companies can request and receive a copy of your Clinical Record, they cannot receive a copy of your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your writtensigned, signed written Authorization. Insurance companies cannot require your authorization Authorization as a condition of coverage nor penalize you in any way for your refusal refusal. You may examine and/or receive a copy of your Psychotherapy Notes unless I determine that knowledge of the health care information would be injurious to provide ityour health. Patient Rights PATIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include:include requesting that I amend your record; requesting restrictions on what information from your Clinical Records is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights with you. MINORS & PARENTS Patients under 16 years of age who are not emancipated and their parents should be aware that the law may allow parents to examine their child’s treatment records. While privacy in psychotherapy is very important, particularly with teenagers, parental involvement is also essential to successful treatment. Therefore, it is usually my policy to request an agreement from any patient between 16 and 18 and his/her parents allowing me to share general information about the progress of treatment and their child’s attendance at scheduled sessions. I will also provide parents with a summary of their child’s treatment when it is complete. Any other communication will require the child’s authorization, unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have. BILLING AND PAYMENTS You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. In circumstances of unusual financial hardship, I may be willing to negotiate a fee adjustment or payment installment plan. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require me to disclose otherwise confidential information. In most collection situations, the only information I release regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due. If such legal action is necessary, its costs will be included in the claim. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, I will be willing to call the company on your behalf. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in short-term therapy, some patients feel that they need more services after insurance benefits end. You should also be aware that your contract with your health insurance company requires that I provide it with information relevant to the services that I provide to you. Maryland permits me to send some information without your consent in order to file appropriate claims. I am required to provide them with a clinical diagnosis. Sometimes I am required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. Maryland law prevents insurers from making unreasonable demands for information, but there are no specific guidelines about what unreasonable includes. If I believe that your health insurance company is requesting an unreasonable amount of information, I will call it to your attention and we can discuss what to do. You can instruct me not to send requested information, but this could result in claims not being paid and an additional financial burden being placed on you. Once the insurance company has this information, it will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your sessions. It is important to remember that you always have the right to pay for my services yourself to avoid the problems described above unless prohibited by contract.
Appears in 1 contract
Samples: Patient Services Agreement
Meetings. I normally We usually conduct an evaluation that will last from 1-2 one to two sessions. During this time, we can both decide if I am we are the best person to provide the services you need in order to meet your treatment goals. If therapy has psychotherapy is begun, I we will usually schedule one 45-minute ses- sion 45minute appointment per week at a time we agree on, although some sessions may be longer or more more/less frequent. CANCELLATION POLICY Note: Please Read and Sign Once an appointment hour is scheduled, you will be expected to pay for it un- less if you do not provide 24-24 hours advanced (one business day) advance notice of cancellation. It is important For appointments scheduled for a Monday, you must notify us by the Friday before by 5pm to note avoid the $130 cancellation fee. You will be expected to pay for that yourself as insurance companies do not allow us to charge for missed appointments (i.e., No show or Late (same day) cancel fees). You will be expected to pay that fee in full prior to or at your next appointment. We have a very busy practice and many patients that want to be seen. Please afford others the same courtesy you would want as they may be waiting for someone to cancel. Without prior notice, we are unable to fill your time. If it is possible, we will try to find another time to reschedule the appointment that week but you will still be responsible for the missed appointment fee of $130. Thank you for your understanding of and respect for this policy. I understand this policy and have had the opportunity to ask questions. I agree to personally pay $130 for any appointment where I fail to provide reimbursement for cancelled notice as described above. Signature/Date Reasonable Exceptions: Weather Related (e.g., severe weather advisories); Unexpected Family Emergencies; Physical Illness where you did not go to work or school as a result; Automobile Accidents or other potential circumstances beyond your control that we BOTH discuss and agree on a case by case basis. Please Turn to Page 3 While sometimes things do happen such as mandatory work meetings; child care issues; transportation problems, etc., it will be to your personal and financial benefit to make your therapy a priority and carve out that time in your day to minimize or eliminate blocks to attending your sessions. Professional Fees My hourly Unfortunately, the late cancellation penalty cannot be waived for these types of reasons. PROFESSIONAL FEES Our fee varies depending on services is $130 for psychotherapy visits (typically a 45-minute appointment, as described above) and duration$150 for intake evaluations (also typically a 45-minute appointment). In addition to weekly ap- pointmentsappointments, I we charge this amount for other professional services you may need. How- ever, I though we will break down down, at our discretion, the hourly cost if I we work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services include report writing, telephone conversations lasting longer than 10-a few minutes, Skype appoint- ments or checkresponses to lengthy e-ins, mails; consulting with other professionals with your permission, prepar- ing preparation of records or treatment summaries, and the time spent performing any other ser- vices service you may request of meus. Please see fees and options for therapy services done outside of a face to face appointment. NOTE: IF YOU ARE INVOLVED IN LEGAL PROCEEDINGS If you become involved in legal proceedings that require my our participation, you will be expected to pay for all of my our professional time, including preparation preparation, travel time and transportation costs, and time waiting to appear, even if I am we are called to testify by another party. Be- cause Since everything is confidential, we only would be called to testify if you made it known that you were seeing us. Thus, involving us in the process. Because of the difficulty of legal involvement, I we charge $500 400 per hour for preparation and attendance at any legal proceedingsproceeding. Contacting Me CONTACTING US Due to my our work scheduleschedules, I am we are often not immediately available by telephone. While I am usually in my office four days a week, I We probably will not answer the phone when I am we are with a clientpatient. I When we are unavailable, our telephone is answered by voicemail. We will typically make every effort to return your call by on the end of my business daysame day you make it, with the exception of weekends and holidays. If you are difficult to reach, please inform me us of some times when you will be availableavailable and provide several numbers. Calls are often returned late into the evening so if there is a time before or after which you do not want to be called, please make that known. Note that routine matters such as scheduling may take up to 24 hours to return calls. Please Turn To Page 4 If you are unable to reach me us and you feel that you can’t wait for me us to return your call, contact your family physician, the nearest emergency room physician or Laurelwood Hospital at (000) 000-0000 and ask for the psychologist or psychiatrist on call, or call 911intake. If I it is a life-threatening emergency after business hours and we are unavailable, please call 911 or go to your nearest hospital emergency room. If we will be unavailable for an extended time, I we will provide you with the name of a colleague to contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality LIMITS ON CONFIDENTIALITY The law generally protects the privacy of all communications between a client patient and a therapistpsychologist. In most situations, I we can only release information about your treatment to others if you sign a written Authorization Form authorization form that meets certain legal requirements imposed by HIPAA. HIPAA does allow us, however, to provide certain of your confidential information for treatment, payment or healthcare operations. There are other situations that require only that you provide where, we like to obtain your written, ad- xxxxx advance consent. Your signature on this Agreement provides consent for those activities, as follows: I • We may occasionally find it helpful to consult other health and mental health profes- sionals professionals about a case. During a consultation, I we make every effort to avoid revealing the identity of my clientour patient. The other professionals are also legally bound to keep informa- tion the information confidential. If you don’t object, I we will not tell you about these consultations un- less I unless we feel that it is important to our work together. I We will note all consultations in your Clinical RecordRecord (which is called “PHI” in our Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information). • You should be aware that we sometimes practice with other mental health professionals and that we may contract with administrative staff. In most cases, we need to share protected information with these individuals for both clinical and administrative purposes, such as scheduling, billing and quality assurance. All of the mental health professionals are bound by the same rules of confidentiality. All staff members have been given training about protecting your privacy and have agreed not to release any information outside of the practice without the permission of a professional staff member. • Disclosures required by health insurers or to collect overdue fees are discussed else- where elsewhere in this Agreement. There are some situations where I am we are permitted or required to disclose information without either your consent or Authorization: • If you are involved in a court proceeding and a request is made for information concerning your evaluation, diagnosis and or treatment, such information is generally protected by the social workerpsychologist-client patient privilege law. I We cannot typically provide any information without your (or your personal or legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me Please Turn To Page 5 Psychological Solutions, LLC Agreement for Psychological Services us to disclose information. If you are coming for marital/couple therapy BOTH individuals must consent to the release of a record. • If a government agency is requesting the information for health oversight activities, I we may be required to provide it for them. • If a client patient files a complaint or lawsuit against meone of us, I we may disclose relevant information regarding that client patient in order to defend myselfourselves. • If a client patient files a worker’s compensation claim, I mustthe patient must execute a release so that we may release the information, upon appropriate request, pro- vide a copy of the client’s record records or reports relevant to the Labor and Industrial Commission or the Work- ers’ Compensation Division, or the client’s employerclaim. There are some situations in which I am we may be legally obligated or allowed to take actionsaction and in those situations, which I be- lieve we believe are necessary to attempt to protect others from harm and I we may have to reveal some confidential information about a client’s treatmentpatient. These situations are unusual in my practice. If I have reasonable cause to suspect that a child has been or may be subjected to abuse or neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglect, the law requires that I file a report with Tennessee’s Department of Children’s Services. Once such a report is filed, I may be required to provide additional information. If I have reasonable cause to suspect that an elderly or disabled adult presents a like- lihood of suffering serious physical harm our practices and is in need of protective services, the law requires that I file a report with Adult Protective Services. Once such a report is filed, I may be required to provide additional information. If I believe that it is necessary to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by the client on him/her- self or another person, I may be required to take protective action. These actions may include, and/or initiating hospitalization and/or contacting the potential victim, and/or the police and/or the client’s family. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure is reasonably likely to endanger you and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harm, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of 35 cents per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Records, you have a right of review, which I will discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents of our conversations, my analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentially.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes but are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights includenecessarily limited to:
Appears in 1 contract
Samples: www.docrich.com
Meetings. I normally conduct Our first few sessions will involve an evaluation that will last from 1-2 sessionsof your needs. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If therapy has begunBy the end of the evaluation, I will be able to offer you some first impressions of what our work could include if we decide to continue together with therapy. You should evaluate this information along with your own opinions of whether you feel comfortable working with me. If you have any questions about my procedures, we can discuss them whenever they arise. If we decide not to work together, I will be happy to help you contact another mental health professional. If psychotherapy is begun, we will usually schedule meet, on average, for one 45-minute ses- sion session per week at a time we agree on. These sessions will range in length from 40-55 minutes, although some depending on the nature of the service being provided. Some sessions may be slightly longer or shorter or more or less frequent. Once an appointment hour is scheduled, you will be expected to pay my full fee for it un- less unless you provide 24-48 business hours advanced advance notice of cancellation. It is important to note that insurance companies do not provide reimbursement for cancelled missed sessions. Professional Fees My hourly fee varies fees range from $200-$300 per session or consultation, depending on the nature of the service. These fees are subject to change at any time. Other services such as telephone consultations, report and durationletter writing, document/email review, consulting with other professionals (authorized by you), etc. In addition will be charged on a pro-rated basis of the above fees. It is important to weekly ap- pointments, I charge this amount for other professional services you may need. How- ever, I will break down the hourly cost if I work for periods of less than one hour. Note understand that these additional services are not covered by insurancehealth insurance and you will be responsible for payment if you request them. Other services include report writingAlso, telephone conversations lasting longer than 10-minutes, Skype appoint- ments or check-ins, consulting with other professionals with your permission, prepar- ing of records or treatment summaries, and the time spent performing any other ser- vices you may request of me. If if you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Be- cause Because of the difficulty of legal involvement, I charge $500 per hour for preparation preparation, transportation, and attendance at any legal proceedingsproceeding, even if I am called to testify by another party. Contacting Me Due to my work schedule, I am often not immediately available by telephone. While When I am usually in unavailable, my office four days a week, I probably will not answer the phone when I am with a clienttelephone is answered by voice mail. I will make every effort to return your call by the end of my business daywithin 48 hours, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. If you are unable to reach me and you feel that you can’t wait for me to return your call, contact your family physician, physician or the nearest emergency room and ask for the psychologist or psychiatrist on call, or call 911. If I will be unavailable for an extended time, I you can contact the on-call clinician, (name and number will provide you with the name of a colleague contact, be on my voice mail) if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality The law protects the privacy of all communications between a client and a therapist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, ad- xxxxx consent. Your signature on this Agreement provides consent for those activities, as follows: I may occasionally find it helpful to consult other health and mental health profes- sionals about a case. During consultation, I make every effort to avoid revealing the identity of my client. The other professionals are also legally bound to keep informa- tion confidential. If you don’t object, I will not tell you about these consultations un- less I feel that it is important to our work together. I will note all consultations in your Clinical Record. Disclosures required by health insurers or to collect overdue fees are discussed else- where in this Agreement. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the social worker-client privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client in order to defend myself. If a client files a worker’s compensation claim, I must, upon appropriate request, pro- vide a copy of the client’s record to the Labor and Industrial Commission or the Work- ers’ Compensation Division, or the client’s employer. There are some situations in which I am legally obligated to take actions, which I be- lieve are necessary to attempt to protect others from harm and I may have to reveal some information about a client’s treatment. These situations are unusual in my practice. If I have reasonable cause to suspect that a child has been or may be subjected to abuse or neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglect, the law requires that I file a report with Tennessee’s Department of Children’s Services. Once such a report is filed, I may be required to provide additional information. If I have reasonable cause to suspect that an elderly or disabled adult presents a like- lihood of suffering serious physical harm and is in need of protective services, the law requires that I file a report with Adult Protective Services. Once such a report is filed, I may be required to provide additional information. If I believe that it is necessary to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by the client on him/her- self or another person, I may be required to take protective action. These actions may include, and/or initiating hospitalization and/or contacting the potential victim, and/or the police and/or the client’s family. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure is reasonably likely to endanger you and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harm, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of 35 cents per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Records, you have a right of review, which I will discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents of our conversations, my analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentially.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include:
Appears in 1 contract
Samples: Patient Services Agreement
Meetings. I normally conduct an evaluation that will may last from 1-2 to 4 sessions. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If therapy has psychotherapy is begun, I will usually schedule one 45-45 to 50 minute ses- sion session per week at a time we agree on, although some sessions may be longer or may be more or less frequent. Please be aware that you are responsible for remembering the date and time of your appointment, as we do not make confirmation calls. If you wish to provide us with your e-mail, our scheduling system will send out confirmation e-mails a few days prior to your scheduled appointment. If you do not wish to leave your e-mail on file, it is your responsibility to remember the date and time of your scheduled appointment. Once an appointment hour is scheduled, you will be expected it is your responsibility to pay for it un- less that appointment. If you provide are unable to attend your scheduled appointment, you MUST call the practice at least twenty-four (24-) hours advanced notice of cancellationprior to your scheduled appointment time, to cancel or reschedule that appointment. Failure to do so will result in a $110 fee being charged to your account. It is important to note that insurance companies do not provide reimbursement reimburse for missed and/or cancelled sessionsappointments; it is the client’s responsibility to pay for such charges. Professional Fees We do understand that extenuating circumstances sometimes occur. If you miss or cancel an appointment due to an extenuating circumstance, please call BPA as soon as possible to address the matter with our billing department. It is at the discretion of our billing department and the clinician as to whether you will be required to pay for the missed appointment. PROFESSIONAL FEES My hourly fee varies depending on services and durationschedule is available upon request. In addition to weekly ap- pointmentsappointments, I charge this amount for other professional services you may need. How- ever, I will break down the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services include such as report writing, telephone conversations lasting longer than 10-15 minutes, Skype appoint- ments or check-ins, consulting with other professionals with your permission, prepar- ing preparation of records or treatment summaries, and the time spent performing any other ser- vices service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Be- cause Because of the difficulty of legal involvement, I charge $500 100 per hour 15 minutes for preparation preparation, transportation, and attendance at any legal proceedingsproceeding. Contacting Me Please note that it is our policy to avoid being a party to litigation under most circumstances. CONTACTING ME Due to my work schedule, I am often not immediately available by telephone. While My hours vary from day-to-day. When I am usually in unavailable, my office four days a week, telephone is answered by voice mail that I probably will not answer the phone when I am with a clientmonitor frequently. I will make every effort to return your call by on the end of my business daysame day you make it, with the exception of weekends holidays, vacation days, and holidaysother days I am not in the office. If you are difficult to reach, please inform me of some times when you will be available. In emergencies, you can follow our emergency back-up protocol as instructed on our voice mail. The clinician on call will contact you as soon as possible. If you are unable to reach me and you feel that you can’t cannot wait for me to return your call, contact your family physician, physician or the nearest emergency room and ask for the psychologist or psychiatrist on call, or call 911room. If I will be unavailable for an extended time, I our office will provide you with the name of a trusted colleague to contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality The law protects the privacy of all communications between a client and a therapist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, ad- xxxxx consent. Your signature on this Agreement provides consent for those activities, as follows: I may occasionally find it helpful to consult other health and mental health profes- sionals about a case. During consultation, I make every effort to avoid revealing the identity of my client. The other professionals are also legally bound to keep informa- tion confidential. If you don’t object, I will not tell you about these consultations un- less I feel that it is important to our work together. I will note all consultations in your Clinical Record. Disclosures required by health insurers or to collect overdue fees are discussed else- where in this Agreement. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the social worker-client privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client in order to defend myself. If a client files a worker’s compensation claim, I must, upon appropriate request, pro- vide a copy of the client’s record to the Labor and Industrial Commission or the Work- ers’ Compensation Division, or the client’s employer. There are some situations in which I am legally obligated to take actions, which I be- lieve are necessary to attempt to protect others from harm and I may have to reveal some information about a client’s treatment. These situations are unusual in my practice. If I have reasonable cause to suspect that a child has been or may be subjected to abuse or neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglect, the law requires that I file a report with Tennessee’s Department of Children’s Services. Once such a report is filed, I may be required to provide additional information. If I have reasonable cause to suspect that an elderly or disabled adult presents a like- lihood of suffering serious physical harm and is in need of protective services, the law requires that I file a report with Adult Protective Services. Once such a report is filed, I may be required to provide additional information. If I believe that it is necessary to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by the client on him/her- self or another person, I may be required to take protective action. These actions may include, and/or initiating hospitalization and/or contacting the potential victim, and/or the police and/or the client’s family. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure is reasonably likely to endanger you and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harm, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of 35 cents per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Records, you have a right of review, which I will discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents of our conversations, my analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentially.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include:
Appears in 1 contract
Samples: Services Agreement
Meetings. I normally conduct an evaluation that will last from 1-2 sessionsinitial intake session to obtain relevant background information and to identify your current needs and reasons for seeking therapy. During this timetime and the first several sessions, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If therapy has begunyou decide to begin psychotherapy, I will usually schedule one 45-minute ses- sion session per week at a time we agree on, although some sessions may be longer or more frequent. Once If you schedule further appointments, please let me know if you can’t make it. I can’t charge insurance for missed appointments and don’t like to charge clients. If you miss more than an appointment hour or two without notice I probably won’t schedule further meetings. PROFESSIONAL FEES The charges for my services are based on the usual, customary and reasonable fee profiles for the Oklahoma City area. My fee for an Initial Psychological Interview is scheduled$175. The Psychotherapy fee is $150 per 45 minute psychological therapy session. This fee also includes my time spent on your behalf, including record keeping and consultation. Fees for psychological assessments vary according to the extent and nature of the assessment and can range from $250 to $2000. Please clarify assessment fees before proceeding with any psychological evaluation. I also encourage you will be to discuss fees with me at any time. My clients are expected to pay for it un- less you provide 24-hours advanced notice of cancellationservices at the time that they are provided unless other arrangements have been made in advance. It is important for you to note understand that I am ethically prohibited from billing health insurance companies do not provide reimbursement for cancelled sessionsany forensic evaluation or forensic consultation. Professional Fees My hourly fee varies depending on services and duration. In addition to weekly ap- pointments, I charge this amount for other professional services you may need. How- ever, I will break down the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services include report writing, telephone conversations lasting longer than 10-minutes, Skype appoint- ments or check-ins, consulting with other professionals with your permission, prepar- ing of records or treatment summaries, and the time spent performing any other ser- vices you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Be- cause of the difficulty of legal involvement, I charge $500 per hour for preparation and attendance at any legal proceedings. Contacting Me CONTACTING ME Due to my work scheduleschedule and off-site consulting agreements, I am often not rarely immediately available by telephone. While I am usually in my office four days My telephone is answered by RSVP Telephone Answering Service. A telephone secretary will take your message and immediately send me a week, I probably will not answer the phone when I am with a clienttext page. I will make every effort to return your call by on the end of my business day, with the exception of weekends and holidayssame day you make it. If you are difficult to reach, please inform me of some times when you will be available. If you are unable to reach me and you feel that you can’t wait for me to return your call, contact your family physician, physician or the nearest emergency room and ask for the psychologist or psychiatrist on call, or call 911. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client and a therapistpsychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, ad- xxxxx advance consent. Your signature on this Agreement provides consent for those activities, as followsthe following: • I may occasionally find it helpful to consult other health and mental health profes- sionals professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my client. The other professionals are also legally bound to keep informa- tion the information confidential. If you don’t object, I will not tell you about these consultations un- less unless I feel that it is important to our work together. I will note all consultations in your Clinical RecordRecord (which is called “PHI” in my Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information). • You should be aware that I employ administrative staff. In most cases, I need to share protected information with these individuals for administrative purposes, such as billing. All staff members have been given training about protecting your privacy and have agreed not to release any information outside of the practice without my permission. • Disclosures required by health insurers or to collect overdue fees are discussed else- where elsewhere in this Agreement. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: • If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the social workerpsychologist-client privilege law. I cannot provide any information without your (or your personal or legal representative’s) written authorization, authorization or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. • If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. • If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client in order to defend myself. • If a client files a worker’s compensation claim, I mustmay disclose information relevant to that claim to the appropriate parties, upon appropriate request, pro- vide a copy including the Administrator of the client’s record to the Labor and Industrial Commission or the Work- ersWorkers’ Compensation Division, or the client’s employerCourt. There are some situations in which I am legally obligated to take actions, which I be- lieve believe are necessary to attempt to protect others from harm and I may have to reveal some information about a client’s treatment. These situations are unusual in my practice. If I have reasonable cause to suspect that a child has been or may be subjected to abuse or neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglect, the law requires that I file a report with Tennessee’s Department of Children’s Services. Once such a report is filed, I may be required to provide additional information. If I have reasonable cause to suspect that an elderly or disabled adult presents a like- lihood of suffering serious physical harm and is in need of protective services, the law requires that I file a report with Adult Protective Services. Once such a report is filed, I may be required to provide additional information. If I believe that it is necessary to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by the client on him/her- self or another person, I may be required to take protective action. These actions may include, and/or initiating hospitalization and/or contacting the potential victim, and/or the police and/or the client’s family. treatment If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. These situations are unusual in my practice. ▪ If I have reason to believe that a child under the age of 18 years is the victim of abuse or neglect, the law requires a report to the appropriate government agency, usually the Department of Human Services. Once such a report is filed, I may be required to provide additional information. ▪ If I have reason to believe that a vulnerable adult is suffering from abuse, neglect, or exploitation, the law requires that I report to the appropriate government agency, usually the Department of Human Services. Once such a report is filed, I may be required to provide additional information. ▪ If a client communicates an explicit threat to kill or inflict serious bodily injury upon a reasonably identifiable victim and he/she has the apparent intent and ability to carry out the threat, or if a client has a history of violence and I have reason to believe that there is a clear and imminent danger that the client will attempt to kill or inflict serious bodily injury upon a reasonably identified person, I may be required to take protective actions. These actions may include notifying the potential victim, contacting the police, and/or seeking hospitalization for the client. ▪ If a client threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her, or to contact family members or others who can help provide protection. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records You should The laws governing confidentiality can be aware thatquite complex, pursuant to HIPAAand I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. PROFESSIONAL RECORDS The laws and standards of my profession require that I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure is reasonably likely circumstances that involve danger to endanger you yourself and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that where information puts the other person at risk of substantial harmhas been supplied to me confidentially by others, you may examine and/or receive a copy of your Clinical Record, Record if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of 35 cents $0.10 per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Recordsrecords, you have a right of review, which I will discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents of our conversations, my analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentially.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights CLIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your Clinical Records Record and disclosures of protected health information. These rights include:include requesting that I amend your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights with you. MINORS & PARENTS OR GUARDIANS Clients under 18 years of age who are not emancipated and their parents or guardians should be aware that the law allows parents or guardians to examine their child’s treatment records. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is my policy to request an agreement from parents or guardians that, during treatment, I will provide them only with general information about the progress of the child’s treatment and his/her attendance at scheduled sessions. Other communication will require the child’s agreement, unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify the parents or guardians of my concern.
Appears in 1 contract
Samples: Client Services Agreement
Meetings. I normally conduct an evaluation that will last from 1-2 1 to 3 sessions. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If therapy has psychotherapy is begun, I will usually schedule one 45-minute ses- sion per week at a time sessions (one appointment hour of 45 minutes duration) on dates and times that we agree on, although some sessions may be longer or more frequentupon together. Once an appointment hour is scheduled, you will be expected to pay for it un- less it, at my hourly fee, unless you provide 24-24 hours advanced advance notice of cancellation (unless we both agree that you were unable to attend, or to provide 24 hour notice of cancellation, due to circumstances beyond your control). It is important to note that insurance companies do not provide reimbursement for cancelled or missed sessions, and therefore payment in full becomes the patient’s responsibility. Professional Fees PROFESSIONAL FEES My fee for an initial diagnostic interview is $180.00; this interview will last from 60 to 90 minutes. After this initial interview, my hourly fee varies depending on services and durationis $130.00. In addition to weekly ap- pointmentstherapy appointments, I charge this amount for any and all other professional services you may need. How- ever, though I will break down prorate the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services include report writing, telephone conversations lasting longer than 10-5 minutes, Skype appoint- ments or check-ins, consulting with other professionals with your permission, prepar- ing preparation of records or treatment summaries, completion of any reports or forms, and the time spent performing any other ser- vices service you may request of me. If you become involved in legal or educational proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Be- cause Because of the potential difficulty of legal or educational involvement, I charge $500 180.00 per hour for preparation and attendance at any legal proceedingsor educational proceeding. Contacting Me Your insurance benefit will likely cover only face-to-face therapy sessions, and will not cover many of the costs discussed in this section. CONTACTING ME Due to my work schedule, I am often not immediately available by telephone. While I am usually in , and it is generally my office four days a week, I probably will policy not to answer the phone when I am with a clientpatient. When I am unavailable, my telephone is answered by voice mail that I monitor frequently. I will make every effort to return your call by on the end of my business day, with the exception of weekends and holidayssame day you make it. If you are difficult to reach, please inform me of some times when you will be available. If you are unable to reach me and you feel that you can’t wait for me to return your call, contact your family physician, call 911, or contact the nearest emergency room and ask for the psychologist or psychiatrist (psychiatrist) on call. If you need to contact me between sessions due to a true emergency, or call 911I may be willing to waive my fee for the phone call. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client patient and a therapistpsychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form form that meets certain legal requirements imposed by HIPAA. There However, there are other situations that require only that you provide written, ad- xxxxx advance consent. Your signature on this Agreement provides consent for those activitiesthese specific situations, as follows: • I may occasionally find it helpful to consult other health and mental health profes- sionals professionals about a case. During a consultation, I make every effort to avoid revealing do not disclose the identity of my clientpatient. The other professionals are also legally bound to keep informa- tion the information confidential. If you don’t object, I will not tell you about these consultations un- less I feel that it is important to our work together. I will note all consultations in your Clinical RecordRecord (which is called “PHI” in my Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information). • Disclosures required by health insurers or to collect overdue fees are discussed else- where elsewhere in this Agreement. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: • If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the social workerpsychologist-client patient privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. • If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. • If a client patient files a complaint or lawsuit against me, I may disclose relevant information regarding that client patient in order to defend myself. • If a client patient files a worker’s compensation claim, I must, upon appropriate request, pro- vide provide appropriate information, including a copy of the clientpatient’s record record, to the Labor and Industrial Commission patient’s employer, the insurer or the Work- ers’ Compensation Division, or the clientDepartment of Worker’s employerCompensation. There are some situations in which I am legally obligated to take actions, which I be- lieve believe are necessary to attempt to protect others from harm and I may have to reveal some information about a clientpatient’s treatment. These situations are unusual in my practice. ▪ If I have reasonable cause to suspect believe that a child has been under age 18 is suffering physical or may be subjected emotional injury resulting from abuse inflicted upon him or her which causes harm or substantial risk of harm to abuse the child's health or welfare (including sexual abuse), or from neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglect(including malnutrition), the law requires that I file a report with Tennessee’s the Department of Children’s Social Services. Once such a report is filed, I may be required to provide additional information. ▪ If I have reasonable cause reason to suspect believe that an elderly individual is suffering from or disabled adult presents has died as a like- lihood result of suffering serious physical harm and is in need of protective servicesabuse (including financial exploitation), the law requires that I file report to the Department of Elder Affairs. If I have reason to believe that a mentally or physically disabled individual is suffering from or has died as result of a reportable condition (which is defined as a serious physical or emotional injury resulting from abuse and includes non-consensual sexual activity), the law requires that I report with Adult Protective Servicesto the Disabled Persons Protection Commission and/or other appropriate agencies. Once such a report is filed, I may be required to provide additional information. I need not report abuse if a disabled person invokes the psychotherapist-patient privilege to maintain confidential communications. ▪ If I believe that it is necessary a patient communicates an immediate threat of serious physical harm to disclose information an identifiable victim or if a patient has a history of violence and the apparent intent and ability to protect against a clear and substantial risk of imminent serious harm being inflicted by carry out the client on him/her- self or another personthreat, I may be required to take protective actionactions. These actions may include, and/or initiating hospitalization and/or contacting include notifying the potential victim, contacting the police, and/or seeking hospitalization for the police and/or the client’s familypatient. ▪ If a patient threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her, or to contact family members or others who can help provide protection. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records The laws governing confidentiality can be quite complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. PROFESSIONAL RECORDS You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards toward those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure is reasonably likely to endanger you and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harm, you You may examine and/or receive a copy of your Clinical Record, Record if you request it in writingwriting unless I believe that access would endanger you. In those situations, you have a right to a summary and to have your record sent to another mental health provider or your attorney. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstancessituations, I am allowed to charge a copying fee of 35 cents $1.00 per page (and for certain other expenses)page. The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Recordsrecords, you have a right of review, which I will discuss with you upon your request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentially.] These Psychotherapy Notes are kept separate from your Clinical Record. Your While insurance companies can request and receive a copy of your Clinical Record, they cannot receive a copy of your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your writtensigned, signed written Authorization. Insurance companies cannot require your authorization Authorization as a condition of coverage nor penalize you in any way for your refusal refusal. You may examine and/or receive a copy of your Psychotherapy Notes unless I determine that it would adversely affect your well-being, in which case you have a right to provide ita summary and to have your record sent to another mental health provider or your attorney. Patient Rights PATIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your Clinical Records Record and disclosures of protected health information. These rights include:include requesting that I amend your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights with you. MINORS AND PARENTS Prior to meeting with patients under 18 years of age, I conduct an initial interview with the patient’s parent(s) or guardian(s) to review information such as precipitants to treatment, background history, confidentiality issues, and any legal and/or custody arrangements. If a minor patient’s parents are divorced and both parents retain legal custody, I will notify both parents that the patient has begun therapy with me. Patients under 18 years of age who are not emancipated, and their parents, should be aware that the law allows parents to examine their child’s treatment records, unless I believe this review would be harmful to the patient and his/her treatment. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, in unusual circumstances I may request an agreement from parents that they consent to give up their access to their child’s records. If they agree, during treatment, I will provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. I will also provide parents with a summary of their child’s treatment when it is complete. Any other communication will require the child’s Authorization, unless I feel that the child is in danger or is a danger to someone else, in which case, I will immediately notify the parents of my concern. Before giving parents any information, and when appropriate, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have. BILLING AND PAYMENTS You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. In circumstances of unusual financial hardship, I may be willing to negotiate a fee adjustment or payment installment plan. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require me to disclose otherwise confidential information. In most collection situations, the only information I release regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due. If such legal action is necessary, its costs will be included in the claim. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms, including any required authorizations, and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. It is very important that you find out exactly what mental health services your insurance policy covers. If you have questions about the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company. You should also be aware that your contract with your health insurance company requires that I provide it with information relevant to the services that I provide to you. I am required to provide a clinical diagnosis. Sometimes I am required to provide additional clinical information such as treatment plans or summaries, or, more rarely, copies of your entire clinical record. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your sessions. It is important to remember that you always have the right to self-pay for my services, instead of using your insurance benefits, to avoid situations such as those described above. Your signature below indicates that you have read the information in this document (the Agreement) and agree to abide by its terms during our professional relationship. Your signature also indicates that you have had the opportunity to discuss any questions you may have had about information contained in this Agreement and are consenting to treatment. For parents or guardians of patients under 18 years of age, your signature below also indicates that you consent to treatment for the minor. Patient Name (printed) Patient (or Guardian) Signature Date
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Meetings. I normally conduct an evaluation that will last from 1-2 to 4 sessions. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If therapy has psychotherapy is begun, I will usually schedule one 45-minute ses- sion session or appointment per week at a time we agree on, although some sessions may be longer or more frequent. As you progress toward your goal(s), we’ll likely meet less often and then end our sessions. Once an appointment hour is scheduled, you will be expected to pay for it un- less unless you provide 2448-hours advanced advance notice of cancellation. It PROFESSIONAL FEES My current fee for most sessions is important to note that insurance companies do not provide reimbursement for cancelled sessions. Professional Fees My hourly fee varies depending on services and duration$210. In addition to weekly ap- pointmentsappointments, I charge this amount for other professional services you may need. How- ever, though I will break down prorate the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurance45 minutes. Other services include report writing, telephone conversations lasting longer than 10-5 minutes, Skype appoint- ments or check-ins, consulting with other professionals with your permission, prepar- ing preparation of records or treatment summaries, and the time spent performing any other ser- vices service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Be- cause [Because of the difficulty of legal involvement, I charge $500 300 per hour 45-minute period for preparation and my fee is higher for attendance at any legal proceedings. Contacting Me proceeding.] CONTACTING ME Due to my work schedule, I am often not immediately available by telephone. While I am usually in my office four days a weekbetween 9 AM and 6 PM, I probably will not answer the phone when I am with a clientpatient. I am sometimes available between 9AM and 11 AM on Monday through Thursday. When I am unavailable, my telephone is answered by voice mail or my assistant who now handles many of my scheduling and other calls. We return calls during regular business hours and will make every effort try to return your call by within 24-hours, if not on the end of my business daysame day you make it, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. [In emergencies, you can call me at 000-000-0000.] If you are unable to reach me and you feel that you can’t wait for me to return your call, contact your family physician, physician or the nearest emergency room and ask for the psychologist [or psychiatrist psychiatrist] on call, or call 911. If I will be unavailable for an extended time, I will provide you with the name and phone number of a colleague to contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client patient and a therapistpsychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, ad- xxxxx advance consent. Your signature on this Agreement provides consent for those activities, as follows: • I may occasionally find it helpful to consult other health and mental health profes- sionals professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my clientpatient. The other professionals are also legally bound to keep informa- tion the information confidential. If you don’t object, I will not tell you about these consultations un- less unless I feel that it is important to our work together. I will note all consultations in your Clinical RecordRecord (which is called “PHI” in my Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information). • You should be aware that I share office space with other mental health professionals and that I may employ administrative staff. In most cases, I may need to share protected information with these individuals for both clinical and administrative purposes, such as scheduling, billing and quality assurance. All staff members have been given training about protecting your privacy and have agreed not to release any information outside of the practice without the permission of a professional staff member. • Disclosures required by health insurers or to collect overdue fees are discussed else- where elsewhere in this Agreement. • If a patient threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her or to contact family members or others who can help provide protection. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: • If you are a patient is involved in a court proceeding and a request is made for information concerning your diagnosis and treatmentmy professional services, such information is protected by the social worker-client psychologist- patient privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. • If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. • If a client patient files a complaint or lawsuit against me, I may disclose relevant information regarding that client patient in order to defend myself. • If a client patient files a worker’s compensation claim, and I am providing treatment related to the claim, I must, upon appropriate request, pro- vide a copy furnish copies of the client’s record to the Labor all medical reports and Industrial Commission or the Work- ers’ Compensation Division, or the client’s employerbills. There are some situations in which I am legally obligated to take actions, which I be- lieve believe are necessary to attempt to protect others from harm and I may have to reveal some information about a clientpatient’s treatment. These situations are unusual in my practice. ▪ If I have reasonable cause reason to suspect believe that a child has been or may be subjected to abuse or neglect or observe a child is being subjected to conditions or circumstances that would reasonably result in abuse or neglectabused, the law requires that I file a report with Tennessee’s Department of Children’s Servicesthe appropriate governmental agency. Once such a report is filed, I may be required to provide additional information. ▪ If I have reasonable cause to suspect believe that an elderly or a disabled adult presents or elder person has had a like- lihood physical injury or injuries inflicted upon such disabled adult or elder person, other than by accidental means, or has been neglected or exploited, I must report to an agency designated by the Department of suffering serious physical harm and is in need of protective services, the law requires that I file a report with Adult Protective ServicesHuman Resources. Once such a report is filed, I may be required to provide additional information. ▪ If I believe determine that it is necessary a patient presents a serious danger of violence to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by the client on him/her- self or another personanother, I may be required to take protective actionactions. These actions may include, and/or initiating hospitalization and/or contacting include notifying the potential victim, and/or contacting the police police, and/or seeking hospitalization for the client’s familypatient. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records The laws governing confidentiality can be quite complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. PROFESSIONAL RECORDS You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure circumstances that involve danger to yourself or others or makes reference to another person (unless such other person is a health care provider) and I believe that access is reasonably likely to endanger you and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the cause substantial harm to such other person at risk of substantial harm[or if information is supplied to me confidentially by others, (you can elect to put this information in your psychotherapy notes, see below)] you or your legal representative may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstancessituations, I am allowed to charge a fee for copying fee of 35 cents per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Recordsrecords, you have a right of review, review of this decision (except for information provided to me confidentially by others) which I will discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. Record [They also include in- formation from others provided and information supplied to me confidentially.] confidentially by others]. These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights PATIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your Clinical Records Record and disclosures of protected health information. These rights include:include requesting that I amend your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights with you. MINORS & PARENTS Patients under 18 years of age, who are not emancipated, and their parents should be aware the law allows parents to examine their child’s treatment records unless I believe doing so would endanger the child or we agree otherwise. Because privacy in psychotherapy is crucial to success, particularly with teenagers, it is my policy to request an agreement from parents that they consent to give up their access to their child’s records. If they agree, during treatment, I will provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. I will also provide parents with a summary of their child’s treatment when it is complete. Any other communication will require the child’s authorization, unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have. BILLING AND PAYMENTS You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require me to disclose otherwise confidential information. In most collection situations, the only information I release regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due. [If such legal action is necessary, its costs will be included in the claim.] INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with receipts you can submit to receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, we may call the company together. Insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in short-term therapy, some patients feel that they need more services after insurance benefits end. [Some managed-care plans will not reimburse you for my services to you once your benefits end. If this is the case, you may continue to work with me without your being reimbursed, or I will try to find a new provider who will help you continue your psychotherapy.] You should also be aware that if you seek reimbursement your contract with your health insurance company requires that my receipt includes information relevant to the services that I provide to you. Usually the receipt must have your clinical diagnosis. Sometimes insurance companies seek treatment plans or summaries, or copies of your entire Clinical Record (except for psychotherapy notes). In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. We can discuss what we can expect to accomplish with the insurance benefits available to you and what will happen if they run out before you feel ready to end your sessions. It is important to remember that you always have the right to pay for my services yourself to avoid the problems described above. YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS AND ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPAA NOTICE FORM DESCRIBED ABOVE. Printed Name of Patient Printed Name of Person Signing Agreement
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Samples: drrenmassey.com
Meetings. I normally conduct an evaluation intake interview that will last from 1-2 sessionsfor approximately 60 minutes. The purpose of the intake interview is for me to gain background information, clarify your concerns, and determine the instruments to use for the evaluation. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If therapy has begunUsually, I schedule 2-3 appointments lasting 2-3 hours each for testing. After testing is completed, I will usually score tests, analyze data, and complete a report. We will schedule one 45-minute ses- sion per week at a time final meeting lasting approximately 60 minutes during which we will review the findings of the evaluation. PROFESSIONAL FEES AND PAYMENT I charge a flat rate of $2800 for a comprehensive psychological evaluation. If we agree onthat the questions you would like addressed by the evaluation do not require a comprehensive psychological evaluation, although some sessions may I will decrease the price and determine the total cost based on the tests I recommend. My initials indicate that I agree that the evaluation is not going to be longer or more frequenta comprehensive psychological evaluation and that I agree to pay in full the fee of $ . Once an appointment hour My hourly rate is scheduled$200. In the event of a rate change, you will be expected charged my prevailing hourly rate for any services you request other than assessment. Payment for assessment is required no later than the date of our results conference. No reports will be released without payment in full. A receipt will be provided upon request by the client. If you pay with a check that is returned for any reason, you will be charged a $35.00 returned check fee. If this occurs, you will be required to pay for it un- less services using cash, credit card, or cashier’s check. If your account balance has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency, an attorney, or going through small claims court. If such legal action is necessary, you provide 24-hours advanced notice of cancellation. It is important to note that insurance companies do not provide reimbursement will be responsible for cancelled sessions. Professional Fees My hourly fee varies depending on services all collection costs and durationattorneys’ fees, and they will be included in the claim. In addition to weekly ap- pointmentsmost collection situations, the only information I charge this amount for other professional release regarding a patient’s treatment is his/her name, the nature of services you may need. How- ever, I will break down the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services include report writing, telephone conversations lasting longer than 10-minutes, Skype appoint- ments or check-ins, consulting with other professionals with your permission, prepar- ing of records or treatment summariesprovided, and the time spent performing any other ser- vices amount due. I will work with you may request of meto avoid these circumstances. If you become involved in any legal proceedings proceeding that require requires my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Be- cause of the difficulty of legal involvement, I charge $500 200 per hour with a minimum of 8 hours for preparation and attendance at any legal proceedingsproceeding ($1600). Contacting Me Due You will be expected to pay this minimum fee prior to my work scheduleappearance at any legal proceeding and may be billed additional fees if the time preparing for or being involved in the proceeding exceeds 8 hours. I may require a subpoena to appear at any legal proceeding and the party who provides me with a subpoena is responsible for my payment in full. If both parties agree to my involvement, the fee may be split equally between the parties. Though the judicial system in Maryland protects experts from being compelled to appear without remuneration when their opinions are being sought, the law does not protect experts from being subpoenaed as fact witnesses (for example: to describe, as an eye-witness to an accident might, events that transpired in their presence). I must, therefore, require that you agree that if my presence is requested for any reason, my fee of $200 per hour will be paid by the party requesting my presence, unless other arrangements have been made in advance or the Court has ordered that responsibility for these fees be apportioned in some other manner. A minimum payment in full of $1600 is required no later 3 business days prior to my appearance. Cancellations must be made at least 2 business days before my appearance in order to receive a refund. Cancellations made less than 2 business days before my appearance will result in the fee being forfeited. INSURANCE REIMBURSEMENT Please note that I am often not immediately available currently a provider in any insurance network or managed care contract. You are responsible for all payments directly to Xxxxxxx Psychological Services, P.A. Additionally, psychological evaluation is not typically covered by telephoneinsurance. While PROFESSIONAL RECORDS The laws and standards of my profession require that I keep records. You are entitled to receive a copy of your records, or I can prepare a summary for you instead. Test data will only be released upon your request to a licensed psychologist or psychiatrist. Fees for copying your file are $.76 per page and may include a fee of $22.88 for preparation and any applicable mailing costs. I will provide them to you within 28 days of your request. I require a written request for records with your original signature and payment for copies in advance of providing copies to you. CHANGES OR CANCELLATION POLICY To cancel or change an appointment, 24 hours advanced notice must be given. If you do not provide 24 hours notice to cancel or change an appointment, you will be charged $200. You can cancel an appointment by contacting the office at (000) 000-0000. If I cannot make it into the office due to inclement weather or any other reason, every effort will be made to reach you. You may also call the office to check the status of your appointment. CONTACTING ME My hours of operation differ daily based on the professional activities in which I am usually in engaged. You may leave a message with my assistant or on my office four days a week, I probably will not answer the phone when I am with a clientvoicemail. I will make every effort to return your call by on the end of my business daysame day you make it, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. If you are unable to reach me and you feel that you can’t wait for me to return your call, contact your family physician, Because I often work later into the nearest emergency room and ask for the psychologist or psychiatrist on call, or call 911. If I will be unavailable for an extended time, I will provide you with the name of a colleague contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality The law protects the privacy of all communications between a client and a therapist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, ad- xxxxx consent. Your signature on this Agreement provides consent for those activities, as follows: I may occasionally find it helpful to consult other health and mental health profes- sionals about a case. During consultation, I make every effort to avoid revealing the identity of my client. The other professionals are also legally bound to keep informa- tion confidential. If you don’t object, I will not tell you about these consultations un- less I feel that it is important to our work together. I will note all consultations in your Clinical Record. Disclosures required by health insurers or to collect overdue fees are discussed else- where in this Agreement. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the social worker-client privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. If a government agency is requesting the information for health oversight activitiesevenings, I may be required to provide it for them. If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client in order to defend myself. If a client files a worker’s compensation claim, I must, upon appropriate request, pro- vide a copy of the client’s record to the Labor and Industrial Commission or the Work- ers’ Compensation Division, or the client’s employer. There are some situations in which I am legally obligated to take actions, which I be- lieve are necessary to attempt to protect others from harm and I may have to reveal some information about a client’s treatment. These situations are unusual in my practice. If I have reasonable cause to suspect that a child has been or may be subjected to abuse or neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglect, the law requires that I file a report with Tennessee’s Department of Children’s Services. Once such a report is filed, I may be required to provide additional information. If I have reasonable cause to suspect that an elderly or disabled adult presents a like- lihood of suffering serious physical harm and is in need of protective services, the law requires that I file a report with Adult Protective Services. Once such a report is filed, I may be required to provide additional information. If I believe that it is necessary to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by the client on him/her- self or another person, I may be required to take protective action. These actions may include, and/or initiating hospitalization and/or contacting the potential victim, and/or the police and/or the client’s family. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets of professional records. One set constitutes return your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure is reasonably likely to endanger you and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harm, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of 35 cents per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Records, you have a right of review, which I will discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents of our conversations, my analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentially.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include:call after 5:00 p.m.
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Meetings. I normally conduct an evaluation that will last from 1-2 sessions. During this timeAfter our initial visit, we both will decide whether or not to begin psychotherapy. Over the first few sessions, we will assess if I am the best person to provide the services you need in order to meet your treatment goalsyou. If therapy has begun, I will usually schedule one 4560 minute session (one appointment hour of 55-minute ses- sion 60 minutes duration) per week at a time we agree on, although some sessions may be longer or more more/less frequent. Once an appointment hour is scheduled, you will be expected to pay for it un- less unless you provide 24-24 hours advanced advance notice of cancellation. You will be charged $50.00 the first time you miss an appointment or fail to cancel 24 hours prior. Any further missed or cancelled appointments will be charged at full fee and therapy may be terminated. It is important to note that insurance companies do not provide reimbursement for cancelled or missed sessions. Professional Fees PROFESSIONAL FEES Initial Diagnostic Evaluations are billed at $155.00. My hourly fee varies depending on services and durationfor a 55-60 minute session is $145.00. My fee for a 45 minute session is $135.00. In addition to weekly ap- pointmentsappointments, I charge this amount $145.00 for other professional services you may need. How- ever, though I will break down the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services include report writing, telephone conversations lasting longer than 10-minutes, Skype appoint- ments or check-insconversations, consulting with other professionals with your permission, prepar- ing preparation of records or treatment summaries, and the time spent performing any other ser- vices service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Be- cause of the difficulty of legal involvement, I charge $500 per hour for preparation and attendance at any legal proceedings. Contacting Me CONTACTING ME Due to my work schedule, I am often not immediately available by telephone. While I am usually in my office four days a weekbetween 9 AM and 5 PM, I probably will not answer the phone when I am with a clientpatient. When I am unavailable, my telephone is answered by an answering machine that I monitor frequently. I will make every effort to return your call by on the end of my business daysame day you make it, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. In emergencies, you can call me on my cell phone at 000-000-0000. If you are unable to reach me and you feel that you can’t wait for me to return your call, contact your family physician, physician or the nearest emergency room and ask for the psychologist or psychiatrist on call, or call 911. If I will be unavailable for an extended time, I will provide you with the name of have a colleague contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with therapist who is “on call” for me. Limits Please do not rely on email to contact me about anything urgent, as I only check email once or twice a day. Email contact should be limited to an occasional question, comment, or appointment change and should not be used in excess. Abuse of Confidentiality email may result in termination of therapy. LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client patient and a therapistpsychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, ad- xxxxx advance consent. Your signature on this Agreement provides consent for those activities, as follows: I may occasionally find it helpful to consult other health and mental health profes- sionals professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my clientpatient. The other professionals are also legally bound to keep informa- tion the information confidential. If you don’t object, I will not tell you about these consultations un- less unless I feel that it is important to our work together. I will note all consultations in your Clinical Record. Disclosures required by health insurers or to collect overdue fees are discussed else- where in this Agreement If a patient threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her, or to contact family members or others who can help provide protection. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: If you authorization (these are involved discussed in a court proceeding and a request is made detail in the Virginia Notice Form): Judicial or Administrative Proceedings Health Oversight Request for information concerning your diagnosis and treatment, such information is protected by the social worker-client privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client in order to defend myself. If a client files a worker’s compensation claim, I must, upon appropriate request, pro- vide a copy of the client’s record to the Labor and Industrial Commission or the Work- ers’ Information Worker's Compensation Division, or the client’s employer. Claims There are some situations in which I am legally obligated to take actions, which I be- lieve believe are necessary to attempt to protect others from harm and I may have to reveal some information about a clientpatient’s treatment. These situations are unusual in my practice. If I have reasonable cause Adult and Domestic Abuse Serious Threat to suspect that a child has been Health or may be subjected to abuse or neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglect, the law requires that I file a report with Tennessee’s Department of Children’s Services. Once such a report is filed, I may be required to provide additional information. If I have reasonable cause to suspect that an elderly or disabled adult presents a like- lihood of suffering serious physical harm and is in need of protective services, the law requires that I file a report with Adult Protective Services. Once such a report is filed, I may be required to provide additional information. If I believe that it is necessary to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by the client on him/her- self or another person, I may be required to take protective action. These actions may include, and/or initiating hospitalization and/or contacting the potential victim, and/or the police and/or the client’s family. Safety Child Abuse If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records The laws governing confidentiality can be quite complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. PROFESSIONAL RECORDS You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets the form of professional records. One set constitutes your a Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure is reasonably likely circumstances that involve danger to endanger you and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harmyourself, you may examine and/or receive a copy of your Clinical Record, Record if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a reasonable copying fee of 35 cents per page (and for certain other expenses). The exceptions to this policy are contained in the attached Virginia Notice Form. If I refuse your request for access to your Clinical RecordsRecord, you have a right of review, which I will discuss with you upon your request. In additionMINORS & PARENTS Children of any age have the right to independently consent to and receive mental health treatment without parental consent and, in that situation, information about that treatment cannot be disclosed to anyone without the child’s agreement. While privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, parental involvement is also essential to successful treatment, particularly with younger children and this requires that some private information be shared with parents. Generally, I request an agreement between my patient and his/her parents allowing me to share general information about the progress of the child’s treatment and his/her attendance at scheduled sessions. I will also keep provide parents with a set summary of Psychotherapy Notestheir child’s treatment when it is complete. These Notes are for Any other communication will require the child’s authorization, unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify the parents of my own use and are designed to assist me in providing you concern. Before giving parents any information, I will discuss the matter with the best treatment. While the contents of Psychotherapy Notes vary from client to clientchild, they can include the con- tents of our conversations, my analysis of those conversationsif possible, and how do my best to handle any objections he/she may have. BILLING AND PAYMENTS You will be expected to pay for each session (by check or cash) at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they impact are requested. In circumstances of unusual financial hardship, I may be willing to negotiate a fee adjustment or payment installment plan. If your therapyaccount has not been paid for more than 60 days I will add a Late Fee of $15.00 for every month the account goes unpaid. They I also contain particularly sensitive have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require me to disclose otherwise confidential information. In most collection situations, the only information that you may reveal to me that I release regarding a patient’s treatment is not required to his/her name, the nature of services provided, and the amount due. If such legal action is necessary, its costs will be included in the claim. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your Clinical Recordtreatment. [They also include in- formation from others provided If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to me confidentially.] These Psychotherapy Notes which you are kept separate entitled; however, you (not your insurance company) are responsible for full payment of my fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your Clinical Recordinsurance company. Your Psychotherapy Notes Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services. These plans are not available often limited to you short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in short-term therapy, some patients feel that they need more services after insurance benefits end. You should also be aware that your contract with your health insurance company requires that I provide it with information relevant to the services that I provide to you. I am required to provide a clinical diagnosis and cannot be sent brief substantiation of that diagnosis. Sometimes I am required to anyone elseprovide additional clinical information. This information is limited to the dates of treatment and a brief description of the services provided, including the type of therapy provided. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies without your writtenclaim to keep such information confidential, signed AuthorizationI have no control over what they do with it once it is in their hands. Insurance companies cannot require your authorization as a condition of coverage nor penalize By signing this Agreement, you in any way for your refusal to agree that I can provide it. Patient Rights HIPAA provides you with several new or expanded rights with regard requested information to your Clinical Records and disclosures of protected health information. These rights include:carrier.
Appears in 1 contract
Samples: Patient Services Agreement
Meetings. I normally conduct an evaluation that will last from 1-2 two to four sessions. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If therapy has begun, psychotherapy is begun I will usually schedule one 45-45 minute ses- sion session (one appointment hour of 45 minutes duration) per week at a time we agree on, although some sessions may be longer or more frequent. Once an appointment hour is scheduled, you will be expected to pay for it un- less unless you provide 24-forty eight hours advanced (two days) advance notice of cancellation. It is important If you find that you must cancel an appointment, and forty eight hours advance notice has been given, you may, on request, be offered a make-up session prior to note that insurance companies do not provide reimbursement for cancelled sessionsyour next usual appointment, as my schedule permits. Professional Fees My hourly fee varies depending on services and durationis currently $350.00. In addition to weekly ap- pointmentsappointments, I charge this amount for other professional services you may need. How- ever, though I will break down prorate the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services include report writingthe writing of reports, letters and affidavits, telephone conversations lasting longer than 10-minutesconferences and other calls made on your behalf, Skype appoint- ments or check-ins, consulting consultations with other professionals with your permission, prepar- ing preparation of treatment records or treatment summaries, and the time spent performing any other ser- vices service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, as well as the cost of any legal representation I may incur, even if I am called to testify by another party. Be- cause of Due to the difficulty complexity of legal involvement, I charge my current fee is $500 700.00 per hour for preparation and attendance at any legal proceedingsproceeding. Contacting Me Due to the nature of my work schedulework, I am often not immediately available by telephone. While I am usually in my office four days a weekdaily, I probably will not answer the phone telephone when I am with a clientpatient. When I am unavailable, my telephone is answered by a voice mail system that I monitor frequently. I will make every effort to return your call by the end of my business day, with the exception of weekends and holidayspromptly. If you are difficult to reach, please inform me of some times when you will be available. If you are unable to reach me and you feel that you can’t cannot wait for me to return your call, contact your family physician, go to the nearest hospital emergency room and ask for the psychologist or psychiatrist on call, or call 911. If In the unlikely event that I will be unavailable for an extended timeperiod, I you will provide you be provided with the name of contact information for a colleague contactor associate, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of On Confidentiality The law protects the privacy of all communications between a client patient and a therapistpsychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, ad- xxxxx advance consent. Your signature on this Agreement agreement provides consent for those activities, as follows: • I may occasionally find it helpful to consult other health and mental health profes- sionals professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my clientpatient. The other professionals are also legally bound to keep informa- tion the information confidential. If you don’t do not object, I will not tell you about these consultations un- less unless I feel that it is important to our work together. together I will note all consultations in your Clinical Recordclinical record ( which is called “PHI” in my Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information). • You should be aware that I practice with other mental health professionals and that I employ administrative staff. In some cases, I need to share protected information with these individuals for both clinical and administrative purposes, such as billing. All of the mental health professionals are bound by the same rules of confidentiality. All staff members have been given training about protecting privacy and have agreed not to release any information outside of the practice without the permission of a professional staff member. • Disclosures required by health insurers or to collect overdue fees are discussed else- where elsewhere in this Agreement. • If a patient threatens to harm herself/himself, I may be obligated to seek hospitalization for her/him, or to contact family members or others who can provide protection. There are some other situations where I am permitted or required to disclose information without either your consent or Authorization: • If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatmentthe professional services that I provided you, such information is protected by the social workerpsychologist-client patient privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, authorization or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. • If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. • If a client patient files a complaint or lawsuit against me, I may disclose relevant information regarding that client patient in order to defend myself. • If a client files a I am providing treatment for conditions directly related to worker’s compensation claim, I mustmay have to submit such records, upon appropriate request, pro- vide a copy to Chairman of the clientWorker’s record to Compensation Board on such forms and at such times as the Labor and Industrial Commission or the Work- ers’ Compensation Division, or the client’s employerchairman may require. There are some situations in which I am legally obligated to take actions, which I be- lieve believe are necessary to attempt to protect others from harm and I may have to reveal some information about a clientpatient’s treatment. These situations are unusual are, however, unusual: • If I receive information in my practice. If I have professional capacity from a child or the parents or guardians or other custodian of a child that gives me reasonable cause to suspect that a child has been is an abused or may be subjected to abuse or neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglectneglected child, the law requires that I file a report with Tennessee’s Department to the appropriate governmental agency, usually the statewide central register of Children’s Serviceschild abuse and maltreatment, or the local child protective services office. Once such a report is filed, I may be required to provide additional information. • If I have reasonable cause to suspect that a patient communicates an elderly or disabled adult presents a like- lihood immediate threat of suffering serious physical harm and is in need of protective services, the law requires that I file a report with Adult Protective Services. Once such a report is filed, I may be required to provide additional information. If I believe that it is necessary to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by the client on him/her- self or another personan identifiable victim, I may be required to take protective actionactions. These actions may include, and/or initiating hospitalization and/or contacting include notifying the potential victim, and/or contacting the police and/or police, or seeking hospitalization for the client’s familypatient. If such a situation arises, I will make every effort to fully discuss it with you you, before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. The laws governing confidentiality can be quite complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. Professional Records You should be aware that, pursuant to HIPAA, The laws and standards of my profession require that I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure is reasonably likely circumstances that involve danger to endanger you yourself and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that where information puts the other person at risk of substantial harmhas been supplied to me confidentially by others, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, reason I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of 35 cents per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I may refuse your request for access to your Clinical Records, you records. You have a right to a review of reviewmy decision, however, which I will discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents of our conversations, my analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentially.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures disclosure of protected health information. These rights include:include requesting that I amend your record; requesting restrictions on what information from your Clinical Records is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and my privacy policies and procedures. I will discuss any of these rights with you upon your request. Minors & Parents Patients under 18 years of age who are not emancipated and their parents should be aware that the law may allow parents to examine their child’s treatment records. Even where parental consent is given, children over age 12 may have the right to control access to their treatment records. While privacy in psychotherapy is very important, particularly with teenagers, parental involvement is also essential to successful treatment, particularly with younger children. For children age 12 and over, I request an agreement between my patient and her/his parents allowing me to share general information about the progress of the child’s treatment and her/his attendance at scheduled sessions. Any other communications will require the child’s Authorization, unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the child, if possible, and do my best to handle any objections she/he may have. Billing and Payments You will be expected to pay for each session at the time it is held. Payment schedules for other services will be arranged as needed. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure payment. This may involve employing the services of a collection agency or utilizing small claims court which will require that I disclose otherwise confidential information. In most collection situations, the only information released regarding a patient's treatment is her/his name, the nature of the services provided, and the amount due, including any costs incurred in the process. Insurance Reimbursement In order to set realistic treatment goals and priorities, it is essential to evaluate resources available to pay for your treatment. If you have health insurance, it will usually provide some mental health coverage. I will provide invoices and assistance in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of all fees. It is important, therefore, that you determine exactly what mental health services your insurance policy covers. In this regard, carefully read the section in your insurance policy describing mental health services, and call your plan administrator if you have any questions. Of course, I will provide you with information based upon my experience and will assist you in understanding information you receive from your insurer, if necessary. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require authorization before they provide reimbursement. These plans are often limited to short-term treatment approaches to work out specific problems that interfere with a person’s usual level of functioning. It may therefore, be necessary to obtain approval for more therapy after a certain number of sessions. While much can be accomplished in short-term therapy, patients often feel that they require additional services after insurance benefits have been exhausted. You should be aware that your contract with your health insurance company requires that I provide information relevant to the services I provide you. I am required to provide a clinical diagnosis. Sometimes additional information is required. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purposes requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases they may share the information with a national medical information database. I will apprise you of any request and/or submission I make, if you request it. By signing this Agreement, you agree that I can provide information to your carrier.
Appears in 1 contract
Samples: Services Agreement
Meetings. I normally conduct an evaluation that will last from 1-2 to 3 sessions. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If therapy has psychotherapy is begun, I will usually initially schedule one 4550-minute ses- sion session (one appointment hour of 50 minutes duration) per week at a time we agree on. As therapy progresses, although some sessions we may be longer or more frequentmutually agree to meet less frequently. Once an appointment hour is scheduled, you will be expected to pay for it un- less unless you provide 24-24 hours advanced advance notice of cancellationcancellation [unless we both agree that you were unable to attend due to circumstances beyond your control]. It is important to note that insurance companies do not provide reimbursement for cancelled sessions. Professional Fees Repeated no-shows or late cancellations may be cause to terminate therapy. PROFESSIONAL FEES My hourly fee varies depending on services psychotherapy fees are: $185 for the initial visit and duration$165/session (50-minute) for subsequent visits. In addition to weekly ap- pointmentsscheduled appointments, I it is my practice to charge this amount on a pro-rated basis for other professional services you may need. How- ever, I will break down the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services include such as report writing, telephone conversations lasting longer than 10-10 minutes, Skype appoint- ments or check-ins, consulting with other professionals with your permission, prepar- ing preparation of records or treatment summaries, and the time spent performing any other ser- vices service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Be- cause of the Due to complexity and difficulty of legal involvement, I charge $500 175 per hour for preparation and attendance at any legal proceedingsproceeding. Contacting Me You will be expected to pay in full for each session at the time it is held, unless we have reached a prior agreement or you have an insurance coverage which requires another arrangement. In the rare case that your account becomes more than 60 days in arrears and suitable arrangements have not been agreed to, I have the option of using legal means to secure payment, including collection agencies or small claims court. You will be assessed the cost of bringing that proceeding. I strongly encourage you to talk with me directly if you are having financial difficulties so that we can work out a suitable plan. CONTACTING ME Due to my work schedule, I am often not immediately available by telephone. While I am usually in my office four days a weekbetween 9 AM and 5 PM, I probably will not answer the phone when I am with a clientpatient except in cases of a valid emergency. When I am unavailable, my telephone is routed to a confidential voice mail that I monitor frequently during office hours. I will make every effort to return your call by on the end of my business daysame day you make it, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. In after hour emergencies, you can try me at my home number (provided on my voice mail message). If you are unable to reach me and you feel that you can’t wait for me to return your call, contact your family physician, physician or the nearest emergency room and ask for the psychologist or psychiatrist on call, or call 911. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client patient and a therapistpsychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, ad- xxxxx advance consent. Your signature on this Agreement provides consent for those activities, as follows: I may occasionally find it helpful to consult other health and mental health profes- sionals professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my clientpatient. The other professionals are also legally bound to keep informa- tion the information confidential. If you don’t object, I will not tell you about these consultations un- less unless I feel that it is important to our work together. I will note all consultations in your Clinical RecordRecord (which is called “PHI” in my Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information). You should be aware that I employ a part-time administrative staff person. In most cases, I need to share protected information with this individual for purposes such as scheduling and billing. My phones are answered by Shared Secretarial staff in the Tidewater office building. All staff have been given training about protecting your privacy and have agreed not to release any information outside of the practice. Disclosures required by health insurers or to collect overdue fees are discussed else- where elsewhere in this Agreement. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatmentthe professional services I provided you, such information is protected by the social workerpsychologist-client patient privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. If a government agency is requesting the information for health oversight activities, I may be am required to provide it for to them. If a client patient files a complaint or lawsuit against me, I may disclose relevant information regarding that client patient in order to defend myself. If I am treating a client patient who files a worker’s workers’ compensation claim, I mustmay, upon appropriate request, pro- vide a copy of the client’s record be required to provide otherwise confidential information to the Labor and Industrial Commission or patient’s employer, the Work- ers’ Compensation Divisioninsurer, or the client’s employerWorkers’ Compensation Commission. There are some situations in which I am legally obligated to take actions, which I be- lieve believe are necessary to attempt to protect others from harm and I may have to reveal some information about a clientpatient’s treatment. These situations are unusual in my practice. If I have reasonable cause receive information that gives me reason to suspect believe that a child child’s physical or mental health or welfare has been or may be subjected to adversely affected by abuse or neglect, or by acts or omissions that would be abuse or neglect if committed by a parent or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglectother caretaker, the law requires that I file a report with Tennessee’s the county Department of Children’s Social Services. If I believe that a child has been or may be abused or neglected by any other person, I must report that to the appropriate law enforcement agency. Once such a report is filed, I may be required to provide additional information. If I have reasonable cause reason to suspect believe that an elderly a vulnerable adult has been or disabled adult presents a like- lihood of suffering serious physical harm and is in need of protective serviceslikely to be abused, neglected, or exploited, the law requires that I file a report with to the Adult Protective ServicesServices Program. Once such a report is filed, I may be required to provide additional information. If I believe that it is necessary to disclose information to protect against a patient presents a clear and substantial risk of imminent imminent, serious harm being inflicted by the client on him/her- self or another personto another, I may be required to take protective action. These actions may include, and/or initiating hospitalization and/or contacting including notifying the potential victim, contacting the police, and/or seeking hospitalization for the police and/or patient. If a patient threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her, or to contact family members or others who can help provide protection. If a patient reveals his or her intent to commit a crime, I may be required to take preventative action, such as calling the client’s familypolice. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records You should The laws governing confidentiality can be aware thatquite complex, pursuant and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. I believe for the therapy process to HIPAAbe most effective that it is imperative that the process include a safe, confidential atmosphere. Therefore, it is my policy to ask you to agree in advance to NOT request my records or testimony in the event of any legal proceedings unless we have mutually agreed to this in advance of therapy starting or unless one of the above exceptions occur. By signing this agreement, you are agreeing to abide by this. PROFESSIONAL RECORDS The laws and standards of my profession require that I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in unusual circumstances that involve danger to yourself and/or others or where information has been supplied to me confidentially by others, or the unusual circumstance where disclosure record makes reference to another person (unless such other person is a health care provider) and I believe that access is reasonably likely to endanger you and/or others or when another individual (cause substantial harm to such other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harmperson, you may examine and/or receive a copy of your Clinical Record, Record if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of 35 20 cents per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Recordsrecords, you have a right of review, review (except for information supplied to me confidentially by others) which I will discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents of our conversations, my analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentially.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights PATIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your Clinical Records Record and disclosures of protected health information. These rights include:include requesting that I amend your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights with you. MINORS & PARENTS Patients under 18 years of age who are not emancipated and their parents should be aware that the law allows parents to examine their child’s Clinical Records, unless I decide that such access is likely to injure the child, or we agree otherwise. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is sometimes my policy to request an agreement from parents that they consent to give up their access to their child’s records. If they agree, during treatment, I will provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. I will also provide parents with a summary of their child’s treatment when it is complete. Any other communication will require the child’s Authorization, unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it may provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company. Please note that I am not a “participating provider” with any HMO or PPO insurance plans. Therefore, you will be responsible for paying for my fee at the time of the visit, and then you will receive a form which will allow you to file for benefits with your insurance company. You should also be aware that your contract with your health insurance company requires that I provide it with information relevant to the services that I provide to you. I am required to provide a clinical diagnosis. Sometimes I am required to provide additional clinical information such as treatment plans or summaries. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier. YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS AND ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPAA NOTICE FORM DESCRIBED ABOVE. signature of client date signature of client (if marital/couples therapy) date signature of parent (if minor is client) date South Carolina provides the consumer the opportunity to file inquiries with its Board of Examiners in Psychology. Board offices may be reached at: South Carolina Board of Examiners in Psychology PO Box 11329
Appears in 1 contract
Samples: Patient Services Agreement
Meetings. I normally We usually conduct an evaluation that will last from 1-2 one to two sessions. During this time, we can both decide if I am we are the best person to provide the services you need in order to meet your treatment goals. If therapy has psychotherapy is begun, I we will usually schedule one 45-minute ses- sion per appointment every other week at a time we agree on, although some sessions may be longer more or more less frequent. CANCELLATION POLICY Note: Please Read and Sign Once an appointment hour is scheduled, you will be expected to pay for it un- less if you provide 24-hours advanced notice of cancellationdo not cancel by 5pm the day before your scheduled appointment. It is important For appointments scheduled for a Monday, you must notify us by the Friday before by 5pm to note avoid the $180 cancellation fee. You will be expected to pay for that yourself as insurance companies do not allow us to charge for missed appointments (i.e., No show or Late (same day) cancel fees). You will be expected to pay that fee in full prior to or at your next appointment. We have a very busy practice and many patients that want to be seen. Please afford others the same courtesy you would want as they may be waiting for someone to cancel. Without prior notice, we are unable to fill your time. If it is possible, we will try to find another time to reschedule the appointment that week but you will still be responsible for the missed appointment fee of $180. Thank you for your understanding of and respect for this policy. I understand this policy and have had the opportunity to ask questions. I agree to personally pay $180 for any appointment where I fail to provide reimbursement for cancelled notice as described above. Signature/Date Reasonable Exceptions: Weather Related (e.g., severe weather advisories); Unexpected Family Emergencies; Physical Illness where you did not go to work or school as a result; Automobile Accidents or other potential circumstances beyond your control that we BOTH discuss and agree on a case by case basis. Please Turn to Page 3 While sometimes things do happen such as mandatory work meetings; child care issues; transportation problems, etc., it will be to your personal and financial benefit to make your therapy a priority and carve out that time in your day to minimize or eliminate blocks to attending your sessions. Professional Fees My hourly Unfortunately, the late cancellation penalty cannot be waived for these types of reasons. PROFESSIONAL FEES Our fee varies depending on services is $180 for psychotherapy visits (typically a 40-45 minute appointment, as described above) and duration$200 for an intake evaluation. In addition to weekly ap- pointmentsappointments, I we charge this amount for other professional services you may need. How- ever, I though we will break down down, at our discretion, the hourly cost if I we work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services include report writing, telephone conversations lasting longer than 10-a few minutes, Skype appoint- ments or checkresponses to lengthy e-ins, mails; consulting with other professionals with your permission, prepar- ing preparation of records or treatment summaries, and the time spent performing any other ser- vices service you may request of meus. Please see fees and options for therapy services done outside of a face to face appointment. NOTE: IF YOU ARE INVOLVED IN LEGAL PROCEEDINGS If you become involved in legal proceedings that require my our participation, you will be expected to pay for all of my our professional time, including preparation preparation, travel time and transportation costs, and time waiting to appear, even if I am we are called to testify by another party. Be- cause Since everything is confidential, we only would be called to testify if you made it known that you were seeing us. Thus, involving us in the process. Because of the difficulty of legal involvement, I we charge $500 per hour for preparation and attendance at any legal proceedingsproceeding. Contacting Me CONTACTING US Due to my our work scheduleschedules, I am often we are not immediately available by telephone. While I am usually in my office four days a week, I probably will We do not answer the phone when I am with a clientdirectly. I Our telephone is answered by voicemail. We will typically make every effort to return your call by on the end of my business daysame day you make it, with the exception of weekends and holidays. If you are difficult to reach, please inform me us of some times when you will be availableavailable and provide several numbers. Calls are often returned late into the evening so if there is a time before or after which you do not want to be called, please make that known. Note that routine matters such as scheduling may take up to 24 hours to return calls. Please Turn To Page 4 If you are unable to reach me us and you feel that you can’t wait for me us to return your call, contact your family physician, the nearest emergency room and ask for the psychologist or psychiatrist on call, or call 911. If I it is a life-threatening emergency after business hours and we are unavailable, please call 911 or go to your nearest hospital emergency room. If we will be unavailable for an extended time, I we will provide you with the name of a colleague to contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality LIMITS ON CONFIDENTIALITY The law generally protects the privacy of all communications between a client patient and a therapistpsychologist. In most situations, I we can only release information about your treatment to others if you sign a written Authorization Form authorization form that meets certain legal requirements imposed by HIPAA. HIPAA does allow us, however, to provide certain of your confidential information for treatment, payment or healthcare operations. There are other situations that require only that you provide where, we like to obtain your written, ad- xxxxx advance consent. Your signature on this Agreement provides consent for those activities, as follows: I • We may occasionally find it helpful to consult other health and mental health profes- sionals professionals about a case. During a consultation, I we make every effort to avoid revealing the identity of my clientour patient. The other professionals are also legally bound to keep informa- tion the information confidential. If you don’t object, I we will not tell you about these consultations un- less I unless we feel that it is important to our work together. I We will note all consultations in your Clinical RecordRecord (which is called “PHI” in our Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information). • You should be aware that we sometimes practice with other mental health professionals and that we may contract with administrative staff. In most cases, we need to share protected information with these individuals for both clinical and administrative purposes, such as scheduling, billing and quality assurance. All of the mental health professionals are bound by the same rules of confidentiality. All staff members have been given training about protecting your privacy and have agreed not to release any information outside of the practice without the permission of a professional staff member. • Disclosures required by health insurers or to collect overdue fees are discussed else- where elsewhere in this Agreement. There are some situations where I am we are permitted or required to disclose information without either your consent or Authorization: • If you are involved in a court proceeding and a request is made for information concerning your evaluation, diagnosis and or treatment, such information is generally protected by the social workerpsychologist-client patient privilege law. I We cannot typically provide any information without your (or your personal or legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me Please Turn To Page 5 us to disclose information. If you are coming for marital/couple therapy BOTH individuals must consent to the release of a record. • If a government agency is requesting the information for health oversight activities, I we may be required to provide it for them. • If a client patient files a complaint or lawsuit against meone of us, I we may disclose relevant information regarding that client patient in order to defend myselfourselves. • If a client patient files a worker’s compensation claim, I mustthe patient must execute a release so that we may release the information, upon appropriate request, pro- vide a copy of the client’s record records or reports relevant to the Labor and Industrial Commission or the Work- ers’ Compensation Division, or the client’s employerclaim. There are some situations in which I am we may be legally obligated or allowed to take actionsaction and in those situations, which I be- lieve we believe are necessary to attempt to protect others from harm and I we may have to reveal some confidential information about a client’s treatmentpatient. These situations are unusual in my practice. If I have reasonable cause to suspect that a child has been or may be subjected to abuse or neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglect, the law requires that I file a report with Tennessee’s Department of Children’s Services. Once such a report is filed, I may be required to provide additional information. If I have reasonable cause to suspect that an elderly or disabled adult presents a like- lihood of suffering serious physical harm our practices and is in need of protective services, the law requires that I file a report with Adult Protective Services. Once such a report is filed, I may be required to provide additional information. If I believe that it is necessary to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by the client on him/her- self or another person, I may be required to take protective action. These actions may include, and/or initiating hospitalization and/or contacting the potential victim, and/or the police and/or the client’s family. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure is reasonably likely to endanger you and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harm, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of 35 cents per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Records, you have a right of review, which I will discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents of our conversations, my analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentially.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes but are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights includenecessarily limited to:
Appears in 1 contract
Samples: www.docrich.com
Meetings. I normally We usually conduct an evaluation that will last from 1-2 one to two sessions. During this time, we can both decide if I am we are the best person to provide the services you need in order to meet your treatment goals. If therapy has psychotherapy is begun, I we will usually schedule one 45-minute ses- sion per appointment every other week at a time we agree on, although some sessions may be longer more or more less frequent. CANCELLATION POLICY Note: Please Read and Sign Once an appointment hour is scheduled, you will be expected to pay for it un- less if you provide 24-hours advanced notice of cancellationdo not cancel by 5pm the day before your scheduled appointment. It is important For appointments scheduled for a Monday, you must notify us by the Friday before by 5pm to note avoid the $200 cancellation fee. You will be expected to pay for that yourself as insurance companies do not allow us to charge for missed appointments (i.e., No show or Late (same day) cancel fees). You will be expected to pay that fee in full prior to or at your next appointment. We have a very busy practice and many patients that want to be seen. Please afford others the same courtesy you would want as they may be waiting for someone to cancel. Without prior notice, we are unable to fill your time. If it is possible, we will try to find another time to reschedule the appointment that week but you will still be responsible for the missed appointment fee of $200. Thank you for your understanding of and respect for this policy. I understand this policy and have had the opportunity to ask questions. I agree to personally pay $200 for any appointment where I fail to provide reimbursement for cancelled notice as described above. Signature/Date Reasonable Exceptions: Weather Related (e.g., severe weather advisories); Unexpected Family Emergencies; Physical Illness where you did not go to work or school as a result; Automobile Accidents or other potential circumstances beyond your control that we BOTH discuss and agree on a case by case basis. Please Turn to Page 3 While sometimes things do happen such as mandatory work meetings; child care issues; transportation problems, etc., it will be to your personal and financial benefit to make your therapy a priority and carve out that time in your day to minimize or eliminate blocks to attending your sessions. Professional Fees My hourly Unfortunately, the late cancellation penalty cannot be waived for these types of reasons. PROFESSIONAL FEES Our fee varies depending on services is $200 for psychotherapy visits (typically a 40-45 minute appointment, as described above) and duration$220 for an intake evaluation. In addition to weekly ap- pointmentsappointments, I we charge this amount for other professional services you may need. How- ever, I though we will break down down, at our discretion, the hourly cost if I we work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services include report writing, telephone conversations lasting longer than 10-a few minutes, Skype appoint- ments or checkresponses to lengthy e-ins, mails; consulting with other professionals with your permission, prepar- ing preparation of records or treatment summaries, and the time spent performing any other ser- vices service you may request of meus. Please see fees and options for therapy services done outside of a face to face appointment. NOTE: IF YOU ARE INVOLVED IN LEGAL PROCEEDINGS If you become involved in legal proceedings that require my our participation, you will be expected to pay for all of my our professional time, including preparation preparation, travel time and transportation costs, and time waiting to appear, even if I am we are called to testify by another party. Be- cause Since everything is confidential, we only would be called to testify if you made it known that you were seeing us. Thus, involving us in the process. Because of the difficulty of legal involvement, I we charge $500 per hour for preparation and attendance at any legal proceedingsproceeding. Contacting Me CONTACTING US Due to my our work scheduleschedules, I am often we are not immediately available by telephone. While I am usually in my office four days a week, I probably will We do not answer the phone when I am with a clientdirectly. I Our telephone is answered by voicemail. We will typically make every effort to return your call by on the end of my business daysame day you make it, with the exception of weekends and holidays. If you are difficult to reach, please inform me us of some times when you will be availableavailable and provide several numbers. Calls are often returned late into the evening so if there is a time before or after which you do not want to be called, please make that known. Note that routine matters such as scheduling may take up to 24 hours to return calls. Please Turn To Page 4 If you are unable to reach me us and you feel that you can’t wait for me us to return your call, contact your family physician, the nearest emergency room and ask for the psychologist or psychiatrist on call, or call 911. If I it is a life-threatening emergency after business hours and we are unavailable, please call 911 or go to your nearest hospital emergency room. If we will be unavailable for an extended time, I we will provide you with the name of a colleague to contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality LIMITS ON CONFIDENTIALITY The law generally protects the privacy of all communications between a client patient and a therapistpsychologist. In most situations, I we can only release information about your treatment to others if you sign a written Authorization Form authorization form that meets certain legal requirements imposed by HIPAA. HIPAA does allow us, however, to provide certain of your confidential information for treatment, payment or healthcare operations. There are other situations that require only that you provide where, we like to obtain your written, ad- xxxxx advance consent. Your signature on this Agreement provides consent for those activities, as follows: I • We may occasionally find it helpful to consult other health and mental health profes- sionals professionals about a case. During a consultation, I we make every effort to avoid revealing the identity of my clientour patient. The other professionals are also legally bound to keep informa- tion the information confidential. If you don’t object, I we will not tell you about these consultations un- less I unless we feel that it is important to our work together. I We will note all consultations in your Clinical RecordRecord (which is called “PHI” in our Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information). • You should be aware that we sometimes practice with other mental health professionals and that we may contract with administrative staff. In most cases, we need to share protected information with these individuals for both clinical and administrative purposes, such as scheduling, billing and quality assurance. All of the mental health professionals are bound by the same rules of confidentiality. All staff members have been given training about protecting your privacy and have agreed not to release any information outside of the practice without the permission of a professional staff member. • Disclosures required by health insurers or to collect overdue fees are discussed else- where elsewhere in this Agreement. There are some situations where I am we are permitted or required to disclose information without either your consent or Authorization: • If you are involved in a court proceeding and a request is made for information concerning your evaluation, diagnosis and or treatment, such information is generally protected by the social workerpsychologist-client patient privilege law. I We cannot typically provide any information without your (or your personal or legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me Please Turn To Page 5 us to disclose information. If you are coming for marital/couple therapy BOTH individuals must consent to the release of a record. • If a government agency is requesting the information for health oversight activities, I we may be required to provide it for them. • If a client patient files a complaint or lawsuit against meone of us, I we may disclose relevant information regarding that client patient in order to defend myselfourselves. • If a client patient files a worker’s compensation claim, I mustthe patient must execute a release so that we may release the information, upon appropriate request, pro- vide a copy of the client’s record records or reports relevant to the Labor and Industrial Commission or the Work- ers’ Compensation Division, or the client’s employerclaim. There are some situations in which I am we may be legally obligated or allowed to take actionsaction and in those situations, which I be- lieve we believe are necessary to attempt to protect others from harm and I we may have to reveal some confidential information about a client’s treatmentpatient. These situations are unusual in my practice. If I have reasonable cause to suspect that a child has been or may be subjected to abuse or neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglect, the law requires that I file a report with Tennessee’s Department of Children’s Services. Once such a report is filed, I may be required to provide additional information. If I have reasonable cause to suspect that an elderly or disabled adult presents a like- lihood of suffering serious physical harm our practices and is in need of protective services, the law requires that I file a report with Adult Protective Services. Once such a report is filed, I may be required to provide additional information. If I believe that it is necessary to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by the client on him/her- self or another person, I may be required to take protective action. These actions may include, and/or initiating hospitalization and/or contacting the potential victim, and/or the police and/or the client’s family. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure is reasonably likely to endanger you and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harm, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of 35 cents per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Records, you have a right of review, which I will discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents of our conversations, my analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentially.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes but are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights includenecessarily limited to:
Appears in 1 contract
Samples: www.docrich.com
Meetings. I normally conduct an evaluation that will last from 1-1 to 2 sessions. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If we decide to proceed with therapy has begunwe would schedule appointments at whatever frequency we decide on (e.g. weekly, I will usually schedule one 45-minute ses- sion per week biweekly, monthly). Sessions are 50 or 90 minutes long. PROFESSIONAL FEES Fees are normally collected at a time we agree on, although some sessions the end of each session and receipts are available. If you have extended health benefits you can submit your receipts for direct reimbursement from your insurer. It may be longer or more frequent. Once an appointment hour is scheduled, you will be expected your responsibility to pay for it un- less you provide 24-hours advanced notice of cancellation. It is important to note that insurance companies do not provide pursue reimbursement for cancelled sessions. Professional Fees My hourly fee varies depending on services and durationfrom your insurer. In addition to weekly ap- pointments, I charge this amount appointment fees you will be billed at the above mentioned hourly rate for other professional services you may need. How- ever, I will break down the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services include need such as report writing, completion of insurance forms, telephone conversations lasting longer or email communication which accumulates to more than 10-minutesten minutes over the course of a week, Skype appoint- ments or check-ins, consulting attendance at meetings with other professionals with your permissionyou have authorized, prepar- ing preparation of records or treatment summaries, and the time spent performing any other ser- vices service you may request of me. My cancellation policy requires 24 hours notice. If you become involved in legal proceedings that require my participation, miss an appointment without providing notice you will may be expected to pay billed for all of my professional time, including preparation and transportation costs, even if the missed session. CONTACTING ME I am called to testify by another party. Be- cause of the difficulty of legal involvement, I charge $500 per hour for preparation and attendance at any legal proceedings. Contacting Me Due to my work schedule, I am often not usually available immediately available by telephone. While I am usually in monitor my office four days a week, I probably voice mail messages regularly throughout the day and will not answer the phone when I am with a client. I will make every effort to return your call by the end of my business day, with the exception of weekends and holidaysas soon as I am able. If you are difficult to reach, please inform me of some leave times and numbers when you will be available. If you are unable to reach me and you feel that you can’t wait for me to return your callI do not normally make calls or check messages on evenings, contact your family physician, the nearest emergency room and ask for the psychologist weekends or psychiatrist on call, or call 911. If I will be unavailable for an extended time, I will provide you with the name of a colleague contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality The law protects the privacy of all communications between a client and a therapist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, ad- xxxxx consent. Your signature on this Agreement provides consent for those activities, as follows: I may occasionally find it helpful to consult other health and mental health profes- sionals about a case. During consultation, I make every effort to avoid revealing the identity of my client. The other professionals are also legally bound to keep informa- tion confidential. If you don’t object, I will not tell you about these consultations un- less I feel that it is important to our work together. I will note all consultations in your Clinical Record. Disclosures required by health insurers or to collect overdue fees are discussed else- where in this Agreement. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the social worker-client privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court orderholidays. If you are involved in or contemplating litigationcalling and it is an emergency, you should consult are welcome to use my home number if we have pre-arranged this as part of a safety plan. Otherwise, you can contact your family doctor or a crisis service. See below for some crisis service phone numbers. Assaulted Woman’s Helpline (000) 000-0000 Sexual Assault Centre London Crisis Line (000) 000-0000 Kids Help Phone (000) 000-0000 London Distress Centre (000) 000-0000 London and Middlesex Mental Health Crisis Service (000) 000-0000 You have the right to ask questions about anything that happens in therapy. I’m always willing to discuss how and why I’ve decided to do what I’m doing and look for alternatives that might work better. You can feel free to ask me to try something that you think will be helpful. You are free to leave therapy at any time. If either of us feel I do not have the skills or expertise to help with your attorney to determine whether a court would particular problem I will be likely to order me to disclose information. If a government agency is requesting the information for health oversight activities, I may be required pleased to provide it for themyou with names of other local professionals. If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client in order to defend myself. If a client files a worker’s compensation claim, I must, upon appropriate request, pro- vide a copy of the client’s record to the Labor and Industrial Commission or the Work- ers’ Compensation Division, or the client’s employer. LIMITS OF THERAPY There are some situations in circumstances under which I am legally obligated may choose to take actionsterminate therapy. Therapy will be terminated if there are any verbal or physical threats or acts of violence/harassment towards the office, which I be- lieve are necessary to attempt to protect others from harm and I may have to reveal some information about a client’s treatmentmy family or myself. These situations are unusual in my practice. If ACKNOWLEDGEMENT I have reasonable cause read this document and have had sufficient time to suspect that a child has been or may be subjected to abuse or neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglect, the law requires sure that I file a report with Tennessee’s Department of Children’s Services. Once such a report is filedhave considered it carefully, I may be required to provide additional information. If I have reasonable cause to suspect that an elderly or disabled adult presents a like- lihood of suffering serious physical harm and is in need of protective services, the law requires asked any questions that I file a report with Adult Protective Servicesneeded to, and understand it. Once such a report is filed, I may be required agree to provide additional informationabide by its terms during our professional relationship. If I believe that it is necessary Please sign here to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by the client on him/her- self or another person, I may be required to take protective action. These actions may include, and/or initiating hospitalization and/or contacting the potential victim, and/or the police and/or the client’s family. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns indicate that you may have now or in read and understood the futureabove. Professional Records You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure is reasonably likely to endanger you and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harm, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of 35 cents per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Records, you have a right of review, which I will discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents of our conversations, my analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentially.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include:Signature Date
Appears in 1 contract
Samples: www.lindalibis.com
Meetings. I normally conduct an evaluation typically meet with parent(s)/legal guardian and the son or daughter at the initial intake/consultation. At this meeting, I ask the family for detailed information about the problems that their son or daughter has been experiencing. At the end of the session, I will last from 1-2 sessions. During this time, we both decide let the family know if I am think I can be helpful given the best person to provide the services you need in order to meet your treatment goalshistory they have provided. If therapy has begunpsychotherapy commences, I will usually schedule one 45-50 minute ses- sion session (one appointment hour of 45-50 minutes duration) per week at a time we agree on, although some sessions may be longer or more frequentweek. Once an the appointment hour is scheduled, you will be expected to pay for it un- less unless you provide 24-48 hours advanced advance notice of cancellation. It PROFESSIONAL FEES The fee for the initial intake/consultation and for subsequent sessions is important to note that insurance companies do not provide reimbursement for cancelled sessions. Professional Fees My hourly fee varies depending on services and duration. In addition to weekly ap- pointments, I charge this amount for other professional services you may need. How- ever, I will break down the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services include report writing, telephone conversations lasting longer than 10-minutes, Skype appoint- ments or check-ins, consulting with other professionals with your permission, prepar- ing of records or treatment summaries, and the time spent performing any other ser- vices you may request of me$200.00. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Be- cause Because of the difficulty of legal involvement, I charge $500 400.00 per hour for preparation and attendance at any legal proceedingsproceeding. Contacting Me CONTACTING ME Due to my work schedule, I am often not immediately available by telephone. While When I am usually in unavailable you may leave a message on my office four days a week, I probably will not answer the phone when I am with a clientvoice mail at 000-000-0000. I will make every effort to return your call by the end of my business day, with the exception of weekends and holidayswithin 24 hours. If you are difficult to reach, please inform me of some times when you will be available. Please be advised that I am not in the office on Saturdays or Sundays and non-urgent messages left on those days will be returned the following Monday. If you are unable facing a life-threatening emergency, you should go to reach me and you feel that you can’t wait for me to return your call, contact your family physician, the nearest emergency room and ask for the psychologist or psychiatrist mental health professional on call. You should then leave a message for me at 000-000-0000, or call 911which I will return when I am available. If I will be unavailable for an extended timeto return emergency calls, I will provide you with the name of a colleague to contact, if necessary. You may also It is often helpful for me to utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx e-mail to communicate some information with memy clients between sessions. Limits of Confidentiality This information exchange is generally regarding logistical matters such as scheduling and appointment changes. My e-mail should not be used as a means to contact me in an emergency. I often check my e-mail more than once a day, but do not do so at specified times. Clients in a crisis situation should utilize the procedures noted above. Also, I will not utilize e-mail to conduct a therapy session. Rather I will request that the client address issues related to their therapy at the next scheduled session. LIMITS OF CONFIDENTIALITY The law protects the privacy of all communications between a client patient and a therapistpsychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, ad- xxxxx advance consent. Your signature on this Agreement agreement provides consent for those activities, as follows: I may occasionally find it helpful to consult other health and mental health profes- sionals professions about a case. During a consultation, I make every effort to avoid revealing the identity of my clientpatient. The other professionals are also legally bound to keep informa- tion the information confidential. If you don’t object, I will not tell you about these consultations un- less unless I feel that it is important to our work together. If a patient seriously threatens to harm himself/herself, I will note all consultations in your Clinical Record. Disclosures required by health insurers may be obligated to seek hospitalization for him/her, or to collect overdue fees are discussed else- where in this Agreementcontact family members or others who can help provide protection. Texas law provides that a professional may disclose confidential information only to medical or law enforcement personnel if the professional determines that there is a probability of imminent physical injury by the patient to the patient or others, or there is a probability of immediate mental or emotional injury to the patient. There are some situations where I am permitted or required to disclose information without either your consent or Authorizationauthorization: • If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the social worker-client privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. • If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. • If a client patient files a complaint or lawsuit against me, I may disclose relevant information regarding that client patient in order to defend myself. • If a client patient files a worker’s compensation claim, I must, upon appropriate requestrequest provide records relating to treatment or hospitalization for which compensation is being sought. • If a patient fails to pay for services I have rendered, pro- vide I may disclose relevant information in a copy of the client’s record to the Labor and Industrial Commission or the Work- ers’ Compensation Division, or the client’s employersuit seeking payment. There are some situations in which I am legally obligated to take actionsaction, which I be- lieve are believe is necessary to attempt to protect others from harm and I may have to reveal some information about a clientpatient’s treatment. These situations are unusual in my practice. • If I have reasonable cause to suspect believe that a child under 18 has been or may be subjected to abuse abused or neglected (including physical injury, substantial threat of harm, mental or emotional injury, or any kind of sexual contact or conduct), or that a child is a victim of a sexual offense, or that an elderly or disabled person is in a state of abuse, neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglectexploitation, the law requires that I file make a report with Tennessee’s to the appropriate governmental agency, usually the Department of Children’s Protective and Regulatory Services. Once such a report is filed, I may be required to provide additional information. • If I have reasonable cause to suspect determine that an elderly or disabled adult presents there is a like- lihood of suffering serious probability that the patient will inflict imminent physical harm and is in need of protective services, the law requires that I file a report with Adult Protective Services. Once such a report is filed, I may be required to provide additional information. If I believe that it is necessary to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by the client injury on him/her- self herself, or another personor that the patient will inflict imminent mental or emotional harm upon others, I may be required to take a protective action. These actions may include, and/or initiating action by disclosing information to medical or law enforcement personnel or by securing hospitalization and/or contacting of the potential victim, and/or the police and/or the client’s familypatient. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and and, I will limit my disclosure to what is necessary. By signing this agreement, you authorize me to contact any person/entity in a position to prevent harm to the patient or a third party if I determine there is a probability of harm to the patient or third party. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records You should The laws governing confidentiality can be aware thatquite complex and I am not an attorney. In situations where specific advice is required, pursuant to HIPAA, formal legal consultation may be needed. PROFESSIONAL RECORDS The laws and standards of my profession require that I keep Protected Health Information about you or your child in two sets of professional records. One set constitutes your Clinical Record. It The Clinical Record includes information about you or your child’s reasons for seeking therapy, a description of the ways in which your the problem impacts you or your child’s life, your the diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrierchild’s school. Except in the unusual circumstance where disclosure is reasonably likely circumstances that involve danger to endanger you yourself and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harmothers, you may examine and/or receive a copy of your Clinical Record, Record if you request it in writing. You should be aware that pursuant to Texas law, psychological test data are not part of a patient’s record. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of 35 cents $.50 per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Recordsrecords, you have a right of review, which I will discuss with you upon your request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents of our conversations, my analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentially.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights PATIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your Clinical Records Record and disclosures of protected health information. These rights include:include requesting that I amend your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of most disclosures of protect health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and my privacy policies and procedures. MINORS & PARENTS Patients under 18 years of age who are not emancipated and their parents should be aware that the law may allow parents to examine their child’s treatment records. However, if the treatment is for suicide prevention, chemical addiction or dependency, or sexual, physical or emotional abuse, the law provides that parents may not access their child’s records. For children and adolescents, because privacy in psychotherapy is often critical in building rapport with the therapist, which is crucial to successful progress, it is my policy to discuss the manner in which I will communicate with the son or daughter and the parents. This discussion will typically take place early on in therapy so that all parties are informed as to how we will work together. BILLING & PAYMENTS You will be expected to pay for each session at the time it is held, unless we agree otherwise. Payment schedules for other professional services will be agreed to when they are requested. You will be asked to pay at the end of each session. You may pay in cash, check, or credit card. You will be given a receipt that provides information an insurer would need if you decide to ask for some type of reimbursement from your carrier. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require me to disclose otherwise confidential information. In most collection situations, the only information I release regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due. If such legal action is necessary, its costs will be included in the claim. By signing this agreement, you authorize me to employ the services of an outside collection agent or attorney to seek payment of all unpaid fees. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. It is very important that you find out exactly what mental health services your insurance policy covers. Also, please note that I am not on any insurance panels. I will provide you with a receipt at time of payment that you may use to request reimbursement from your insurance carrier. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, I will be willing to call the company on your behalf. Due to rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in a short-term therapy, some patients feel that they need more services after insurance benefits end. Some managed-care plans will not allow me to provide services to you once your benefits end. If this is the case, I will do my best to find another provider who will help you continue your psychotherapy. You should also be aware that your contract with your health insurance company requires that I provide it with information relevant to the services that I provide to you. I am required to provide a clinical diagnosis. Sometimes I am required to provide additional clinical information such as treatment plans or summaries, or copies of your entire clinical record. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. By signing the Agreement, you agree that I can provide requested information to your carrier. By signing this agreement, you authorize me to provide your health insurance company with all information requested of me pertaining to the services I provide to you or your family member. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your sessions. It is important to remember that you always have the right to pay for my service yourself to avoid the problem described above. YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ABIDE BY ITS TERMS DURING OUR PROFESSIONAL RELATIONSHIP. IN ADDITION, YOUR SIGNATURE ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPAA NOTICE FORM DESCRIBED ABOVE. SIGNED Parent/Patient Date Parent/Patient Date Xxxxx Xxxxxx, Ph. D. Date Texas License#33013 Xxxxx Xxxxxx, Ph.D. 0000 Xxxxxxxxx Xxxxx Xxxxx Xxxxx 000 Dallas, Texas 75230 214.507.6370 N otice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Appears in 1 contract
Samples: Patient Services Agreement
Meetings. I normally conduct an evaluation assessment that will last from 1-2 to 3 sessions. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If therapy has psychotherapy is begun, I will usually schedule one 4550-minute ses- sion session (one appointment hour of 50 minutes duration) per week at a time we agree on, although some sessions may be longer or more frequent. Once an appointment hour is scheduled, you will be expected to pay for it un- less unless you provide 24-24 hours advanced advance notice of cancellationcancellation (unless we both agree that you were unable to attend due to circumstances beyond your control). It is important to note that insurance companies do not provide reimbursement for cancelled sessions. Professional Fees PROFESSIONAL FEES My hourly fee varies depending on services and durationis $125.00. In addition to weekly ap- pointmentsappointments, I charge this amount for other professional services you may need. How- ever, though I will break down the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services may include report writing, telephone conversations lasting longer than 10-15 minutes, Skype appoint- ments or check-ins, consulting with other professionals with your permission, prepar- ing preparation of records or treatment summaries, and the time spent performing any other ser- vices service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Be- cause Because of the difficulty of legal involvement, I charge $500 150 per hour for preparation and attendance at any legal proceedingsproceeding. Contacting Me CONTACTING ME Due to my work schedule, I am often not immediately available by telephone. My office hours are currently 8:30 AM to 5:00 PM, Monday through Friday. I also have evening hours by appointment. While I am usually in my office four days a weekduring these hours, I probably will not answer the phone when I am with a clientpatient. When I am unavailable, my telephone is answered by an answering machine that I monitor frequently. I will make every effort to return your call by on the end of my business daysame day you make it, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. If you are unable to reach me and you feel that you can’t wait for me to return your call, contact your family physician, physician or the nearest emergency room and ask for the psychologist or psychiatrist on call, or call 911. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client patient and a therapistpsychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, ad- xxxxx advance consent. Your signature on this Agreement provides consent for those activities, as follows: • I may occasionally find it helpful to consult other health and mental health profes- sionals professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my clientpatient. The other professionals are also legally bound to keep informa- tion the information confidential. If you don’t object, I will not tell you about these consultations un- less unless I feel that it is important to our work together. I will note all consultations in your Clinical Record. Disclosures required • You should be aware that I practice with other mental health professionals and that I employ administrative staff. In most cases, I need to share protected information with these individuals for both clinical and administrative purposes, such as scheduling, billing and quality assurance. All of the mental health professionals are bound by health insurers or the same rules of confidentiality. All staff members have been given training about protecting your privacy and have agreed not to collect overdue fees are discussed else- where in this Agreementrelease any information outside of the practice without the permission of a professional staff member. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: • If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatmentthe professional services I provided you, such information is protected by the social workerpsychologist-client patient privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. • If a government agency is requesting the information for health oversight activities, I may be am required to provide it for to them. • If a client patient files a complaint or lawsuit against me, I may disclose relevant information regarding that client patient in order to defend myself. • If I am treating a client patient who files a worker’s workers’ compensation claim, I mustmay, upon appropriate request, pro- vide a copy of the client’s record be required to provide otherwise confidential information to the Labor and Industrial Commission or patient’s employer, the Work- ers’ Compensation Divisioninsurer, or the client’s employerWorkers’ Compensation Commission. There are some situations in which I am legally obligated to take actions, actions which I be- lieve believe are necessary to attempt to protect others from harm and I may have to reveal some information about a clientpatient’s treatment. These situations are unusual in my practice. ▪ If I have reasonable cause receive information that gives me reason to suspect believe that a child child’s physical or mental health or welfare has been or may be subjected to adversely affected by abuse or neglect, or by acts or omissions that would be abuse or neglect if committed by a parent or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglectother caretaker, the law requires that I file a report with Tennessee’s the county Department of Children’s Social Services. If I believe that a child has been or may be abused or neglected by any other person, I must report that to the appropriate law enforcement agency. Once such a report is filed, I may be required to provide additional information. ▪ If I have reasonable cause reason to suspect believe that an elderly a vulnerable adult has been or disabled adult presents a like- lihood of suffering serious physical harm and is in need of protective serviceslikely to be abused, neglected, or exploited, the law requires that I file a report with to the Adult Protective ServicesServices Program. Once such a report is filed, I may be required to provide additional information. ▪ If I believe that it is necessary to disclose information to protect against a patient presents a clear and substantial risk of imminent imminent, serious harm being inflicted by the client on him/her- self or another personto another, I may be required to take protective action. These actions may include, and/or initiating hospitalization and/or contacting including notifying the potential victim, contacting the police, and/or seeking hospitalization for the police and/or patient. ▪ If a patient threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her, or to contact family members or others who can help provide protection. ▪ If a patient reveals his or her intent to commit a crime, I may be required to take preventative action, such as calling the client’s familypolice. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records The laws governing confidentiality can be quite complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. PROFESSIONAL RECORDS You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in unusual circumstances that involve danger to yourself and others, or others have supplied information to me confidentially by others, or the unusual circumstance where disclosure record makes reference to another person (unless such other person is a health care provider) and I believe that access is reasonably likely to endanger you and/or others or when another individual (cause substantial harm to such other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harmperson, you may examine and/or receive a copy of your Clinical Record, Record if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. I am sometimes willing to conduct this review meeting without charge. In most circumstances, I am allowed to charge a copying fee of 35 50 cents per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical RecordsRecord, you have a right of reviewreview (except for information supplied to me confidentially by others), which I will discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentially.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies companies, without your written, signed Authorizationconsent. Insurance companies cannot require your authorization Authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights PATIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your Clinical Records Record and disclosures of protected health information. These rights include:include requesting that I amend your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights with you. MINORS & PARENTS Patients under 18 years of age who are not emancipated, as well as their parents, should be aware that the law allows parents to examine their child’s Clinical Records, unless I decide that such access is likely to injure the child, or we agree otherwise. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is sometimes my policy to request an agreement from parents that they consent to give up their access to their child’s records. If they agree, during treatment I will provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. I will also provide parents with a summary of their child’s treatment when it is complete. Any other communication will require the child’s Authorization, unless I feel that the child is in danger or is a danger to someone else, in which case I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have. BILLING AND PAYMENTS You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require me to disclose otherwise confidential information. In most collection situations, the only information I release regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due. If such legal action is necessary, its costs will be included in the claim. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, I will be willing to call the company on your behalf. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in short- term therapy, some patients feel that they need more services after insurance benefits end. Some managed-care plans will not allow me to provide services to you once your benefits end. If this is the case, and you desire to continue receiving services, you will be expected to pay the full fee. Most managed-care companies will allow this arrangement with your written approval. You should also be aware that your contract with your health insurance company requires that I provide it with information relevant to the services that I provide to you. I am required to provide a clinical diagnosis. Sometimes I am required to provide additional clinical information such as treatment plans or summaries. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier.
Appears in 1 contract
Meetings. I normally conduct an evaluation that will last from 1-2 to 4 sessions. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If therapy has psychotherapy is begun, I will usually schedule one 4550-minute ses- sion session (one appointment hour of 50 minutes in duration) per week at a time we agree on, although some sessions may be longer or more frequent. Once an appointment hour is scheduled, you will be expected to attend the session. If you do not, you will be expected to pay for it un- less a No Show fee of $15.00 unless you provide 24-24 hours advanced of advance notice of cancellationcancellation [unless we both agree that you were unable to attend due to circumstances beyond your control]. It is important to note that insurance companies do not provide reimbursement for cancelled sessions. Professional Fees [If it is possible, I will try to find another time to reschedule the appointment.] PROFESSIONAL FEES/BILLING/PAYMENTS My hourly fee varies depending on services and durationis $110.00. In addition to weekly ap- pointmentsYou should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, I charge this amount for other professional services you may needcall your plan administrator. How- everOf course, I will break down provide you with whatever information I can based on my experience and will be happy to help you in understanding the hourly cost if information you receive from your insurance company. If it is necessary to clear confusion, I work will be willing to call the company on your behalf. We invoice insurance companies directly and have contracts for periods of less than one houragreed upon rates with a major insurance companies. Note that these additional services However, you are not covered by insuranceresponsible for the deductible and copayment. Other services include report writing, telephone conversations lasting longer than 10-minutes, Skype appoint- ments or check-ins, consulting with other professionals with your permission, prepar- ing of records or treatment summaries, and You will be expected to pay for each session at the time spent performing any other ser- vices it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. My office has a sliding fee scale policy and I will work with you individually to create an agreed upon payment plan. Very rarely, a client may request me to complete summaries of metreatment or consult with another professional about matters that would require an extensive amount of my time. I will discuss these situations with you and we will decide whether or not you would want to pay $25.00 (the current rate billable to most outside agencies) for such services. If you become involved in legal proceedings that require my participation, you we will be expected to pay discuss payment for all of my professional time, including preparation and transportation costs, even if I l am called to testify by another party. Be- cause of the difficulty of legal involvement, I charge $500 per hour for preparation and attendance at any legal proceedings. Contacting Me CONTACTING ME Due to my work schedule, I am often not immediately available by telephone. While I am usually in my office four days a week, I probably will not answer the phone when I am with a client. When I am unavailable, my telephone is answered by voice mail that I monitor frequently. I will make every effort to return your call by on the end of my business daysame day you make it, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. [In emergencies, or if l am out of the service area you can contact me at my emergency cell phone number at (000) 000-0000]. If you are unable to reach me and you feel that you can’t n't wait for me to return your call, contact your family physician, the nearest emergency room and ask for the psychologist or psychiatrist on call, or call 911Centre County Can Help Line at (800) 643- 5432. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client and a therapistpsychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, ad- xxxxx advance consent. Your signature on this Agreement provides consent for those activities, as follows: • I may occasionally find it helpful to consult other health and mental health profes- sionals professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my client. The other professionals are also legally bound to keep informa- tion the information confidential. If you don’t n't object, I will not tell you about these consultations un- less unless I feel that it is important to our work together. I will note all consultations in your Clinical RecordRecord (which is called "PHI" in my Notice of Psychologist's Policies and Practices to Protect the Privacy of Your Health Information). Disclosures • I also have a bookkeeper who completes claim forms for insurance companies and may at time contact you regarding insurance information. As required by health insurers or HIPAA, this person has received training to collect overdue fees are discussed else- where in maintain the confidentiality of this data and has signed a Confidentiality Agreement. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: . The PA Notice Form, part of this agreement, also addresses instances where no written authorization is necessary to inform other agencies of involvement in therapy. • If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatmentthe professional services I provided to you, such information is protected by the social workerpsychologist-client privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. • If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. • If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client in order to defend myself. • If I am treating a client who files a worker’s 's compensation claim, I mustmay, upon appropriate request, pro- vide a copy of the client’s record be required to the Labor and Industrial Commission or the Work- ers’ Compensation Division, or the client’s provide otherwise confidential information to your employer. There are some situations in which I am legally obligated to take actions, which I be- lieve believe are necessary to attempt to protect others from harm and I may have to reveal some information about a client’s 's treatment. These situations are unusual in my practice. • If I have reasonable cause reason to suspect believe that a child has been who I am evaluating or may be subjected to abuse or neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglecttreating is an abused child, the law requires that I file a report with Tennessee’s the appropriate government agency, usually the Department of Children’s ServicesPublic Welfare. Once such a report is filed, I may be required to provide additional information. • If I have reasonable cause reason to suspect believe that an elderly person or disabled other adult presents a like- lihood of suffering serious physical harm and is in need of protective servicesservices (regarding abuse, neglect, exploitation or abandonment), the law requires that I file a allows me to report with Adult Protective Servicesthis to appropriate authorities, usually the Department of Aging, in the case of an elderly person. Once such a report is filed, I may be required to provide additional information. • If I believe that it one of my clients presents a specific and immediate threat of serious bodily injury regarding a specifically identified or a reasonably identifiable victim and he/she is necessary likely to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by carry out the client on him/her- self threat or another personintent, I may be required to take protective action. These actions may includeactions, and/or initiating hospitalization and/or contacting such as warning the potential victim, and/or contacting the police and/or the client’s family. police, or initiating proceedings for hospitalization If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records You should The laws governing confidentiality can be aware thatquite complex, pursuant to HIPAAand I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. PROFESSIONAL RECORDS The laws and standards of my profession require that I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in unusual circumstances that involve danger to yourself and/or others or where information has been supplied to me confidentially by others, or the unusual circumstance where disclosure record makes reference to another person (unless such other person is a health care provider) and I believe that access is reasonably likely to endanger you and/or others or when another individual (cause substantial harm to such other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harmperson, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed (SEE: Professional Fees: If you elect to charge a copying fee of 35 cents per page (and for certain other expenses). The exceptions have copies forwarded to this policy are contained in the attached Notice Form. another professional.) If I refuse your request for access to your Clinical Recordsrecords, you have a right of review, review (except for information has been supplied to me confidentially by others) which I will discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents of our conversations, my analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentially.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights CLIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your Clinical Records Record and disclosures of protected health information. These rights include:include requesting that I amend your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights with you. MINORS & PARENTS Clients under 18 years of age who are not emancipated and their parents should be aware that the law may allow parents to examine their child's treatment records. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is sometimes my policy to request an agreement from parents that they consent to give up their access to their child's records. If they agree, during treatment, I will provide them only with general information about the progress of the child's treatment, and his/her attendance at scheduled sessions. I will also provide parents with a summary of their child's treatment when it is complete. Any other communication will require the child's Authorization, unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should also be aware that your contract with your health insurance company requires that I provide it with information relevant to the services that I provide to you. I am required to provide a clinical diagnosis. Sometimes I am required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your sessions. It is important to remember that you always have the right to pay for my services yourself to avoid the problems described above [unless prohibited by contract]. SOCIAL MEDIA POLICY I have found that my clients prefer using text messaging for altering, cancelling, or scheduling appointments. It is easier to be in touch and my office cellphone is accessible throughout the day. I will also utilize more traditional methods if that is your preference. It is important to understand that I cannot guarantee complete confidentiality due to the nature of wireless communication. I do make every effort to provide confidentiality through the use of an initial for your name in my contact list. I also have clients who will email me information regarding their clinical work. I will print out the information and include this as a part of your ongoing file. Again, I do not have a secure server for such messages although I have pass worded all of my office electronic communications and documents. I do not have an office Facebook page and I do not peruse client Facebook pages unless we do so as a part of your clinical session. At times this has been found to be helpful in social connection therapeutic goals. We will discuss your personal preferences with the understanding of limitations on confidentiality. PENNSYLVANIA NOTICE FORM Notice of Psychologists’ Policies and Practices to Protect the Privacy of Your Health Information THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAYBE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Appears in 1 contract
Samples: twelchpsychologist.com
Meetings. During our initial meeting(s), I normally conduct an evaluation that will last from 1-2 sessionsbe getting a better understanding of your concerns, condition, and goals. During this time, we We can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If therapy has psychotherapy is begun, I we will usually schedule one 45-minute ses- sion session per week at a time we agree onon (usually 50 minutes in duration), although some sessions may be longer or more frequentplanned more frequently. Once SCHEDULING / CANCELLATION POLICY If you need to re-schedule an appointment appointment, please let me know as soon as possible, so that we have a better chance of finding an alternate time to meet. A fee will not be charged for cancellation as long as you notify me 24 hours in advance of your scheduled appointment. If a session is cancelled with less than 24-hour is schedulednotice or if you fail a scheduled appointment, you will be expected responsible for the full session fee as indicated in the PAYMENT section below. I understand and consent to pay this cancellation policy: __________ (initial and date) PAYMENT Your fee for it un- less you provide 24-hours advanced notice of cancellationservice is payable by cash, check, or credit card at each session. It The current fee schedule is important to note that insurance companies do not provide reimbursement as follows: $220 for cancelled the initial assessment, $180 for individual sessions. Professional Fees My hourly fee varies depending on services and duration. In addition to weekly ap- pointments, I charge this amount for other professional services you may need. How- ever, I will break down the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services include report writing, telephone conversations lasting longer than 10-minutes, Skype appoint- ments or check-ins, consulting with other professionals with your permission, prepar- ing of records or treatment summaries, and the time spent performing any other ser- vices you may request of me$200 for couple sessions. If you become involved in legal proceedings request a “super statement” to submit to your insurance company for later reimbursement according to their policy of reimbursing “out of network providers,” please be aware that require my participationI will include dates of service, you will be expected types of service (e.g., individual psychotherapy, family therapy, etc.) provided, and diagnoses. I understand and consent to pay for all of my professional time, including preparation this payment policy: ________ (initial and transportation costs, even if date) CONTACTING ME I am called to testify by another party. Be- cause of the difficulty of legal involvement, I charge $500 per hour for preparation a solo practitioner and attendance at any legal proceedings. Contacting Me Due to my work schedule, I am not often not immediately available by telephone. While I am usually in my office four days You can leave me a week, I probably will voice mail message at 708-655-0063 or email me at xxxxxxxxxxxxxx@xxxxx.xxx (recognizing that email is not answer the phone when I am with a cliententirely secure). I will check messages several times a day and make every an effort to return your call by the end calls and messages within 24 hours. In case of my business day, with the exception of weekends and holidays. If you are difficult to reacha mental health emergency, please inform me of some times when you will be available. If you are unable go to reach me and you feel that you can’t wait for me to return your call, contact your family physician, the nearest emergency room and ask for the psychologist or psychiatrist on call, or call phone 911. If I will be unavailable for an extended time, I will provide you with the name of a colleague contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client patient and a therapistpsychologist. In most situations, I the therapist can only release information about your treatment to others if you sign a written Authorization Form form that meets certain legal requirements imposed by HIPAAHIPAA and/or Illinois law. There are other situations that require only that you provide writtenHowever, ad- xxxxx consent. Your signature on this Agreement provides consent for those activitiesin the following situations, as followsno authorization is required: I may occasionally find it helpful to consult other health and mental health profes- sionals professionals about a case. During a consultation, I will make every effort to avoid revealing the identity of my clientyour identity. The other professionals are also legally bound to keep informa- tion the information confidential. Very occasionally, I may have contracts with other vendors to assist with my practice, such as a billing service. As required by HIPAA, I will have a formal business associate contract with these businesses, in which it/they promise to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you don’t objectwish, I will not tell can provide you about with the names of these consultations un- less I feel that it is important to our work togetherorganizations and/or a blank copy of this contract. I will note all consultations in your Clinical Record. Disclosures required by health insurers or to collect overdue fees are discussed else- where in this Agreement. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the social workerpsychologist-client patient privilege law. , but I cannot provide any may be required to disclose information without your (or your legal representative’s) written authorization, or in the case of a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose the disclosure of information. If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. If a client patient files a complaint or lawsuit against me, I may disclose relevant information regarding that client in order to defend myself. If a client files you file a worker’s compensation claim, and I am rendering treatment or services in accordance with the provisions of Illinois Workers’ Compensation law, I must, upon appropriate request, pro- vide provide a copy of the client’s your record to the Labor and Industrial Commission your employer or the Work- ers’ Compensation Division, or the client’s employerhis/her appropriate designee. There are some situations in which I am legally obligated to take actions, which actions that I be- lieve believe are necessary to attempt to protect others from harm and harm. I may have to reveal some information about a clientpatient’s treatment. These situations are unusual in my practiceunusual, but possible. If I have reasonable cause to suspect believe that a child has been or under 18 known to me in my professional capacity may be subjected to abuse an abused child or neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglectneglected child, the law requires that I file a report with Tennessee’s the local office of the Department of Children’s Children and Family Services. Once such a report is filed, I may be required to provide additional information. If I have reasonable cause reason to suspect believe that an elderly adult over the age of 60 living in a domestic situation has been abused or disabled adult presents a like- lihood of suffering serious physical harm and is neglected in need of protective servicesthe preceding 12 months, the law requires that I file a report with Adult Protective Servicesthe agency designated to receive such reports by the Department of Aging. Once such a report is filed, I may be required to provide additional information. If you have made a specific threat of violence against another or if I believe that it is necessary to disclose information to protect against you present a clear and substantial clear, imminent risk of imminent serious physical harm being inflicted by the client on him/her- self or another personto another, I may be required to disclose information in order to take protective actionactions. These actions may include, and/or initiating hospitalization and/or contacting include notifying the potential victim, and/or contacting the police and/or the client’s familypolice, or seeking your hospitalization. If I believe that you present a clear, imminent risk of serious physical or mental injury or death to yourself, I may be required to disclose information in order to take protective actions. These actions may include your hospitalization or contacting family members or others who can assist in protecting you. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records You should The laws governing confidentiality can be aware thatquite complex, pursuant to HIPAAand I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. PROFESSIONAL RECORDS The laws and standards require that I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure is reasonably likely to endanger you and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harm, you You may examine and/or receive a copy of your Clinical Record, if you request it requested in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend it is recommended that you initially review them in my presencewith me, or or, have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge There will be a copying fee of 35 cents $0.25 per page (and for certain other expenses)page. The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Records, you have a right of review, which I will discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents of our conversations, my analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentially.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights PATIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to regarding your Clinical Records and disclosures of protected health information. These rights include:include requesting that the therapist amend your record; requesting restrictions on what information from your Clinical Records is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about his/her policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and his/her privacy policies and procedures. I am happy to discuss any of these rights with you. MINORS & PARENTS Patients under 12 years of age and their parents should be aware that the law allows parents to examine their child’s treatment records. Parents of children between 12 and 17 cannot examine their child’s records unless the child consents and unless the therapist finds that there are no compelling reasons for denying the access. Parents are entitled to information concerning their child’s current physical and mental condition, diagnosis, treatment needs, services provided, and services needed. Since parental involvement is often crucial to successful treatment, in most cases, patients between 12 and 17 years of age and their parents enter into an agreement that allows parents access to certain additional treatment information. If everyone agrees, during treatment I will provide parents with general information about the progress of their child’s treatment, and his/her attendance at scheduled sessions. I will also provide parents with a verbal summary of treatment when it is complete. Any other communication will require the child’s Authorization, unless I believe that the child is in danger or is a danger to someone else, in which case, parents will be notified of this concern. Before giving parents any information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have. YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS, INCLUDING YOUR CONSENT FOR MENTAL HEALTH SERVICES. YOUR SIGNATURE BELOW ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE READ AND BEEN OFFERED A COPY OF THE HIPAA NOTICE FORM DESCRIBED ABOVE. I have read and agree to all these arrangements, ___________________________________________________ Patient/Client Signature Date ___________________________________________________ Print Name Date ___________________________________________________ Parent Signature (for minor) Date ___________________________________________________ Child’s Name/Signature if appropriate Date
Appears in 1 contract
Samples: Patient Services Agreement
Meetings. I normally conduct an evaluation that will last from 1-2 to 4 sessions. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If therapy has psychotherapy is begun, I will usually schedule one 4550-minute ses- sion session (one appointment hour of 50 minutes duration) per week at a time we agree on, although some sessions may be longer or more frequent. Once an appointment hour is scheduled, you will be expected to pay for it un- less unless you provide 24-24 hours advanced advance notice of cancellationcancellation (unless we both agree that you were unable to attend due to circumstances beyond your control). No show appointments will be charged. It is important to note that insurance companies do not provide reimbursement for cancelled sessions. Professional Fees If it is possible, I will try to find another time to reschedule the appointment. PROFESSIONAL FEES My hourly fee varies depending on services and durationis $150.00. In addition to weekly ap- pointmentsappointments, I charge this amount for other professional services you may need. How- ever, though I will break down the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services include report writing, telephone conversations lasting longer than 10-20 minutes, Skype appoint- ments or check-ins, consulting with other professionals with your permission, prepar- ing preparation of records or of treatment summaries, and the time spent performing any other ser- vices service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Be- cause Because of the difficulty of legal involvement, I charge $500 300 per hour for preparation and attendance at any legal proceedingsproceeding. Contacting Me CONTACTING ME Due to my work schedule, I am often not immediately available by telephone. While I am usually in my office four days a week, I will probably will not answer the phone when I am with a clientpatient. When I am not available, my telephone is answered by an answering machine that I monitor frequently. I will make every effort to return your call by on the end of my business daysame day you make it, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. If In an emergency, if you are unable to reach me and you feel that you can’t wait for me to return your call, contact your family physician, physician or go to the nearest emergency room and ask for the psychologist or psychiatrist on call, or call 911. If I will be unavailable for an extended time, I my answering machine will provide you with the name of a colleague to contact, if necessary. You may also utilize email Although I do use e-mail for communication and you can contact me through e-mail if you like, I am not at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx my computer all the time. Therefore, if you need to communicate with reach me about something that needs immediate attention, it is best to leave a voice message for me. Limits Please don’t assume that I will be checking e-mails throughout the day when I am in the office. Also please notify me if you do not want me to use e-mails as a way of Confidentiality communicating with you. LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client patient and a therapistpsychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form form that meets certain legal requirements imposed by HIPAAHIPAA or Maryland law. There are other situations that require only that you provide writtenHowever in the following situations, ad- xxxxx consent. Your signature on this Agreement provides consent for those activities, as followsno authorization is required: I may occasionally find it helpful to consult other health and mental health profes- sionals professionals about a case. During a consultation, I make every effort to avoid revealing the identity identify of my clientpatient. The other professionals are also legally bound to keep informa- tion confidential. If you don’t object, I will not tell you about these consultations un- less I feel that it is important to our work together. I will note all consultations in your Clinical Record. Disclosures required by health insurers or to collect overdue fees are discussed else- where in this Agreement. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the social worker-client privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client in order to defend myself. If a client files a worker’s compensation claim, I must, upon appropriate request, pro- vide a copy of the client’s record to the Labor and Industrial Commission or the Work- ers’ Compensation Division, or the client’s employer. There are some situations in which I am legally obligated to take actions, which I be- lieve are necessary to attempt to protect others from harm and I may have to reveal some information about a client’s treatment. These situations are unusual in my practice. If I have reasonable cause to suspect that a child has been or may be subjected to abuse or neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglect, the law requires that I file a report with Tennessee’s Department of Children’s Services. Once such a report is filed, I may be required to provide additional information. If I have reasonable cause to suspect that an elderly or disabled adult presents a like- lihood of suffering serious physical harm and is in need of protective services, the law requires that I file a report with Adult Protective Services. Once such a report is filed, I may be required to provide additional information. If I believe that it is necessary to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by the client on him/her- self or another person, I may be required to take protective action. These actions may include, and/or initiating hospitalization and/or contacting the potential victim, and/or the police and/or the client’s family. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure is reasonably likely to endanger you and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harm, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of 35 cents per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Records, you have a right of review, which I will discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents of our conversations, my analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentially.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include:
Appears in 1 contract
Samples: Patient Services Agreement
Meetings. I normally conduct an evaluation that will last from 1-2 to 4 sessions. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If therapy has psychotherapy is begun, I will usually schedule one 4550-minute ses- sion session (one appointment hour of 50 minutes duration) per week at a time we agree on, although some sessions may be longer or more frequent. Once an appointment hour is scheduled, you will be expected to pay for it un- less unless you provide 24-24 hours advanced advance notice of cancellationcancellation [unless we both agree that you were unable to attend due to circumstances beyond your control]. It is important to note that insurance companies do not provide reimbursement for cancelled sessions. Professional Fees PROFESSIONAL FEES Initial appointments are $180. My hourly fee varies depending on services and durationis $160. In addition to weekly ap- pointmentsappointments, I charge this amount for other professional services you may need. How- ever, though I will break down the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services include report writing, telephone conversations lasting longer than 10-15 minutes, Skype appoint- ments or check-ins, consulting with other professionals with your permission, prepar- ing preparation of records or treatment summaries, and the time spent performing any other ser- vices service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Be- cause of the difficulty of legal involvement, I charge $500 per hour for preparation and attendance at any legal proceedings. Contacting Me CONTACTING ME Due to my work schedule, I am often not immediately available by telephone. While When I am usually in my office four days unavailable, you may leave me a week, I probably will not answer the phone when I am with a client. message and I will make every effort try to return your call by the end of my business day, within 48 hours with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. I do not provide emergency services. If you are unable to reach me and you feel that you can’t wait for me need emergency service please contact the South Shore Crisis Services at 0- 000-000-0000 or go to return your call, contact your family physician, the nearest emergency room and ask for the psychologist or psychiatrist on call, or call 911room. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client Client and a therapistpsychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, ad- xxxxx advance consent. Your signature on this Agreement provides consent for those activities, as follows: • I may occasionally find it helpful to consult other health and mental health profes- sionals professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my clientClient. The other professionals are also legally bound to keep informa- tion the information confidential. If you don’t object, I will not tell you about these consultations un- less unless I feel that it is important to our work together. I will note all consultations in your Clinical RecordRecord (which is called “PHI” in my Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information). • Disclosures required by health insurers or to collect overdue fees are discussed else- where elsewhere in this Agreement. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: • If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the social workerpsychologist-client Client privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. • If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. If a client Client files a complaint or lawsuit against me, I may disclose relevant information regarding that client Client in order to defend myself. • If a client Client files a worker’s compensation claim, I must, upon appropriate request, pro- vide provide appropriate information, including a copy of the clientClient’s record record, to the Labor and Industrial Commission Client’s employer, the insurer or the Work- ers’ Compensation Division, or the clientDepartment of Worker’s employerCompensation. There are some situations in which I am legally obligated to take actions, which I be- lieve believe are necessary to attempt to protect others from harm and I may have to reveal some information about a clientClient’s treatment. These situations are unusual in my practice. ▪ If I have reasonable cause to suspect believe that a child has been under age 18 is suffering physical or may be subjected emotional injury resulting from abuse inflicted upon him or her which causes harm or substantial risk of harm to abuse the child's health or welfare (including sexual abuse), or from neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglect(including malnutrition), the law requires that I file a report with Tennessee’s the Department of Children’s Social Services. Once such a report is filed, I may be required to provide additional information. ▪ If I have reasonable cause reason to suspect believe that an elderly individual is suffering from or has died as a result of abuse (including financial exploitation) the law requires that I report to the Department of Elder Affairs. If I have reason to believe that a mentally or physically disabled adult presents individual is suffering from or has died as result of a like- lihood of suffering reportable condition (which is defined as a serious physical harm or emotional injury resulting from abuse and is in need of protective servicesincludes non-consensual sexual activity), the law requires that I file a report with Adult Protective Servicesto the Disabled Persons Protection Commission and/or other appropriate agencies. Once such a report is filed, I may be required to provide additional information. I need not report abuse if a disabled person invokes the psychotherapist-Client privilege to maintain confidential communications. ▪ If I believe that it is necessary a Client communicates an immediate threat of serious physical harm to disclose information an identifiable victim or if a Client has a history of violence and the apparent intent and ability to protect against a clear and substantial risk of imminent serious harm being inflicted by carry out the client on him/her- self or another personthreat, I may be required to take protective actionactions. These actions may include, and/or initiating hospitalization and/or contacting include notifying the potential victim, contacting the police, and/or seeking hospitalization for the police and/or the client’s familyClient. ▪ If a Client threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her, or to contact family members or others who can help provide protection. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records You should The laws governing confidentiality can be aware thatquite complex, pursuant to HIPAAand I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. PROFESSIONAL RECORDS The laws and standards of my profession require that I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure is reasonably likely to endanger you and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harm, you You may examine and/or receive a copy of your Clinical Record, records if you request it in writing, unless I believe that access would endanger you. In those situations, you have a right to a summary and to have your record sent to another mental health provider or your attorney. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of 35 cents per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Recordsrecords, you have a right of review, which I will discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents of our conversations, my analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentially.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights CLIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your Clinical Records Record and disclosures of protected health information. These rights include:include requesting that I amend your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights with you. MINORS & PARENTS Clients under 18 years of age who are not emancipated and their parents should be aware that the law allows parents to examine their child’s treatment records, unless I believe this review would be harmful to the Client and his/her treatment. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is sometimes my policy to request an agreement from parents that they consent to give up their access to their child’s records. If they agree, during treatment, I will provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. I will also provide parents with a summary of their child’s treatment when it is complete. Any other communication will require the child’s Authorization, unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have. BILLING AND PAYMENTS You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. In circumstances of unusual financial hardship, I may be willing to negotiate a fee adjustment or payment installment plan. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require me to disclose otherwise confidential information. In most collection situations, the only information I release regarding a Client’s treatment is his/her name, the nature of services provided, and the amount due. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, I will be willing to call the company on your behalf. You should also be aware that your contract with your health insurance company requires that I provide it with information relevant to the services that I provide to you. I am required to provide a clinical diagnosis. Sometimes I am required to provide additional clinical information such as treatment plans or summaries, or copies of your entire clinical record. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier. Your signature below indicates that you have read, understood, and agreed to the terms of this document. Your signature also serves as an acknowledgement that you have received the notice of privacy practices described above. Client Name Signature Date Client Name Signature Date This form has been discussed and a copy given to the client.
Appears in 1 contract
Samples: atlanticpsych.org
Meetings. I normally conduct an evaluation that will last from 1-2 to 4 sessions. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If therapy has psychotherapy is begun, I will usually schedule one 4550-minute ses- sion session (one appointment hour of 50 minutes duration) per week at a time we agree on, although some sessions may be longer or more frequent. Once an appointment hour is scheduled, you will be expected to pay for it un- less unless you provide 24-24 hours advanced advance notice of cancellationcancellation or unless we both agree that you were unable to attend due to circumstances beyond your control. It If it is important possible, I will try to note find another time to reschedule the appointment. Unless we reach a different agreement, the full fee will be charged for sessions missed without such notification. Insurance companies do not pay for missed sessions. Lastly, while on occasion sessions are missed due to illness or unexpected events, a pattern of not showing for treatment usually indicates a problem with the work we are doing together. I will always pause at this juncture and address the issue openly to prevent no-shows from interfering with treatment. If it cannot be corrected I will usually discontinue therapy at that time and refer you to another provider or back to your insurance company. My philosophy is simple if you do not come to treatment consistently I am unable to help you with change. And, since most insurance companies do not provide reimbursement allow me to bill for cancelled sessions. Professional Fees My hourly fee varies depending on services and duration. In addition to weekly ap- pointments, I charge this amount for other professional services you may need. How- evermissed appointments, I will break down always address appointment problems immediately. DUAL RELATIONSHIPS Not all dual relationships are unethical or avoidable but I am diligent in ensuring, to the hourly cost if I work for periods best of less than one hourmy ability, that this never happens. Note With that these additional services are not covered by insurancesaid, therapy never involves sexual or any other dual relationship that impairs a therapist’s objectivity, clinical judgment, or therapeutic effectiveness, nor can it be exploitative in nature. Other services include report writing, telephone conversations lasting longer than 10-minutes, Skype appoint- ments or check-ins, consulting with other professionals with your permission, prepar- ing of records or treatment summariesOrange County is a relatively small county, and many patients may know each other. Consequently, you many bump into someone you know in the time spent performing any other ser- vices you may request of mewaiting room or in the community. I personally, will never acknowledge working therapeutically with anyone especially on chance meetings in the community. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional uncomfortable at any time, including preparation and transportation costs, even if I am called it is your responsibility to testify by another party. Be- cause of the difficulty of legal involvement, I charge $500 per hour for preparation and attendance at any legal proceedings. Contacting Me Due to my work schedule, I am often not immediately available by telephone. While I am usually in my office four days a week, I probably will not answer the phone when I am with a clientnotify me. I will make every effort listen carefully to return your call by the end of my business dayconcerns, with the exception of weekends and holidays. If you are difficult respond accordingly to reach, please inform me of some times when you will be available. If you are unable to reach me your feedback and you feel that you can’t wait for me to return your call, contact your family physician, the nearest emergency room and ask for the psychologist or psychiatrist on call, or call 911. If I will be unavailable for an extended time, I will provide you with the name of a colleague contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality The law protects the privacy of all communications between a client and a therapist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, ad- xxxxx consent. Your signature on this Agreement provides consent for those activities, as follows: I may occasionally find it helpful to consult other health and mental health profes- sionals about a case. During consultation, I make every effort to avoid revealing the identity of my client. The other professionals are also legally bound to keep informa- tion confidential. If you don’t object, I will not tell you about these consultations un- less I feel that it is important to our work togetherstated needs. I will note all consultations in your Clinical Record. Disclosures required by health insurers or respect my patient’s needs for privacy and have both a legal and ethical obligation to collect overdue fees are discussed else- where in this Agreement. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: If you are involved in a court proceeding protect my patients and a request is made for information concerning your diagnosis and treatment, such information is protected by the social worker-client privilege lawpatient information. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. If a client files a complaint or lawsuit against me, I may disclose relevant information regarding take that client in order to defend myself. If a client files a worker’s compensation claim, I must, upon appropriate request, pro- vide a copy of the client’s record to the Labor and Industrial Commission or the Work- ers’ Compensation Division, or the client’s employer. There are some situations in which I am legally obligated to take actions, which I be- lieve are necessary to attempt to protect others from harm and I may have to reveal some information about a client’s treatment. These situations are unusual in my practice. If I have reasonable cause to suspect that a child has been or may be subjected to abuse or neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglect, the law requires that I file a report with Tennessee’s Department of Children’s Services. Once such a report is filed, I may be required to provide additional information. If I have reasonable cause to suspect that an elderly or disabled adult presents a like- lihood of suffering serious physical harm and is in need of protective services, the law requires that I file a report with Adult Protective Services. Once such a report is filed, I may be required to provide additional information. If I believe that it is necessary to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by the client on him/her- self or another person, I may be required to take protective action. These actions may include, and/or initiating hospitalization and/or contacting the potential victim, and/or the police and/or the client’s family. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure is reasonably likely to endanger you and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harm, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of 35 cents per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Records, you have a right of review, which I will discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents of our conversations, my analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentiallyresponsibility very seriously.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include:
Appears in 1 contract
Samples: www.berrytherapeutic.com
Meetings. I normally conduct an evaluation that will last from 1-2 sessionsto 4 sessions and may include a written evaluation. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If therapy has psychotherapy is begun, I will usually schedule a 45 minute session (one 45-minute ses- sion appointment session of 45 minutes duration) per week at a time we agree on, although some sessions may be longer or more frequent. Once an appointment hour session is scheduled, you will be expected to pay for it un- less unless you provide 24-48 hours advanced (2 days) advance notice of cancellationcancellation (unless it is due to your personal illness). It is important to note that insurance companies do not provide reimbursement for cancelled sessions. Professional Fees My hourly PROFESSIONAL FEES Our fee varies depending on services and durationschedule is attached. In addition to weekly ap- pointmentsappointments, I we charge this amount a $200/per hour fee for other professional services you may need. How- ever, though I will break down the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services include report writing, telephone conversations lasting longer than 10-5 minutes, Skype appoint- ments or check-ins, consulting with other professionals professional with your permission, prepar- ing preparation of records or treatment summaries, and the time spent performing any other ser- vices service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Be- cause of the difficulty of legal involvement, I charge $500 per hour for preparation and attendance at any legal proceedings. Contacting Me CONTACTING US Due to my our work schedule, I am often we are not immediately available by telephone. While Our telephone is answered by voice mail that I am usually in my office four days a week, I probably will not answer the phone when I am with a clientmonitor frequently. I will make every effort to return your call by the end of my business daywithin 24 hours, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. Note that if you have a phone device that blocks private phone numbers, we may be unable to reach you. If you are unable to reach me and you feel that you can’t cannot wait for me to return your call, contact your family physician, physician or the nearest emergency room and ask for the psychiatrist or psychologist or psychiatrist on call, or call 911. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client patient and a therapistpsychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form form that meets certain legal requirements imposed by HIPAAHIPAA and/or Illinois law. There are other situations that require only that you provide writtenHowever, ad- xxxxx consent. Your signature on this Agreement provides consent for those activitiesin the following situations, as followsno authorization is required: o I may occasionally find it helpful to consult other health and mental health profes- sionals professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my clientpatient. The other professionals are also legally bound to keep informa- tion the information confidential. If you don’t n't object, I will not tell you about these consultations un- less unless I feel that it is important to our work together. I will note all consultations in your Clinical RecordRecord (which is called "PHI" in my Notice of Psychologist's Policies and Practices to Protect that Privacy of your Health Information). o You should be aware that we practice with other mental health professional and that we may employ administrative staff. In most cases, I need to share protected information with these individuals for both clinical and administrative purposes, such as scheduling, billing and quality assurance. All of the mental health professionals are bound by the same rules of confidentiality. All staff members are given training about protecting your privacy and have agreed not to release any information outside of the practice without the permissions of a professional staff member. o Disclosures required by health insurers or to collect overdue fees are discussed else- where elsewhere in this Agreement. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: o If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the social workerpsychologist-client patient privilege law. I cannot provide disclose any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. o If a government agency is requesting the information for health oversight activities, I may be required to provide it for to them. o If a client patient files a complaint or lawsuit against me, I may disclose relevant information regarding that client patient in order to defend myself. o If a client files you file a worker’s 's compensation claim, and I am rendering treatment or services in accordance with the provisions of Illinois Workers' Compensation law, I must, upon appropriate request, pro- vide provide a copy of the client’s your record to the Labor and Industrial Commission your employer or the Work- ers’ Compensation Division, or the client’s employerhis/her appropriate designee. There are some situations in which I am legally obligated to take actions, which I be- lieve believe are necessary to attempt to protect others from harm and I may have to reveal some information about a client’s patient's treatment. These situations are unusual in my practice. o If I have reasonable cause to suspect believe that a child has been or under 18 known to me in my professional capacity may be subjected to abuse an abused or neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglectneglected child, the law requires that I file a report with Tennessee’s the local office of the Department of Children’s Children and Family Services. Once such a report is filed, I may be required to provide additional information. o If I have reasonable cause reason to suspect believe that an elderly adult over the age of 60 living in a domestic situation has been abused or disabled adult presents a like- lihood of suffering serious physical harm and is neglected in need of protective servicesthe preceding 12 months, the law requires that I file a report with Adult Protective Servicesthe agency designated to receive such reports by the Department of Aging. Once such a report is filed, I may be required to provide additional information. o If you have made a specific threat or violence against another, or if I believe that it is necessary to disclose information to protect against you present a clear and substantial clear, imminent risk of imminent serious harm being inflicted by the client on him/her- self or another personto another, I may be required to disclose information in order to take protective actionactions. These actions may include, and/or initiating hospitalization and/or contacting include notifying the potential victim, and/or contacting the police and/or the client’s familypolice, or seeking your hospitalization. o If I believe that you present a clear, imminent risk of serious physical or mental injury or death to yourself, I may be required to disclose information in order to take protective actions. These actions may include seeking your hospitalization or contacting family members or others who can assist in protecting you. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records The laws governing confidentiality can be quite complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. PROFESSIONAL RECORDS You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards toward those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the unusual circumstance where disclosure best treatment. While the contents of Psychotherapy notes vary from client to client, they can include the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me that is reasonably likely not required to endanger be included in your Clinical Record. These Psychotherapy Notes are kept separate from your Clinical Record. While insurance companies can request and receive a copy of your Clinical Record, they cannot receive a copy of your Psychotherapy Notes without your Authorization. Insurance companies cannot require your Authorization as a condition of coverage nor penalize you and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harm, you in any way for your refusal. You may examine and/or receive a copy of your Clinical Recordboth sets of records, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I charge for this review meeting. I also am allowed to charge a copying fee of 35 cents $1.00 per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Records, you have a right of review, which I will discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents of our conversations, my analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentially.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights PATIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include:include requesting that I amend your record; requesting restrictions on what information from your Clinical Records is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consent to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights with you. MINORS & PARENTS Patients under 12 years of age and their parents should be aware that the law allows parents to examine their child's treatment records. Parents of children between 12 and 18 cannot examine their child's records unless the child consents and unless I find that there are no compelling reasons for denying the access. Parents are entitled to information concerning their child's current physical and mental condition, diagnosis, treatment needs, services provided, and services needed. Since parental involvement is often crucial to successful treatment, in most cases, I require that patients between 12 and 18 years of age and their parents enter into an agreement that allows parents access to certain additional treatment information. If everyone agrees, during treatment, I will provide parents with general information about the progress of their child's treatment, and his/her attendance at scheduled sessions. I will also provide parents with a summary of treatment when it is complete. Any other communication will require the child's Authorization, unless I feel that the child is in danger or is a danger to someone else, in which case I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the child, if possible, and do my best to handle and objections he/she may have. BILLING AND PAYMENTS You will be expected to pay for each session at the time it is held, unless we agree otherwise. Payment schedules for other professional services will be agreed to when they are requested. In circumstances of unusual financial hardship, you may formally apply for a fee adjustment. If you account has not been paid for more than 90 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. We are subscribers to TransUnion, a national credit reporting bureau and submit delinquent accounts directly to TransUnion. In most collection situations, the only information I release regarding a patient's treatment is his/her name, the nature of services provided, and the amount due. If legal action is necessary, its costs will be included in the claim. Any costs incurred in securing overdue payments will be charged to you. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. If I have a contract with your insurance company, I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, I will be willing to call the company on your behalf. Please note, however, that my assistance in these matters will occur during our scheduled appointments. Due to rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. "Managed Health Care" plans such as PPOs often require authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person's usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in short-term therapy, some patients feel that they need more services after insurance benefits end. Some managed care companies will not allow me to provide services to you once your benefits end. If this is the case, I will do my best to find another provider who will help you continue your psychotherapy. You should also be aware that your contract with your health insurance company requires that you authorize me to provide it with information relevant to the services that I provide to you. If you are seeking reimbursement for services under your health insurance policy, you will be required to sign an authorization form that allows me to provide such information. I am required to provide a clinical diagnosis. Sometimes I am required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situation, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. Once you have all the information about your insurance coverage, we can discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your sessions. It is important to remember that you always have the right to pay for my services yourself to avoid the problems described above. YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS AND ALSO SERVES AS AN ACKNOWLEDGMENT THAT YOU HAVE RECEIVED THE HIPAA NOTICE FORM DESCRIBED ABOVE. Patient Date Legal Guardian (if patient is under 18 years) Date
Appears in 1 contract
Samples: lwapsych.com
Meetings. I normally conduct an evaluation that will last from 1-2 to 4 sessions. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If therapy has psychotherapy is begun, I will usually schedule one 45-minute ses- sion session (one appointment hour of 45 minutes duration) per week at a time we agree on, although some sessions may be longer or more frequent. Once an appointment hour is scheduled, you will be expected to pay for it un- less unless you provide 24-72 hours advanced advance notice of cancellationcancellation [unless we both agree you were unable to attend due to circumstances beyond your control]. It is important to note that insurance companies do not provide reimbursement for cancelled sessions. Professional Fees It will therefore be your obligation to pay for any missed appointments. I will waive the Late Cancellation fee for the first missed session. The second missed session incurs a $75 fee. The third and future missed sessions incur(s) a $150 fee. If we are able to find a time to reschedule the appointment for the same week I will happily waive the Late Cancellation fee for that missed session. PROFESSIONAL FEES The initial consultation (which lasts one hour) is $300. My hourly (45 min) fee varies depending on services and durationis $175. In addition to weekly ap- pointmentsappointments, I charge this amount for other professional services you may need. How- ever, though I will break down the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services include report writing, telephone conversations lasting longer than 10-10 minutes, Skype appoint- ments or check-ins, consulting attendance at meetings with other professionals with your permissionyou have authorized (including driving time), prepar- ing preparation of records or treatment summaries, and the time spent performing any other ser- vices service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, time even if I am called to testify by another party. Be- cause Because of the difficulty of legal involvement, I charge $500 450 per hour for preparation and attendance at any legal proceedings. Contacting Me Due to my work schedule, I am often not immediately available by telephone. While I am usually in my office four days a week, I probably will not answer the phone when I am with a client. I will make every effort to return your call by the end of my business day, with the exception of weekends and holidaysproceeding. If you parents are difficult to reach, please inform me of some times when you will be available. If you are unable to reach me and you feel that you can’t wait paying for me to return your call, contact your family physician, their minor child or for children over 18 they must sign the nearest emergency room and ask for the psychologist or psychiatrist on call, or call 911. If I will be unavailable for an extended time, I will provide you with the name of a colleague contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality The law protects the privacy of all communications between a client and a therapist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, ad- xxxxx consent. Your signature on this Agreement provides consent for those activities, as follows: I may occasionally find it helpful to consult other health and mental health profes- sionals about a case. During consultation, I make every effort to avoid revealing the identity of my client. The other professionals are also legally bound to keep informa- tion confidential. If you don’t object, I will not tell you about these consultations un- less I feel that it is important to our work together. I will note all consultations in your Clinical Record. Disclosures required by health insurers or to collect overdue fees are discussed else- where in this Agreement. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the social worker-client privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client in order to defend myself. If a client files a worker’s compensation claim, I must, upon appropriate request, pro- vide a copy of the client’s record to the Labor and Industrial Commission or the Work- ers’ Compensation Division, or the client’s employer. There are some situations in which I am legally obligated to take actions, which I be- lieve are necessary to attempt to protect others from harm and I may have to reveal some information about a client’s treatment. These situations are unusual in my practice. If I have reasonable cause to suspect that a child has been or may be subjected to abuse or neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglect, the law requires that I file a report with Tennessee’s Department of Children’s Services. Once such a report is filed, I may be required to provide additional information. If I have reasonable cause to suspect that an elderly or disabled adult presents a like- lihood of suffering serious physical harm and is in need of protective services, the law requires that I file a report with Adult Protective Services. Once such a report is filed, I may be required to provide additional information. If I believe that it is necessary to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by the client on him/her- self or another person, I may be required to take protective action. These actions may include, and/or initiating hospitalization and/or contacting the potential victim, and/or the police and/or the client’s family. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure is reasonably likely to endanger you and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harm, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of 35 cents per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Records, you have a right of review, which I will discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents of our conversations, my analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentiallyfinancial responsibility form.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include:
Appears in 1 contract
Meetings. I normally conduct an evaluation that will last from 1-2 1 to 3 sessions. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If therapy has psychotherapy is begun, I will usually schedule one 4550-minute ses- sion session (one appointment hour of 50 minutes duration) per week at a time we agree on, although some sessions may be longer or more frequent. Once an appointment hour is scheduled, you will be expected to pay for it un- less unless you provide 24-24 hours advanced advance notice of cancellationcancellation [or unless we both agree that you were unable to attend due to circumstances beyond your control]. It is important to note that insurance companies do not provide reimbursement for cancelled sessions. Professional Fees If it is possible, I will try to find another time to reschedule the appointment. PROFESSIONAL FEES My hourly fifty-minute session fee varies depending on services and durationis $150. In addition to weekly ap- pointmentsappointments, I charge this amount for other professional services you may need. How- ever, though I will break down the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurancefifty minutes. Other services include report writing, telephone conversations lasting longer than 10-10 minutes, Skype appoint- ments or check-ins, consulting with other professionals with your permission, prepar- ing preparation of records or treatment summaries, and the time spent performing any other ser- vices service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Be- cause Because of the difficulty of legal involvement, I charge $500 175 per hour for preparation and attendance at any legal proceedingsproceeding. Contacting Me CONTACTING ME Due to my work schedule, I am often not immediately available by telephone. While I am usually in my office four days a weekweekdays between 8 AM and 6 PM, I probably will not answer the phone when I am with a clientpatient. When I am unavailable, my telephone is answered by voice mail. I will make every effort to return your call by on the end of my business same day, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. [In emergencies, you can page me at 256-0463.] If you are unable to reach me and you feel that you can’t wait for me to return your call, contact your family physician, physician or the nearest emergency room and ask for the psychologist or psychiatrist on call, or call 911. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client patient and a therapistpsychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form form that meets certain legal requirements imposed by HIPAAHIPAA and/or Indiana law. There are other situations that require only that you provide writtenHowever, ad- xxxxx consent. Your signature on this Agreement provides consent for those activitiesin the following situations, as followsno authorization is required: • I may occasionally find it helpful to consult other health and mental health profes- sionals professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my clientpatient. The other professionals are also legally bound to keep informa- tion the information confidential. If you don’t object, I will not tell you about these consultations un- less unless I feel that it is important to our work together. I will note all consultations in your Clinical RecordRecord (which is called “PHI” in my Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information). • You should be aware that I may employ administrative staff. In most cases, I need to share protected information with these individuals for both clinical and administrative purposes, such as scheduling, billing and quality assurance. All staff members have been given training about protecting your privacy and have agreed not to release any information outside of the practice without the permission of a professional staff member. • Disclosures required by health insurers or to collect overdue fees are discussed else- where elsewhere in this Agreement. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: • If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatmentthe professional services I provided to you, such information is protected by the social workerpsychologist-client patient privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client in order to defend myself. If a client files a worker’s compensation claim, I must, upon appropriate request, pro- vide a copy of the client’s record to the Labor and Industrial Commission or the Work- ers’ Compensation Division, or the client’s employer. There are some situations in which I am legally obligated to take actions, which I be- lieve are necessary to attempt to protect others from harm and I may have to reveal some information about a client’s treatment. These situations are unusual in my practice. If I have reasonable cause to suspect that a child has been or may be subjected to abuse or neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglect, the law requires that I file a report with Tennessee’s Department of Children’s Services. Once such a report is filed, I may be required to provide additional information. If I have reasonable cause to suspect that an elderly or disabled adult presents a like- lihood of suffering serious physical harm and is in need of protective services, the law requires that I file a report with Adult Protective Services. Once such a report is filed, I may be required to provide additional information. If I believe that it is necessary to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by the client on him/her- self or another person, I may be required to take protective action. These actions may include, and/or initiating hospitalization and/or contacting the potential victim, and/or the police and/or the client’s family. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure is reasonably likely to endanger you and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harm, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of 35 cents per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Records, you have a right of review, which I will discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents of our conversations, my analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentially.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include:
Appears in 1 contract
Samples: Patient Services Agreement
Meetings. I normally conduct an evaluation that will last from 1-2 lasts for approximately two sessions. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If therapy has psychotherapy is begun, I will usually schedule one 45-50 minute ses- sion session per week or every two weeks at a time we agree on, although some sessions may be longer or more frequentupon. Once an appointment hour is scheduled, you will be expected to pay for it un- less unless you provide 24-hours advanced advance notice of cancellationcancellation or unless we both agree that you are unable to attend due to circumstances beyond your control. It is important to note that insurance companies do not provide reimbursement for cancelled sessionscanceled sessions and I cannot xxxx them for no-show fees. Professional Fees Psychological assessments are procedures that are usually requested by another professional who you are working with or may be a procedure that we agree is an appropriate undertaking prior to psychotherapy. Psychological assessments are highly useful for diagnostic clarity and for understanding important psychological dynamics that underlie potential problems. PROFESSIONAL FEES: The fee for the initial diagnostic consultation and clinical interview is $200.00. My regular hourly fee varies depending on services and durationfees for a 50 – minute to 60-minute individual psychotherapy session is $125.00, 20-minute to 30-minute is $110.00. In addition to weekly ap- pointmentsappointments, I charge this amount for other professional services you may need. How- ever, though I will break down breakdown the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services include report writing, telephone conversations lasting longer than 10-minutes, Skype appoint- ments or check-insconversations, consulting with other professionals with on your permissionbehalf, prepar- ing preparation of records or treatment summaries, and the time spent performing any other ser- vices you may request service required of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, time including preparation and transportation costs, cost even if I am called to testify by another party. Be- cause of the difficulty of legal involvement, I charge $500 per hour 215.00, accrued in 15 minute intervals for preparation and attendance at any legal proceedingsproceeding. Contacting Me CONTACTING ME: Due to my work schedule, I am often not immediately available by telephone. While I am usually in my the office four days a weekbetween 9:00 a.m. and 3:00 p.m. Monday to Friday, I probably most likely will not answer the be unable to accept phone calls when I am with a clientpatient. When I am unavailable, my telephone is answered by an answering machine. I will make every effort to return your call by on the end of my business day, same day or following day with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. If you are unable to reach me and you feel that you can’t cannot wait for me to return your call, you may contact your family physician, go to the nearest emergency room and ask for the psychologist or psychiatrist on callroom, or call 911contact your local emergency mental health community organization. If I will be unavailable for an extended timeIn Steuben, I will provide you with the name of a colleague contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality The law protects the privacy of all communications between a client and a therapist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, ad- xxxxx consent. Your signature on this Agreement provides consent for those activities, as follows: I may occasionally find it helpful to consult other health and mental health profes- sionals about a case. During consultation, I make every effort to avoid revealing the identity of my client. The other professionals are also legally bound to keep informa- tion confidential. If you don’t object, I will not tell you about these consultations un- less I feel that it is important to our work together. I will note all consultations in your Clinical Record. Disclosures required by health insurers or to collect overdue fees are discussed else- where in this Agreement. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the social worker000-client privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client in order to defend myself. If a client files a worker’s compensation claim, I must, upon appropriate request, pro- vide a copy of the client’s record to the Labor and Industrial Commission or the Work- ers’ Compensation Division, or the client’s employer. There are some situations in which I am legally obligated to take actions, which I be- lieve are necessary to attempt to protect others from harm and I may have to reveal some information about a client’s treatment. These situations are unusual in my practice. If I have reasonable cause to suspect that a child has been or may be subjected to abuse or neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglect, the law requires that I file a report with Tennessee’s Department of Children’s Services. Once such a report is filed, I may be required to provide additional information. If I have reasonable cause to suspect that an elderly or disabled adult presents a like- lihood of suffering serious physical harm and is in need of protective services, the law requires that I file a report with Adult Protective Services. Once such a report is filed, I may be required to provide additional information. If I believe that it is necessary to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by the client on him/her- self or another person, I may be required to take protective action. These actions may include, and/or initiating hospitalization and/or contacting the potential victim, and/or the police and/or the client’s family. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports of any professional consultations, your billing records000-0000, and any reports that have been sent to anyonein Allegany County, including reports to your insurance carrier. Except in the unusual circumstance where disclosure is reasonably likely to endanger you and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harm, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of 35 cents per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Records, you have a right of review, which I will discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents of our conversations, my analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentiallycontact 000-000-0000.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include:
Appears in 1 contract
Samples: ldemapsych.design
Meetings. I normally conduct an evaluation that will last from 1-2 to 4 sessions. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If therapy has psychotherapy is begun, I will usually schedule one 45-45 or 60 minute ses- sion session (one appointment hour of 45 or 60 minutes duration) per week at a time we agree on, although some sessions may be longer or more frequent. Once an appointment hour is scheduled, you will be expected to pay for it un- less $100 unless you provide 24-24 hours advanced advance notice of cancellationcancellation [unless we both agree that you were unable to attend due to circumstances beyond your control]. It is important to note that insurance companies do not provide reimbursement for cancelled sessions. Professional Fees I will try to find another time to reschedule the appointment. PROFESSIONAL FEES My hourly fee varies depending on services is $250 for an initial session and duration$200 for subsequent sessions. In addition to weekly ap- pointmentsappointments, I charge this amount for other professional services you may need. How- ever, I will break down the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services include report writing, telephone conversations lasting longer than 10-10 minutes, Skype appoint- ments or check-ins, consulting with other professionals with your permission, prepar- ing preparation of records or treatment summaries, and the time spent performing any other ser- vices service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Be- cause Because of the difficulty of legal involvement, I charge $500 250 per hour for preparation and attendance at any legal proceedingsproceeding. Contacting Me CONTACTING ME (000) 000-0000 Due to my work schedule, I am often not immediately available by telephone. While I am usually in my office four days a weekbetween 9 AM and 7 PM, I probably will not answer the phone when I am with a clientpatient. When I am unavailable, my telephone is answered by voice mail that I monitor frequently, or by my secretary who knows where to reach me. I will make every effort to return your call by the end of my business daywithin 24 hours, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. If In emergencies, if you are unable to reach me and you feel that you can’t wait for me to return your call, contact your family physician, the nearest emergency room and ask for the psychologist or psychiatrist on callroom, or call 911. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client patient and a therapistpsychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form form that meets certain legal requirements imposed by HIPAAHIPAA and/or Illinois law. There are other situations that require only that you provide writtenHowever, ad- xxxxx consent. Your signature on this Agreement provides consent for those activitiesin the following situations, as followsno authori- zation is required: • I may occasionally find it helpful to consult other health and mental health profes- sionals professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my clientpatient. The other professionals are also legally bound to keep informa- tion the information confidential. If you don’t object, I will not tell you about these consultations un- less unless I feel that it is important to our work together. I will note all consultations in your Clinical Record. • You should be aware that I practice with other mental health professionals and that I employ administrative staff. In most cases, I need to share protected information with these individuals for both clinical and administrative purposes, such as scheduling, billing and quality assurance. All of the mental health professionals are bound by the same rules of confidentiality. All staff members have been given training about protecting your privacy and have agreed not to release any information outside of the practice without the permission of a professional staff member. • Disclosures required by health insurers or to collect overdue fees are discussed else- where elsewhere in this Agreement. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: • If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the social workerpsychologist-client patient privilege law. .I cannot provide disclose any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. • If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. • If a client patient files a complaint or lawsuit against me, I may disclose relevant information regarding that client patient in order to defend myself. • If a client files you file a worker’s compensation claim, and I rendering treatment or services in accordance with the provisions of Illinois Workers’ Compensation law, I must, upon appropriate request, pro- vide provide a copy of the client’s your record to the Labor and Industrial Commission your employer or the Work- ers’ Compensation Division, or the client’s employerhis/her appropriate designee. There are some situations in which I am legally obligated to take actions, which I be- lieve believe are necessary to attempt to protect others from harm and I may have to reveal some information about a clientpatient’s treatment. These situations are unusual in my practice. • If I have reasonable cause to suspect believe that a child has been or under 18 known to me in my professional capacity may be subjected to abuse an abused child or neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglectneglected child, the law requires that I file a report with Tennessee’s the local office of the Department of Children’s Children and Family Services. Once such a report is filed, I may be required to provide additional information. • If I have reasonable cause reason to suspect believe that an elderly adult over the age of 60 living in a domestic situation has been abused or disabled adult presents a like- lihood of suffering serious physical harm and is neglected in need of protective servicesthe preceding 12 months, the law requires that I file a report with Adult Protective Servicesthe agency designated to receive such reports by the Department of Aging. Once such a report is filed, I may be required to provide additional information. • If you have made a specific threat of violence against another or if I believe that you present a clear, imminent risk of serious physical harm to another, I may be required disclose information in order to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking your hospitalization. • If I believe that it is necessary to disclose information to protect against you present a clear and substantial clear, imminent risk of imminent serious harm being inflicted by the client on him/her- self physical or another personmental injury or death to yourself, I may be required to disclose information in order to take protective actionactions. These actions may include, and/or initiating include seeking your hospitalization and/or or contacting the potential victim, and/or the police and/or the client’s familyfamily members or others who can assist in protecting you. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records You should The laws governing confidentiality can be aware thatquite complex, pursuant to HIPAAand I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. PROFESSIONAL RECORDS The laws and standards of my profession require that I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure is reasonably likely to endanger you and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harm, you You may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a The fee for copying fee of 35 cents per page (and for certain other expenses)records is $50.00. The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Records, you have a right of review, which I will discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents of our conversations, my analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentially.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights PATIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include:include requesting that I amend your record; requesting restrictions on what information from your Clinical Records is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the Illinois Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights with you. MINORS & PARENTS Patients under 12 years of age and their parents should be aware that the law allows parents to examine their child’s treatment records. Parents of children between 12 and 18 cannot examine their child’s records unless the child consents and unless I find that there are no compelling reasons for denying the access. Parents are entitled to information concerning their child’s current physical and mental condition, diagnosis, treatment needs, services provided, and services needed. Since parental involvement is often crucial to successful treatment, in most cases, I require that patients between 12 and 18 years of age and their parents enter into an agreement that allows parents access to certain additional treatment information. If everyone agrees, during treatment, I will provide parents with general information about the progress of their child’s treatment, and his/her attendance at scheduled sessions. I will also provide parents with a summary of treatment when it is complete. Any other communication will require the child’s Authorization, unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have. BILLING AND PAYMENTS You will be expected to pay for each session at the time it is held. This includes your portion of your insurance coverage i.e. deductible not yet met, copayment, and co-insurance amounts. Payment schedules for other professional services will be agreed to when they are requested. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, we will be unable to schedule any more appointments until a payment is made. In addition to that, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require me to disclose otherwise confidential information. In most collection situations, the only information I release regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due. If such legal action is necessary, its costs will be included in the claim. 4 Grand Oaks Behavioral Heath, LLC is licensed in the state of Illinois as a Group Practice with a practice NPI (National Provider Identifier). All professional treatment given is under the general oversight of Xx. Xxxxxx Xxxxxxxx, Licensed Clinical Psychologist, Director of Clinical Services, and Owner. Your insurance plan may also recognize Xx. Xxxxxxxx, or other licensed professionals, as a network provider and his or her name may appear on your explanation of benefits (EOB) that you will receive from your insurance company. Xx. Xxxxxxxx provides ongoing clinical supervision or collaboration to several clinicians at Grand Oaks Behavioral Health who are gaining clinical hours toward independent licensure. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, I will provide you with what- ever information I can based on my experience and will be happy to help you in understanding the informa- tion you receive from your insurance company. If it is necessary to clear confusion, I will be willing to call the company on your behalf. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in short-term therapy, some patients feel that they need more services after insurance benefits end. Some managed-care plans will not allow me to provide services to you once your benefits end. If this is the case, I will do my best to find another provider who will help you continue your psychotherapy. You should also be aware that your contract with your health insurance company requires that you authorize me to provide it with information relevant to the services that I provide to you. If you are seeking reimbursement for services under your health insurance policy, you will be required to sign an authorization form that allows me to provide such information. I am required to provide a clinical diagnosis. Sometimes I am required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your sessions. It is important to remember that you always have the right to pay for my services yourself to avoid the problems described above.
Appears in 1 contract
Meetings. I normally conduct an evaluation that will last from 1-generally schedule family or couples’ sessions for 1.5- 2 sessions. During this timehours, we both decide if I am the best person to provide the services you need in order to meet your treatment goals. If therapy has begun, I will usually schedule one 45-minute ses- sion per every week at a time we agree on, although some sessions may be longer or more frequentevery other week. Once an appointment hour is scheduled, you will be expected to pay for it un- less unless you provide 24-48 hours advanced advance notice of cancellationcancellation [unless we both agree that you were unable to attend due to circumstances beyond your control]. It is important For Monday appointments, please cancel on Thursday prior to note that insurance companies do not provide reimbursement for cancelled sessionsthe time of the appointment. Professional Fees For example, if you have a 2PM appointment on Monday, a cancellation can be accepted (without fee) no later than 1:58PM on Thursday. PROFESSIONAL FEES My hourly fee varies depending on services and durationis $250, so a session of 1.5 hours will cost $375. In addition to weekly ap- pointmentsappointments, I charge this amount the hourly fee for other professional services you may need. How- ever, though I will break down the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services include report writing, telephone conversations or emails lasting longer than 10-10 minutes, Skype appoint- ments or check-ins, consulting with other professionals with your permission, prepar- ing preparation of records or treatment summaries, and the time spent performing any other ser- vices service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Be- cause Person(s) responsible for paying (indicate name and % of the difficulty of legal involvement, I charge $500 per hour for preparation and attendance at any legal proceedings. Contacting Me fee): CLIENT NAME(S): CONTACTING ME Due to my work schedule, I am often not immediately available by telephonetelephone or email. While I am usually in my office four days a weekroughly between 9 AM and 7 PM, I probably will not answer the phone when I am with a clientpatient. When I am unavailable, my telephone is answered by private voice mail, that my assistant and I monitor frequently. I will make every effort to return your call by as quickly as possible. Note that I am not in the end office on Fridays, and there may be the possibility of my business day, with the exception of delay on weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. [In emergencies, you can leave an urgent message on the office line or write an email with “Urgent” in the message line.] If you are unable to reach me and feel that, you feel that you can’t cannot wait for me to return your call, contact your family physician, “911” or go to the nearest emergency room and ask for the psychologist or psychiatrist on call, or call 911. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. I do get a lot of emails daily, so please feel free to re-send if you do not hear back within 24 hours during the work week. RECORDING SESSIONS There is to be no recording of sessions, either video or audio by any of the parties in the room without all parties agreeing. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx agree to communicate with merefrain from taping by signing this agreement. Limits of Confidentiality LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client patient and a therapistpsychologist. The patient in this case is a family, and all communications are privileged between all family members and myself. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form authorization form that meets certain legal requirements imposed by state law and/or HIPAA. There are other situations that require only that you provide writtenNevertheless, ad- xxxxx consent. Your signature on this Agreement provides consent for those activities, as follows: I may occasionally find it helpful to consult other health and mental health profes- sionals about a case. During consultation, I make every effort to avoid revealing the identity of my client. The other professionals are also legally bound to keep informa- tion confidential. If you don’t object, I will not tell you about these consultations un- less I feel that it is important to our work together. I will note all consultations in your Clinical Record. Disclosures required by health insurers or to collect overdue fees are discussed else- where in this Agreement. There there are some situations where I am permitted or required to disclose information without either your consent or Authorization: If you are involved in I may occasionally find it helpful to consult other health and mental health professionals about a court proceeding and case. During a request is made for information concerning your diagnosis and treatment, such information is protected by the social worker-client privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. If a government agency is requesting the information for health oversight activitiesconsultation, I may be required to provide it for them. If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client in order to defend myself. If a client files a worker’s compensation claim, I must, upon appropriate request, pro- vide a copy of the client’s record to the Labor and Industrial Commission or the Work- ers’ Compensation Division, or the client’s employer. There are some situations in which I am legally obligated to take actions, which I be- lieve are necessary to attempt to protect others from harm and I may have to reveal some information about a client’s treatment. These situations are unusual in my practice. If I have reasonable cause to suspect that a child has been or may be subjected to abuse or neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglect, the law requires that I file a report with Tennessee’s Department of Children’s Services. Once such a report is filed, I may be required to provide additional information. If I have reasonable cause to suspect that an elderly or disabled adult presents a like- lihood of suffering serious physical harm and is in need of protective services, the law requires that I file a report with Adult Protective Services. Once such a report is filed, I may be required to provide additional information. If I believe that it is necessary to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by the client on him/her- self or another person, I may be required to take protective action. These actions may include, and/or initiating hospitalization and/or contacting the potential victim, and/or the police and/or the client’s family. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit avoid revealing the identity of my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure is reasonably likely to endanger you and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harm, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of 35 cents per page (and for certain other expenses)patient. The exceptions other professionals are also legally bound to this policy are contained in keep the attached Notice Form. If I refuse your request for access to your Clinical Records, you have a right of review, which I will discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents of our conversations, my analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentially.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include:CLIENT NAME(S):
Appears in 1 contract
Samples: Family Therapy Services Agreement
Meetings. I normally conduct an evaluation that will last from 1-1 to 2 sessions. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If therapy has psychotherapy is begun, I will usually schedule one 4550-minute ses- sion session (one appointment hour of 50 minutes duration) per week at a time we agree on, although some sessions may be longer or more frequent. Once an appointment hour is scheduled, you will be expected to pay for it un- less unless you provide 24-24 hours advanced advance notice of cancellationcancellation [unless we both agree that you were unable to attend due to circumstances beyond your control]. It is important to note that insurance companies do not provide reimbursement for cancelled sessions. Professional Fees [If it is possible, I will try to find another time to reschedule the appointment.] PROFESSIONAL FEES My hourly fee varies depending on services and durationis $135.00. In addition to weekly ap- pointmentsappointments, I charge this amount for other professional services you may need. How- ever, though I will break down the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services include report writing, telephone conversations lasting longer than 10-minutes, Skype appoint- ments or check-insconversations, consulting with other professionals with your permission, prepar- ing preparation of records or treatment summaries, and the time spent performing any other ser- vices service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Be- cause [Because of the difficulty of legal involvement, I charge $500 135.00 per hour for preparation and attendance at any legal proceedings. Contacting Me proceeding.] CONTACTING ME Due to my work schedule, I am often not immediately available by telephone. While I am usually in my office four days a weekbetween 8:15 AM and 5 PM, I probably will not answer the phone when I am with a clientpatient. I frequently have call-in hours from 12:00 to 1:00 weekdays. When I am unavailable, my telephone is answered by voice mail that I monitor frequently. I will make every effort to return your call by on the end of my business daysame day you make it, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. In after hour emergencies, you can dial 112 after leaving a detailed message on my voice mail. This will cause me to be paged. If you are unable to reach me and you feel that you can’t wait for me to return your call, contact your family physician, physician or the nearest emergency room and ask for the psychologist or psychiatrist on call, or call 911room. If I will be unavailable for an extended time, I that information will provide you be on my voice mail along with the name and number of a colleague to contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client patient and a therapistpsychotherapist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form form that meets certain legal requirements imposed by state law and/or HIPAA. There But, there are other some situations that require only that you provide written, ad- xxxxx consent. Your signature on this Agreement provides where I am permitted or required to disclose information without either your consent for those activities, as followsor Authorization: I may occasionally find it helpful to consult other health and mental health profes- sionals professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my clientpatient. The other professionals are also legally bound to keep informa- tion the information confidential. If you don’t object, I will not tell you about these consultations un- less unless I feel that it is important to our work together. I will note all consultations in your Clinical RecordRecord (which is called “PHI” in my Notice of Psychotherapist’s Policies and Practices to Protect the Privacy of Your Health Information). I also have contracts with a claim filing service. As required by HIPAA, I have a formal business associate contract with this business in which they promise to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I can provide you with the name of this organization and/or a blank copy of this contract. Disclosures required by health insurers or to collect overdue fees are discussed else- where elsewhere in this Agreement. There are some situations where If a patient threatens to harm himself/herself, I am permitted may be obligated to seek hospitalization for him/her, or required to disclose information without either your consent contact family members or Authorization: others who can help provide protection. If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatmentabout the professional services that I have provided you and/or the records thereof, such information is protected by the social workerPsychotherapist-client patient privilege law. I cannot provide any information without your (or your legal legally-appointed representative’s) written authorization, or a court order, or compulsory process (a subpoena) or discovery request from another party to the court proceeding where that party has given you proper notice (when required) and has stated valid legal grounds for obtaining PHI, and I do not have grounds for objecting under state law (or you have instructed me not to object). If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. If a government agency is requesting the information for health oversight activitiesactivities pursuant to their legal authority, I may be required to provide it for them. If a client patient files a complaint or lawsuit against me, I may disclose relevant information regarding that client patient in order to defend myself. If a client patient files a worker’s compensation claim, I must, upon appropriate request, pro- vide a copy of the client’s record disclose information relevant to the Labor and Industrial Commission or claimant's condition, to the Work- ers’ Compensation Division, or the clientworker’s employercompensation insurer. There are some situations in which I am legally obligated to take actions, which I be- lieve believe are necessary to attempt to protect others from harm and I may have to reveal some information about a clientpatient’s treatment. These situations are unusual in my practice. If I have reasonable cause to suspect that a child has been under 18 is abused or may be subjected to abuse or neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglectneglected, the law requires that I file a report with Tennessee’s the appropriate governmental agency, usually Department of Children’s Public Health and Human Services. Once such a report is filed, I may be required to provide additional information. If I know or have reasonable cause to suspect that an elderly older person or disabled adult presents a like- lihood of suffering serious physical harm and is in need of protective servicesperson with a developmental disability has been subjected to abuse, sexual abuse, neglect, or exploitation, the law requires that I file a report with Adult Protective the appropriate governmental agency, usually Department of Public Health and Human Services. Once such a report is filed, I may be required to provide additional information. If I believe that it is necessary to disclose information to protect a patient communicates an actual threat of immediate threat of physical violence by specific means against a clear and substantial risk of imminent serious harm being inflicted by the client on him/her- self clearly identified or another personreasonably identifiable victim, I may be required to take protective actiondisclose protected information in order to protect the threatened victim. These actions may include, and/or initiating hospitalization and/or contacting include notifying the potential victim, and/or contacting the police and/or police, or seeking hospitalization for the client’s familypatient. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records The laws governing confidentiality can be quite complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. PROFESSIONAL RECORDS You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure is reasonably likely to endanger you and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harm, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of 35 cents per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Records, you have a right of review, which I will discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentially.] These Psychotherapy Notes are kept separate from your Clinical Record. Your While insurance companies can request and receive a copy of your Clinical Record, they cannot receive a copy of your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your writtensigned, signed written Authorization. Insurance companies cannot require your authorization Authorization as a condition of coverage nor penalize you in any way for your refusal refusal. You may examine and/or receive a copy of both sets of records if you request it in writing, except for information provided by an individual (other than another health care provider) in confidence under circumstances in which confidentiality was appropriate and the access requested would be reasonably likely to provide itreveal the source of the information. Patient Rights Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. [I am sometimes willing to conduct this review meeting without charge.] In most situations, I am allowed to charge a copying fee not to exceed 50 cents per page, and an administrative fee that may not exceed $15 for searching and handling recorded health care information. I may withhold your records until the fees are paid. The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your records, you have a right of review (except for information provided in confidence by another individual other than another health care provider), which I will discuss with you upon request. PATIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include:include requesting that I amend your record; requesting restrictions on what information from your Clinical Records is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights with you. MINORS & PARENTS Patients under 18 years of age who are not emancipated and their parents should be aware that the law may allow parents to examine their child’s treatment records. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is sometimes my policy to request an agreement from parents that they consent to give up their access to their child’s records. If they agree, during treatment, I will provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. I will also provide parents with a summary of their child’s treatment when it is complete. Any other communication will require the child’s Authorization, unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have.
Appears in 1 contract
Samples: www.stevetobin.org
Meetings. I normally conduct an evaluation that will last from 1-1 to 2 sessions. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If therapy has is begun, I will usually schedule one 45approximately 55-minute ses- sion session (one appointment hour of approximately 55 minutes duration) per week or every other week at a time we agree on, although some sessions may be longer or more frequent. Once an appointment hour is scheduled, you will be expected to pay for it un- less unless you provide 24-hours advanced 24 hours’ advance notice of cancellationcancellation or unless we both agree that you were unable to attend due to circumstances beyond your control. If I do not receive any notice and you do not attend your session you will also be charged the full amount. It is important to note that insurance companies do not provide reimbursement for cancelled or missed sessions. If you fail to attend a session without calling to cancel two times, depending on extenuating circumstances, any future appointments will be either be “double booked”. In other words, I will schedule an appointment for you when I have another client scheduled. If that client cancels, you may have that session hour. If that client attends their session, you will be rescheduled in another “double booked” appointment. Arrangements for future dedicated appointments can be discussed when a commitment to treatment is shown through continued contact and attendance at double booked appointments. I also reserve the right to refer you to another clinician after two “no show” appointments. Professional Fees Services My hourly fee varies depending on is $150. Additional services and duration. In addition to weekly ap- pointments, I charge this amount for other professional services you may need. How- ever, I will break down the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services include such as report writing, telephone conversations lasting longer than 10-minutes, Skype appoint- ments or check-ins, consulting with other professionals with your permissionphysicians, prepar- ing of records or treatment summarieswriting reports, and the time spent performing any other ser- vices service you may request of meme will be billed at a prorated rate depending on time. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Be- cause Because of the difficulty of legal involvement, I charge $500 175 per hour for preparation and attendance at any legal proceedingsproceeding. You will be expected to pay for each session at the time that it is held, unless we agree otherwise or if you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. I do accept credit cards however there is a $3 convenience fee. In circumstances of unusual financial hardship, I may be willing to negotiate a fee adjustment or payment installment plan. If your account has not been paid for more than 60 days and arrangements have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require me to disclose otherwise confidential information. In most collection situations, the only information I release regarding a client’s treatment is his or her name, the nature of services provided, and the amount due. If such legal action is necessary, its costs will be included in the claim. Insurance reimbursement In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy (including Medicaid), it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, I will be willing to call the company on your behalf. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services. These plans are often limited to short term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in short term therapy, some clients feel that they need more services after insurance benefits end. You should also be aware that your contract with your health insurance company requires that I provide it with information relevant to the services that I provide to you. I am required to provide a clinical diagnosis. Sometimes I am required to provide additional information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your sessions. It is important to remember that you always have the right to pay for my services yourself and avoid the problems described. Contacting Me me Due to my work schedule, I am often not immediately available by telephone. While Though I have my work phone with me during the work day (approximately 10am to 5pm) I do not answer my phone during sessions. My telephone is answered by voicemail that I check frequently. Be sure to leave me your phone number in case I check messages while I am usually not in my office four days a week, I probably will and do not answer the phone when I am with a clienthave access to your file. I will make every effort to return your call by the end of my business daypromptly, with the exception of evenings, weekends and holidays, when I return the call as soon as possible until 5pm. If you are difficult After 5pm I will answer emergency calls only. I will use my clinical judgment to reach, please inform me of some times when you will be availabledetermine if your call warrants a crisis. If you are unable to reach me and you feel that you can’t wait for me to return your call, contact your family physician, physician or the nearest emergency room and ask for the psychologist or psychiatrist on call, or call 911. If I will be unavailable for an extended time, I will provide you with the name and phone number of a colleague to contact, if necessary. You may also utilize are welcome to contact me via text or email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx as well. If you choose to communicate with metext or email (or want me to contact you in that fashion) please note that these are not secure methods of communication. Limits of Confidentiality on confidentiality The law protects the privacy of all communications between a client patient and a therapist. In most situations, situations I can only release information about your treatment to others if you sign a written Authorization Form form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, ad- xxxxx advance consent. Your signature on this Agreement provides consent for those activities, as follows: - I may occasionally find it helpful to consult other health and mental health profes- sionals professionals about a case. During consultation, consultation I make every effort to avoid revealing the identity of my client. The other professionals are also legally bound to keep informa- tion the information confidential. If you don’t object, I will not tell you about these consultations un- less unless I feel that it is important to our work together. I will note all consultations in your Clinical RecordRecord (which is called “PHI” in my Notice of Therapist’s Policies and Practices to Protect the Privacy of Your Health Information). - Disclosures required by health insurers or to collect overdue fees are discussed else- where elsewhere in this Agreement. - If I believe that a client presents imminent danger to his or her health or safety, I may be obligated to seek hospitalization for him or her or to contact family members or others who can help provide protection. There are some situations where I am permitted or required to disclose information without either your consent or Authorizationauthorization: - If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatmentthe professional services that I provided you, such information is protected by the social workertherapist-client privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, authorization or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. - If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. - If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client in order to defend myself. - If a client files a worker’s compensation claim, and my services are being compensated through workers compensation benefits, I must, upon appropriate request, pro- vide provide a copy of the client’s record to the Labor and Industrial Commission client’s employer or the Work- ers’ Compensation Division, or the client’s employerNorth Carolina Industrial Commission. There are some situations in which I am legally obligated to take actions, which I be- lieve believe are necessary to attempt to protect others from harm and I may have to reveal some information about a client’s treatment. These situations are unusual in my practice. : - If I have reasonable cause to suspect that a child has been under 18 is abused or may be subjected to abuse neglected, or neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglect, the law requires that I file a report with Tennessee’s Department of Children’s Services. Once such a report is filed, I may be required to provide additional information. If if I have reasonable cause to suspect believe that an elderly or a disabled adult presents a like- lihood of suffering serious physical harm and is in need of protective services, the law requires that I file a report with Adult Protective the Department of Social Services. Once such a report is filed, filed I may be required to provide additional information. - If I believe that it is necessary a client presents an imminent danger to disclose information to protect against a clear the health and substantial risk safety of imminent serious harm being inflicted by the client on him/her- self or another person, I may be required to disclose information in order to take protective action. These actions may includeactions, and/or including initiating hospitalization and/or contacting hospitalization, warning the potential victim, if identifiable, and/or calling the police and/or the client’s familypolice. If such a situation arises, arises I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. The laws governing confidentiality can be quite complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. Professional Records records You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets of professional recordsyou. One set This constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in unusual circumstances that involve danger to yourself and/or others or the unusual circumstance where disclosure records makes reference to another person (unless such other person is a health care provider) and I believe that access is reasonably likely to endanger you and/or others or when another individual (cause substantial harm to such other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harmperson, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a the copying fee of 35 cents per page (and for certain other expenses)) of $.50 per page. The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Recordsrecords, you have a right of review, which I will discuss with you upon request. In additionPlease note that your Record is kept in a locked file cabinet within my office. This cabinet is accessible to one clinician with whom I share space. However, I also keep a set your confidentiality is of Psychotherapy Notes. These Notes are for my own use utmost importance and are designed every effort is made to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents of our conversations, my analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentiallymaintain this confidentiality.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include:
Appears in 1 contract
Samples: Therapist Services Agreement
Meetings. I normally conduct an evaluation that will last from 1-2 to 4 sessions. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If therapy has begun, I will usually schedule one 4553-minute ses- sion session per week at a time we agree on, although some sometimes sessions may be longer more or more less frequent. Meeting regularly is important, allowing for continuity and greater progress. Once an appointment hour is scheduled, you will be expected to pay for it un- less unless you provide 24-24 hours advanced advance notice of cancellation, even if that 24 hours falls on a weekend or holiday. It is important to note that insurance companies do not provide reimbursement for cancelled or missed sessions. Professional Fees My hourly fee varies depending on services and durationIf you are late for an appointment, the appointment will end at the usual time. PROFESSIONAL FEES In addition to weekly ap- pointmentsappointments, I charge this amount the same as my normal hourly fee for other professional services you may need. How- everservices, though I will break down the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services include report writing, telephone conversations lasting longer than 10-5 minutes (there is a $35 flat fee and also prorated actual time beyond 5 minutes, Skype appoint- ments or check-ins), consulting with other professionals with your permission, prepar- ing preparation of records or treatment summaries, and the time spent performing any other ser- vices service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Be- cause Because of the difficulty of legal involvement, I charge $500 450.00 per hour for preparation preparation, transportation and attendance at any legal proceedingsproceeding. Contacting Me Due to my work schedule, Legal fee are not covered by insurance. CONTACTING ME I am often not immediately available by telephone. While I am usually in my office four days a weekavailable between 9 AM and 5 PM, I probably will not answer the phone when I am with a clientpatient. When I am unavailable, my telephone is answered by voicemail. However, voicemail and text occasionally delays sending the message. I will make every effort to return your call by within 3 hours and almost always the end of my business same day, with the exception of often including weekends and holidays. If I don’t return the message within that time, feel free to call or text again, because perhaps I did not get the message due to the occasional IT issues. If you are difficult to reach, please inform me of some times when you will be available. If you are unable to reach me and you feel that you can’t wait for me to return your call, contact your family physician, physician or the nearest emergency room and ask for the psychologist or psychiatrist mental health professional on call, or call 911. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client patient and a therapistpsychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form authorization form that meets certain legal requirements imposed by HIPAAHIPAA and/or Illinois law. There are other situations that require only that you provide writtenHowever, ad- xxxxx consent. Your signature on this Agreement provides consent for those activitiesin the following situations, as followsno authorization is required: I may occasionally find it helpful to consult other health and mental health profes- sionals professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my clientpatient. The other professionals are also legally bound to keep informa- tion the information confidential. If you don’t object, I will not tell you about these consultations un- less unless I feel that it is important to our work together. I will note all consultations in your Clinical RecordRecord (which is called “PHI”). As required by HIPAA, if I have a formal business associate contract (ie with a billing clearing house), there would be a contract in which they promise to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. You can ask and see any such contracts if you wish. Disclosures required by health insurers or to collect overdue fees are discussed else- where elsewhere in this Agreement. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the social workerpsychologist-client patient privilege law. I cannot provide disclose any information without your (a court order or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. If a government agency is requesting the information for health oversight activities, I may be required to provide it for to them. If a client patient files a complaint or lawsuit against me, I may disclose relevant information regarding that client patient in order to defend myself. If a client files you file a worker’s compensation claim, and I rendered treatment or services in accordance with the provisions of Illinois Workers’ Compensation law, I must, upon appropriate request, pro- vide provide a copy of the client’s your record to the Labor and Industrial Commission your employer or the Work- ers’ Compensation Division, or the client’s employertheir appropriate designee. There are some situations in which I am legally obligated to take actions, which I be- lieve are necessary to attempt to protect others from harm and I may have to reveal some information about a client’s treatment. These situations are unusual in my practice. If you have made a specific threat of violence against another or if I believe that you present a clear, imminent risk of serious physical harm to another, I am required to disclose information in order to take protective actions. These actions may include notifying the potential victim, contacting law enforcement, seeking your hospitalization and/or reporting you to the FOID data base. If I have reasonable cause to suspect believe that a child has been or under 18 known to me in my professional capacity may be subjected to abuse an abused or neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglectneglected child, the law requires that I file a report with Tennessee’s the local office of the Department of Children’s Children and Family Services. Once such a report is filed, I may be required to provide additional information. If I have reasonable cause reason to suspect believe that an elderly adult over the age of 60 living in a domestic situation has been abused or disabled adult presents a like- lihood of suffering serious physical harm and is neglected in need of protective servicesthe preceding 12 months, the law requires that I file a report with Adult Protective Servicesthe agency designated to receive such reports, ie the Department of Aging or law enforcement. Once such a report is filed, I may be required to provide additional information. If I believe that it is necessary you present a clear, imminent risk of serious physical or mental injury or death to yourself, I am required to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by the client on him/her- self or another person, I may be required in order to take protective actionactions. These actions may includeinclude seeking your hospitalization or contacting family members or others who can assist in protecting you, reporting you to the DHS/FOID data base and/or initiating hospitalization and/or contacting the potential victim, and/or the police and/or the client’s familycalling 911 which may include law enforcement or emergency medical services. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. For security reasons, the office has a video doorbell outside the office and sends alerts to my phone. Images are stored on the cloud for 7-30 days and then they are automatically deleted. They can be downloaded by myself if there is suspicious criminal activity. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records You should The laws governing confidentiality can be aware thatquite complex, pursuant to HIPAAand I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. The addendum describes my responsibility if PHI is hacked, which has never happened in my practice. PROFESSIONAL RECORDS The laws and standards of my profession require that I keep Protected Health Information (PHI) about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure is reasonably likely to endanger you and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harm, you You may examine and/or receive a copy of your Clinical Record, if you request it in writingwriting and your signature is witnessed. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of 35 cents $25 plus $5.00 per page (page, and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Records, you have a right of review, which I will discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents of our conversations, my analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentially.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights PATIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include:include requesting that I amend your record, requesting restrictions on what information from your Clinical Records is disclosed to others, requesting an accounting of disclosures of protected health information that you have neither consented to nor authorized, determining the location to which protected information disclosures are sent, having any complaints you make about my policies and procedures recorded in your records, and the right to a paper copy of this Agreement about my privacy policies and procedures. I am happy to discuss any of these rights with you. MINORS & PARENTS Parents/guardians of children between 12 and 18 cannot examine their child’s records unless the child consents and unless I find that there are no compelling reasons for denying the access. Parents are entitled to information concerning their child’s current physical and mental condition, diagnosis, treatment needs, services provided, and services needed. Since parental involvement is often crucial to successful treatment, in most cases, I require that patients between 12 and 18 years of age and their parents enter into an agreement that allows parents access to certain additional treatment information. If everyone agrees, during treatment I will provide parents with general information about the progress of their child’s treatment and his/her attendance at scheduled sessions. Any other communication will require the minor’s authorization, unless I feel that the minor is in danger or is a danger to someone else, in which case, I will notify the parents/guardians and/or law enforcement. Before giving parents any information, I will discuss the matter with the minor, if possible, and do my best to handle any objections he/she may have. BILLING AND PAYMENTS You are expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require me to disclose otherwise confidential information. In most collection situations, the only information I release regarding a patient’s treatment is his/ her name, the nature of services provided, and the amount due. If such legal action is necessary, its costs will be included in the claim. All unpaid balances over 30 days old will accrue interest at 1½ % per month. This may be turned over to collections and will appear on your credit report if not paid within 30 days. You will also be responsible for the additional charges incurred in the collection and legal process. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have health insurance, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with assistance in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees within 60 days of the service date. It is very important that you find out exactly what out-patient (in office) mental health services your insurance policy covers. If you have questions about the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and will be happy to help you understand the information you receive from your insurance company.
Appears in 1 contract
Samples: apsychologicalservice.com
Meetings. I normally conduct an evaluation that typically meet with patients at the initial intake/consultation. At this meeting, I ask for detailed information about the problems the patient has been experiencing. At the end of the session, I will last from 1-2 sessions. During this time, we both decide let you know if I am think I can be helpful given the best person history you have provided. I ask patients to provide go home and think about the services you need in order meeting. I ask them to meet your treatment goalslet me know by phone or e-mail if they would like to schedule another appointment. If therapy has psychotherapy is begun, I will usually schedule one 45-55 minute ses- sion session (one appointment hour of 55 minutes duration) per week or at specified intervals at a time we agree on, although some sessions may be longer or more frequent. PROFESSIONAL FEES The fee for the initial intake/consultation is $215.00. Fees for subsequent sessions are $175.00. I require keeping a credit card on file. This card will be charged on the date of service, unless you prefer to pay with cash or check at the time of service. Upon request, you will be provided a receipt for your records Once an appointment hour is scheduled, you will be expected to pay for it un- less unless you provide 24-24 hours advanced advance notice of cancellation. It is important cancellation (unless we both agree that you were unable to note that insurance companies do not provide reimbursement for cancelled sessions. Professional Fees My hourly fee varies depending on services and duration. In addition attend due to weekly ap- pointments, I charge this amount for other professional services you may need. How- ever, I will break down the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services include report writing, telephone conversations lasting longer than 10-minutes, Skype appoint- ments or check-ins, consulting with other professionals with circumstances beyond your permission, prepar- ing of records or treatment summaries, and the time spent performing any other ser- vices you may request of mecontrol). If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Be- cause Because of the difficulty of legal involvement, I charge $500 165.00 per hour for preparation and attendance at any legal proceedingsproceeding. Contacting Me This includes preparation, driving time, and all time spent in court. In addition, a charge of $75 per hour will be assessed by my assistant regarding any legal proceeding. CONTACTING ME Due to my work schedule, I am often not immediately available by telephone. While When I am usually in unavailable you may leave a message on my office four days a week, I probably will not answer the phone when I am with a clientvoice mail at 000-000-0000. I will make every effort to return your call by the end of my business day, with the exception of weekends and holidayswithin 24 hours. If you are difficult to reach, please inform me of some times when you will be available. If you are unable facing a life threatening emergency, you should go to reach me and you feel that you can’t wait for me to return your call, contact your family physician, the nearest emergency room and ask for the psychologist or psychiatrist mental health professional on call. The phone number for the Suicide Center of North Texas is (000)000-0000. The National Suicide Prevention lifeline phone number is (000)000-0000. All email communication goes through my administrative assistant (xxxxxxxxx000@xxxxx.xxx) and should not be used to contact me in an emergency. E-mail, or call 911phone texts and similar forms of communication may be vulnerable to unauthorized access which can compromise privacy and confidentiality. If I will be unavailable for an extended time, I will Electronic means of communication are not fail-safe in terms of encryption and do not provide you with the name of a colleague contact, if necessarysame protection as face to face therapy sessions. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx Please do not use electronic communication to communicate with mesend sensitive information. Limits of Confidentiality LIMITS OF CONFIDENTIALITY The law protects the privacy of all communications between a client patient and a therapistpsychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, ad- xxxxx advance consent. Your signature on this Agreement provides consent for those activities, as follows: I may occasionally find it helpful to consult other health and mental health profes- sionals professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my clientpatient. The other professionals are also legally bound to keep informa- tion the information confidential. If you don’t n't object, I will not tell you about these consultations un- less unless I feel that it is important to our work together. I will note all consultations in your Clinical RecordRecord (which is called "PHI" in my Notice of Psychologist's Policies and Practices to Protect the Privacy of Your Health Information). Disclosures required by health insurers If a patient seriously threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her, or to collect overdue fees are discussed else- where in this Agreementcontact family members or others who can help provide protection. Texas law provides that a professional may disclose confidential information only to medical or law enforcement personnel if the professional determines that there is a probability of imminent physical injury by the patient to the patient or others, or there is a probability of immediate mental or emotional injury to the patient. There are some situations where I am permitted or required to disclose information without either your consent or Authorizationauthorization: If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the social worker-client privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. If a client patient files a complaint or lawsuit against me, I may disclose relevant information regarding that client patient in order to defend myself. If a client patient files a worker’s 's compensation claim, I must, upon appropriate request, pro- vide provide records relating to treatment or hospitalization for which compensation is being sought. If a copy of the client’s record patient fails to the Labor and Industrial Commission or the Work- ers’ Compensation Divisionpay for services I have rendered, or the client’s employerI may disclose relevant information in a suit seeking payment. There are some situations in which I am legally obligated to take actions, which I be- lieve believe are necessary to attempt to protect others from harm and I may have to reveal some information about a client’s patient's treatment. These situations are unusual in my practice. If I have reasonable cause to suspect believe that a child under 18 has been or may be subjected to abuse abused or neglected (including physical injury, substantial threat of harm, mental or emotional injury, or any kind of sexual contact or conduct), or that a child is a victim of a sexual offense, or that an elderly or disabled person is in a state of abuse, neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglectexploitation, the law requires that I file make a report with Tennessee’s to the appropriate governmental agency, usually the Department of Children’s Protective and Regulatory Services. Once such a report is filed, I may be required to provide additional information. If I have reasonable cause to suspect determine that an elderly or disabled adult presents there is a like- lihood of suffering serious probability that the patient will inflict imminent physical harm and is in need of protective services, the law requires that I file a report with Adult Protective Services. Once such a report is filed, I may be required to provide additional information. If I believe that it is necessary to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by the client injury on him/her- self herself, or another personanother, or that the patient will inflict imminent mental or emotional harm upon others, I may be required to take protective action. These actions may include, and/or initiating action by disclosing information to medical or law enforcement personnel or by securing hospitalization and/or contacting of the potential victim, and/or the police and/or the client’s familypatient. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and and, I will limit my disclosure to what is necessary. By signing this agreement, you authorize me to contact any person/entity in a position to prevent harm to the patient or a third party if I determine there is a probability of harm to the patient or a third party. In addition, I have an assistant, Xxx Xxxxxx, and part-time assistant Xxxxxx Xxxxxx who work in the office assisting with paper work and office duties. This work brings them into contact with PHI of the clients with whom I work. As an employee working with a psychologist, they are bound by the same duties of confidentiality required of me. I have educated them about the requirement that they view only that portion of PHI required to complete administrative tasks included but not limited to correspondence (scheduling, sending copies of this document…) with a patient’s parents or patient by mail, telephone, or e-mail, filing, copying, and data entry of responses to questionnaires. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records You should The laws governing confidentiality can be aware thatquite complex and I am not an attorney. In situations where specific advice is required, pursuant to HIPAA, formal legal consultation may be needed. PROFESSIONAL RECORDS The laws and standards of my profession require that I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It , The Clinical Record includes information about your reasons for seeking therapy, a description of the ways in which your the problem impacts on your life, your the diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrierschool. Except in the unusual circumstance where disclosure is reasonably likely circumstances that involve danger to endanger you yourself and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harmothers, you may examine and/or receive a copy of your Clinical Record, Record if you request it in writing. You should be aware that pursuant to Texas law, psychological test data are not part of a patient's record. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of 35 cents $.50 per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Recordsrecords, you have a right of review, which I will discuss with you upon your request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents of our conversations, my analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentially.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights PATIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your Clinical Records Record and disclosures of protected health information. These rights include:include requesting that I amend your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and my privacy policies and procedures. MINORS & PARENTS Patients 18 years of age and older must consent for their own treatment. In order for me to communicate with parents, I must have a signed release from the patient. If parents are paying for treatment of their adult son or daughter, I will provide the patient with a receipt after each session that parents can use to file an insurance company claim. In most cases in which a patient has given written permission to speak with his or her parents, I will discuss it with the patient first.
Appears in 1 contract
Samples: Patient Services Agreement
Meetings. I normally conduct an evaluation that will last from 12-2 4 sessions. During this time, we both will decide if I am the best person professional to provide the services help you need in order to meet your treatment goals. If therapy has psychotherapy is begun, I will usually schedule one 45-50 minute ses- sion per week at session (one appointment hour is 45-50 minutes). How often we meet is based on your needs. An appointment is a time we agree on, although some sessions may be longer or more frequentcommitment to our work and a contract between us. Once an appointment hour is scheduled, you will be expected to pay for it un- less the time you have reserved with me unless you provide 24-hours hour advanced notice of cancellation. It is important to Please note that insurance companies do not provide reimbursement reimburse for missed or cancelled sessions. Professional Fees My hourly fee varies depending on services and durationis $130.00 for the initial session, $120.00 for subsequent sessions per 45 minute session. In addition to weekly ap- pointmentsappointments, I charge this amount on a prorated basis for other professional services you may need. How- ever, I will break down the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services include require such as report writing, telephone conversations lasting that last longer than 10-10 minutes, Skype appoint- ments attendance at meetings or check-ins, consulting consultations with other professionals with your permissionwhich you have authorized, prepar- ing preparation of records or treatment summaries, and or the time spent performing required to perform any other ser- vices service that you may request of me. If you become involved in legal proceedings litigation that require requires my participation, you will be expected to pay for all of my the professional time, including preparation and transportation costs, time required even if I am called compelled to testify by for another party. Be- cause Contacting Me Out of the difficulty of legal involvementconsideration for clients, I charge $500 per hour for preparation and attendance at any legal proceedings. Contacting Me Due to my work schedule, I am often do not immediately available by telephone. While I am usually in my office four days a week, I probably will not answer the phone take telephone calls when I am with a clientin sessions. When I am not available, my telephone is answered by voicemail. As soon as I can, I will make every effort respond to your message. You can leave a confidential voicemail message for me at anytime. When listening to messages, I turn the volume off so that others are unable to hear incoming messages left by callers. Voicemail requires a password and is not accessed by others. If you call after hours or on weekends, I will return your call by the end of my business next working day, with the exception of weekends and holidays. If you are difficult to reachcall after 5 PM and it is an emergency, please inform me of some times when you will be available. If you are unable to reach me and you feel that you can’t wait for me to return your call, contact your family physician, follow the nearest emergency room and ask for the psychologist or psychiatrist on call, or call 911directions. If I will be am unavailable for an extended period of time, I will provide you with the name of a colleague to contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality The law protects the privacy of all communications between a client and a therapist. In I have found in most situations, I can only release information about your treatment to others if you sign a written Authorization Form cases that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, ad- xxxxx consent. Your signature on this Agreement provides consent for those activities, as follows: I may occasionally find it helpful to consult other health and mental health profes- sionals about a case. During consultation, I make every effort to avoid revealing the identity of my client. The other professionals are also legally bound to keep informa- tion confidentialtelephone counseling is not effective. If you don’t objectneed more than five minutes to resolve and issue, it is most helpful to schedule an appointment. If a telephone consultation exceeds 10 minutes, I will not tell charge you about these consultations un- less I feel that it is important to at our work togetherusual rate. I will note all consultations in your Clinical RecordIn an emergency…call the office number and follow the instructions on the voice mail recording. Disclosures required by health insurers or to collect overdue fees are discussed else- where in this Agreement. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the social worker-client privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court orderThis xxxx xxxx me. If you are involved in can not reach me or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order can not wait for me to disclose informationreturn your call, contact your family physician or prescribing psychiatrist (if applicable). If a government agency is requesting You also can call the information for health oversight activities, I may be required to provide it for them. If a client files a complaint Respond Program (000) 000-0000 or lawsuit against me, I may disclose relevant information regarding that client in order to defend myself. If a client files a worker’s compensation claim, I must, upon appropriate request, pro- vide a copy of the client’s record 0-000-000-0000 or go to the Labor and Industrial Commission or the Work- ers’ Compensation Division, or the client’s employer. There are some situations in which I am legally obligated to take actions, which I be- lieve are necessary to attempt to protect others from harm and I may have to reveal some information about a client’s treatment. These situations are unusual in my practice. If I have reasonable cause to suspect that a child has been or may be subjected to abuse or neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglect, the law requires that I file a report with Tennessee’s Department of Children’s Services. Once such a report is filed, I may be required to provide additional information. If I have reasonable cause to suspect that an elderly or disabled adult presents a like- lihood of suffering serious physical harm and is in need of protective services, the law requires that I file a report with Adult Protective Services. Once such a report is filed, I may be required to provide additional information. If I believe that it is necessary to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by the client on him/her- self or another person, I may be required to take protective action. These actions may include, and/or initiating hospitalization and/or contacting the potential victim, and/or the police and/or the client’s family. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons nearest emergency room for seeking therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure is reasonably likely to endanger you and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harm, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of 35 cents per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Records, you have a right of review, which I will discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents of our conversations, my analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentiallyimmediate assistance.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include:
Appears in 1 contract
Samples: Psychotherapy Services Agreement
Meetings. I normally conduct an evaluation that will last from 1-2 1 to 3 sessions. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If therapy has psychotherapy is begun, I will usually schedule one 45-50- minute ses- sion session (one appointment hour of 50 minutes duration) per week at a time we agree on, although some sessions may be longer or more frequent. Once an appointment PROFESSIONAL FEES My fees are as follows: Initial 90 minute visit is $250.00; Individual Therapy 50 minute therapeutic hour fee is scheduled$160.00; and, you will be expected to pay for it un- less you provide 24-hours advanced notice of cancellation. It Family Therapy 50 minute session is important to note that insurance companies do not provide reimbursement for cancelled sessions. Professional Fees My hourly fee varies depending on services and duration. In addition to weekly ap- pointments, I charge this amount for other professional services you may need. How- ever, I will break down the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurance$160.00. Other services include report writing, telephone conversations lasting longer than 10-minutes, Skype appoint- ments or check-ins, consulting with other professionals with your permission, prepar- ing preparation of records or treatment summaries, and the time spent performing any other ser- vices service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Be- cause of the difficulty of legal involvement, I charge $500 250.00 per hour for preparation and attendance at any legal proceedingsproceeding. Contacting Me Due Please be advised there will be periodic increases. Should you have any questions regarding fee changes, please feel free to my work schedulediscuss them with me. CANCELLATIONS Your appointment time is reserved exclusively for you. Please help us serve you better by keeping scheduled appointments. Unless cancelled at least 24 hours in advance, I am often you will be charged for the missed appointment/late cancellation at the rate of a normal office visit. It is important to note that insurance companies do not immediately available by telephoneprovide reimbursement for cancelled sessions. Please accept responsibility for keeping your appointments as WE DO NOT CALL YOU OR MAIL YOU A REMINDER. CONTACTING ME / EMERGENCIES While I am usually in my office four days a weekMonday through Thursday, I probably will do not answer the phone when I am with a clientpatient. When I am unavailable, my telephone is answered by an auto-attendant voice mail that I monitor frequently. I will make every effort to return your call by on the end of my business day, with the exception of weekends and holidayssame day you make it. If you are difficult to reach, please inform me of some times when you will be available. If you are unable to reach me and you feel that you can’t wait for me to return your call, contact your family physician, the nearest emergency room and ask for the psychologist or psychiatrist on call, or call 911. [If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary.] For psychological emergencies after hours, call 911 or go to the nearest hospital. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client patient and a therapistpsychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, ad- xxxxx advance consent. Your signature on this Agreement Agreeme nt provides consent for those activities, as follows: I may occasionally find it helpful to consult other health and mental health profes- sionals professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my clientpatient. The other professionals are also legally bound to keep informa- tion the information confidential. If you don’t object, I will not tell you about these consultations un- less unless I feel that it is important to our work together. . You should be aware that I will note all consultations practice in a shared office space environment with other mental health professionals and that I contract with independent business associates to handle the paperwork of my daily business operations. In most cases, I need to share protected information with these individuals for both clinical and administrative purposes, such as scheduling, billing and quality assurance. All of these mental health professionals and business associates are bound by the same rules of confidentiality and have been given training about protecting your Clinical Recordprivacy and have agreed not to release any information outside of this practice without permission. As required by HIPAA, I have a formal business associate contract with these businesses, in which they promise to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I can provide you with the names of these organizations and/or a blank copy of this contract. Disclosures required by health insurers or to collect overdue fees are discussed else- where elsewhere in this Agreement. Licensed Psychological Associates are required by NC statute to receive supervision for providing psychological services. As a level III Psychological Associate, Xx. Xxxxx Xxxxxx will be discussing your PHI during supervision with Xx. Xxxxx Xxxxxxx, PhD on a once per month basis. If I believe that a patient presents an imminent danger to his/her health or safety, I may be obligated to seek hospitalization for him/her, or to contact family members or others who can help provide protection. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatmentthe professional services that I provided you, such information is protected by the social workerpsychologist-client patient privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. If a client patient files a complaint or lawsuit against me, I may disclose relevant information regarding that client patient in order to defend myself. If a client patient files a worker’s compensation claim, and my services are being compensated through workers compensation benefits, I must, upon appropriate request, pro- vide provide a copy of the clientpatient’s record to the Labor and Industrial Commission patient’s employer or the Work- ers’ Compensation Division, or the client’s employerNorth Carolina Industrial Commission. There are some situations in which I am legally obligated to take actions, which I be- lieve believe are necessary to attempt to protect protec t others from harm and I may have to reveal some information about a clientpatient’s treatment. These situations are unusual in my practice. If I have reasonable cause to suspect that a child has been under 18 is abused or may be subjected neglected, or if I have reasonable cause to abuse or neglect or observe believe that a child being subjected to conditions or circumstances that would reasonably result disabled adult is in abuse or neglectneed of protective services, the law requires that I file a report with Tennessee’s Department the County Director of Children’s Social Services. Once such a report is filed, I may be required to provide additional information. If I have reasonable cause believe that a patient presents an imminent danger to suspect that an elderly or disabled adult presents a like- lihood the health and safety of suffering serious physical harm and is in need of protective services, the law requires that I file a report with Adult Protective Services. Once such a report is filedanother, I may be required to provide additional information. If I believe that it is necessary to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by the client on him/her- self or another person, I may be required in order to take protective action. These actions may includeactions, and/or including initiating hospitalization and/or contacting hospitalization, warning the potential victim, if identifiable, and/or calling the police and/or the client’s familypolice. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it i t is important that we discuss any questions or concerns that you may have now or in the future. Professional Records You should The laws governing confidentialit y can be aware thatquite complex, pursuant to HIPAAand I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. PROFESSIONAL RECORDS / COMPLETION OF FORMS The laws and standards of my profession require that I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in unusual circumstances that involve danger to yourself and/or others or the unusual circumstance where disclosure record makes reference to another person (unless such other person is a health care provider) and I believe that access is reasonably likely to endanger you and/or others or when another individual (cause substantial harm to such other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harmpers on, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying processing fee of 35 cents $50.00 per page request for medical records and $10.00 to complete forms (and for certain other expenses)up to 2 pages) to schools, insurance companies, disability services, etc. The exceptions to this policy are contained in A SEPARATE CONSENT TO RELEASE MEDICAL RECORDS form must be executed by the attached Notice Formpatient before we can release these records. If I refuse your request for access to your Clinical Recordsrecords, you have a right of review, which I will discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents of our conversations, my analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentially.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights PATIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include:include requesting that I amend your record; requesting restrictions on what information from your Clinical Records is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and my privacy policies and procedures. I would be happy to discuss any of these rights with you.
Appears in 1 contract
Samples: Patient Services Agreement
Meetings. I normally conduct an evaluation that will may last from 1-2 to 4 sessions. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If therapy has psychotherapy is begun, I will usually schedule one 45-45 to 50 minute ses- sion session per week at a time we agree on, although some sessions may be longer or may be more or less frequent. Please note that, unless you have requested that we do not email, I will attempt to confirm your appointment the day before the scheduled appointment, via email. This is done as a courtesy. Please be aware that you are responsible for remembering the date and time of your appointment whether or not we are able to send you an email reminder. Once an appointment hour is scheduled, you will be expected to pay for it un- less unless you provide 24-24 hours advanced advance notice of cancellationcancellation (unless I feel that you were unable to attend due to circumstances beyond your control). It is important to note that insurance companies do not provide reimbursement for cancelled sessions. Professional Fees PROFESSIONAL FEES My hourly fee varies depending on services and durationschedule is attached. In addition to weekly ap- pointmentsappointments, I it is our practice to charge this amount for other professional services you may need. How- ever, I will break down the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services include such as report writing, telephone conversations lasting longer than 10-10 minutes, Skype appoint- ments or check-ins, consulting with other professionals with your permission, prepar- ing preparation of records or treatment summaries, and the time spent performing any other ser- vices service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Be- cause Because of the difficulty of legal involvement, I charge $500 300 per hour for preparation preparation, transportation, and attendance at any legal proceedingsproceeding. Contacting Me Please note that it is our policy to avoid being a party to litigation under most circumstances. CONTACTING ME Due to my work schedule, I am often not immediately available by telephone. While My hours vary from day-to-day. When I am usually in unavailable, my office four days a week, telephone is answered by voice mail and I probably will not answer the phone when I am with a clientcheck both my voice mail and emails frequently. I will make every effort to return your call by or email on the end of my business daysame day I receive it, with the exception of weekends holidays, vacation days, and holidaysother days off. My email is the most reliable way to reach me, as I often respond to emails after normal business hours, and check my email much more frequently than my office voice mail (xxxxxx@xxxxxxxxxxxxxxxxxxxx.xxxx). If you are difficult would like to reachschedule an appointment, please inform contact me via email to do so. In cases of some times when you will be available. If emergency, you are unable instructed to reach me and you feel that you can’t wait for me to return your call, either contact your family physicianphysician or psychiatrist, the call 911, or go to your nearest emergency room and ask for the psychologist or psychiatrist on call, or call 911. If I will be unavailable for an extended time, I will provide you with the name of a colleague contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality The law protects the privacy of all communications between a client and a therapist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, ad- xxxxx consent. Your signature on this Agreement provides consent for those activities, as follows: I may occasionally find it helpful to consult other health and mental health profes- sionals about a case. During consultation, I make every effort to avoid revealing the identity of my client. The other professionals are also legally bound to keep informa- tion confidential. If you don’t object, I will not tell you about these consultations un- less I feel that it is important to our work together. I will note all consultations in your Clinical Record. Disclosures required by health insurers or to collect overdue fees are discussed else- where in this Agreement. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the social worker-client privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client in order to defend myself. If a client files a worker’s compensation claim, I must, upon appropriate request, pro- vide a copy of the client’s record to the Labor and Industrial Commission or the Work- ers’ Compensation Division, or the client’s employer. There are some situations in which I am legally obligated to take actions, which I be- lieve are necessary to attempt to protect others from harm and I may have to reveal some information about a client’s treatment. These situations are unusual in my practice. If I have reasonable cause to suspect that a child has been or may be subjected to abuse or neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglect, the law requires that I file a report with Tennessee’s Department of Children’s Services. Once such a report is filed, I may be required to provide additional information. If I have reasonable cause to suspect that an elderly or disabled adult presents a like- lihood of suffering serious physical harm and is in need of protective services, the law requires that I file a report with Adult Protective Services. Once such a report is filed, I may be required to provide additional information. If I believe that it is necessary to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by the client on him/her- self or another person, I may be required to take protective action. These actions may include, and/or initiating hospitalization and/or contacting the potential victim, and/or the police and/or the client’s family. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure is reasonably likely to endanger you and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harm, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of 35 cents per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Records, you have a right of review, which I will discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents of our conversations, my analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentiallyroom.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include:
Appears in 1 contract
Samples: Client Services Agreement
Meetings. I normally conduct an evaluation that will last from 1-1 to 2 sessions. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If therapy has psychotherapy is begun, I will usually schedule one 4550-60 minute ses- sion session (one appointment hour of 50-60 minutes duration) per week at a time we agree on, although some sessions may be longer or more frequent. Once an appointment hour is scheduled, you will be expected to pay for it un- less unless you provide 24-48 hours advanced advance notice of cancellationcancellation [unless we both agree that you were unable to attend due to circumstances beyond your control]. It is important to note that insurance companies do not provide reimbursement for cancelled sessions. Professional Fees [If it is possible, I will try to find another time to reschedule the appointment.] PROFESSIONAL FEES My hourly fee varies depending on services and durationis $215.00 after the initial session fee of $325. In addition to weekly ap- pointmentsappointments, I charge this amount for other professional services you may need. How- ever, though I will break down the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services include report writing, telephone conversations lasting longer than 10-10 minutes, Skype appoint- ments or check-ins, consulting with other professionals with your permission, prepar- ing preparation of records or treatment summaries, and the time spent performing any other ser- vices service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Be- cause [Because of the difficulty of legal involvement, I charge $500 400.00 per hour for preparation and attendance at any legal proceedings. Contacting Me proceeding.] CONTACTING ME Due to my work schedule, I am often not immediately available by telephone. While I am usually in my office four days a weekbetween 8:30 AM and 5 PM, I probably will not answer the phone when I am with a clientpatient. When I am unavailable, my telephone is answered by my receptionist staff, and if they are not available, by voice mail that I monitor frequently. I will make every effort to return your call by on the end of my business daysame day you make it, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. If you are unable to reach me and you feel that you can’t wait for me to return your call, contact your family physician, physician or the nearest emergency room and ask for the psychologist or psychiatrist on call, or call 911. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client patient and a therapistpsychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, ad- xxxxx advance consent. Your signature on this Agreement provides consent for those activities, as follows: I may occasionally find it helpful to consult other health and mental health profes- sionals professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my clientpatient. The other professionals are also legally bound to keep informa- tion the information confidential. If you don’t object, I will not tell you about these consultations un- less unless I feel that it is important to our work together. I will note all consultations in your Clinical RecordRecord (which is called “PHI” in my Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information). You should be aware that I employ administrative staff. In most cases, I need to share protected information with these individuals for both clinical and administrative purposes, such as scheduling, billing and quality assurance. All mental health professionals are bound by the same rules of confidentiality. All staff members have been given training about protecting your privacy and have agreed not to release any information outside of the practice without my permission. I also have a contract with a billing service. As required by HIPAA, I have a formal business associate contract with this business, in which it promises to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I can provide you with the name of this organization and/or a blank copy of this contract. Disclosures required by health insurers or to collect overdue fees are discussed else- where elsewhere in this Agreement. If a patient threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her, or to contact family members or others who can help provide protection. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatmentmy professional services, such information is protected by the social workerpsychologist-client patient privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. If a government agency is requesting the information for health oversight activities, I may be am required to provide it for them. If a client patient files a complaint or lawsuit against me, I may disclose relevant information regarding that client patient in order to defend myself. If a client patient files a worker’s compensation claim, I must, upon appropriate request, pro- vide am required to submit a copy of the client’s record report to the Labor and Industrial Commission or the Work- ersWorkers’ Compensation Division, or the client’s employer. There are some situations in which I am legally obligated to take actions, which I be- lieve believe are necessary to attempt to protect others from harm and I may have to reveal some information about a clientpatient’s treatment. These situations are unusual in my practice. If I have reasonable cause to know or suspect that a child has been or may be subjected to abuse or neglect or observe if I have observed a child being subjected to circumstances or conditions or circumstances that which would reasonably result in abuse or neglect, the law requires that I file a report with Tennessee’s Department of Children’s Servicesthe appropriate governmental agency. Once such a report is filed, I may be required to provide additional information. If I have reasonable cause to suspect believe that an elderly at-risk adult has been or disabled adult presents a like- lihood is at imminent risk of suffering serious physical harm and is in need of protective servicesbeing mistreated, self-neglected, or financially exploited, the law requires that I file a report with Adult Protective Servicesthe appropriate governmental agency. Once such a report is filed, I may be required to provide additional information. information If I believe that it is necessary to disclose information to protect a patient communicates a serious threat of imminent physical violence against a clear and substantial risk of imminent serious harm being inflicted by the client on him/her- self specific person or another personpersons, I may be required must make an effort to notify such person; and/or notify an appropriate law enforcement agency; and/or take protective action. These actions may include, and/or initiating other appropriate action including seeking hospitalization and/or contacting of the potential victim, and/or the police and/or the client’s familypatient. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records The laws governing confidentiality can be quite complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. PROFESSIONAL RECORDS You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance circumstances that involve danger to yourself and others [or where disclosure is reasonably likely information has been supplied to endanger you and/or me by others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harmconfidentially], you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstancessituations, I am allowed to charge a copying fee of 35 cents $.50 per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical RecordsRecord, you have a right of review, which I will discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentially.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights PATIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your Clinical Records Record and disclosures of protected health information. These rights include:include requesting that I amend your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights with you. MINORS & PARENTS Patients under 15 years of age who are not emancipated (and their parents) should be aware that the law may allow parents to examine their child’s treatment records, unless I decide that such access is likely to injure the child. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is sometimes my policy to request an agreement from parents that they consent to give up their access to their child’s records. If they agree, during treatment, I will provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. I will also provide parents with a summary of their child’s treatment when it is complete. Any other communication will require the child’s Authorization, unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have. BILLING AND PAYMENTS You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. [In circumstances of unusual financial hardship, I may be willing to negotiate a fee adjustment or payment installment plan.] If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require me to disclose otherwise confidential information. In most collection situations, the only information I release regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due. [If such legal action is necessary, its costs will be included in the claim.] INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, I will be willing to call the company on your behalf. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in short- term therapy, some patients feel that they need more services after insurance benefits end. [Some managed-care plans will not allow me to provide services to you once your benefits end. If this is the case, I will do my best to find another provider who will help you continue your psychotherapy.] You should also be aware that your contract with your health insurance company requires that I provide it with information relevant to the services that I provide to you. I am required to provide a clinical diagnosis. Sometimes I am required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your sessions. It is important to remember that you always have the right to pay for my services yourself to avoid the problems described above [unless prohibited by contract]. YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS AND ALSO SERVES AS AN ACKNOWLEDGMENT THAT YOU HAVE RECEIVED THE HIPAA NOTICE FORM DESCRIBED ABOVE.
Appears in 1 contract
Samples: Patient Services Agreement
Meetings. I normally conduct an evaluation that will last from 1-2 two to four sessions. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If therapy has psychotherapy is begun, I will usually schedule a session of one 45-minute ses- sion per week appointment hour of 45 to 50 minutes duration at a time we agree on, although some . The frequency and duration of these sessions may will be longer or more frequentdiscussed with your input. Once an appointment hour is scheduled, you will be expected to pay for it un- less unless you provide 24-24 hours advanced advance notice of cancellation. Please refer to the Cancellation Policy. It is important to note that insurance companies do not provide reimbursement for cancelled sessions. Professional Fees If it is possible, I will try to find another time to reschedule the appointment. PROFESSIONAL FEES My hourly fee varies depending on services is $165 for the initial session and duration$135 for an individual session. In addition to weekly ap- pointmentsappointments, I charge this amount $75 per hour for other professional services you may need. How- ever, though I will break down the hourly cost if I work for periods of less than one hour. Note that these additional services are not covered by insurance. Other services include report writing, telephone conversations lasting longer than 10-ten minutes, Skype appoint- ments or check-ins, consulting with other professionals with your permission, prepar- ing preparation of records or treatment summaries, and the time spent performing any other ser- vices service you may request of meme (e.g., attending meetings or school staffings). If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Be- cause Because of the difficulty of legal involvement, I charge $500 180 per hour for preparation and attendance at any legal proceedingsproceeding. Contacting Me CONTACTING ME Due to my work schedule, I am often not immediately available by telephone. While I am usually in my office four days a weekbetween 8 AM and 5 PM, I probably will not answer the phone when I am with a client. When I am unavailable, my telephone is answered by voice mail. I will make every an effort to return your call by on the end of my business daysame day you make it, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. If you are unable to reach me and you feel that you can’t n't wait for me to return your call, contact your family physician, the nearest emergency room and ask for room, and/or the psychologist or psychiatrist on call, or call 911crisis telephone numbers you have been provided. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx to communicate with me. Limits of Confidentiality LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client and a therapistmental health professional. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form that meets certain legal requirements imposed by HIPAAHIPAA and/or Iowa law. There are other situations that require only that you provide writtenHowever, ad- xxxxx consent. Your signature on this Agreement provides consent for those activitiesin the following situations, as followsno authorization is required: I may occasionally find it helpful to consult other health and mental health profes- sionals professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my client. The other professionals are also legally bound to keep informa- tion the information confidential. If you don’t n't object, I will not tell you about these consultations un- less unless I feel that it is important to our work together. I will note all consultations in your Clinical RecordRecord (which is called "PHI" in my Notice of Psychotherapist's Policies and Practices to Protect the Privacy of Your Health Information). You should be aware that I practice with other mental health professionals and that I employ administrative staff. In most cases, I need to share protected information with these individuals for both clinical and administrative purposes, such as scheduling, billing and quality assurance. All of the mental health professionals are bound by the same rules of confidentiality. All staff members have been given training about protecting your privacy and have agreed not to release any information outside of the practice without the permission of a professional staff member. I also have contracts with bookkeeping and typing services. As required by HIPAA, I have a formal business associate contract with these businesses, in which they promise to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I can provide you with the names of these organizations and/or a blank copy of this contract. Disclosures required by health insurers or to collect overdue fees are discussed else- where elsewhere in this Agreement. There are some situations where If a client threatens to harm himself/herself, I am permitted may be obligated to seek hospitalization for him/her or required to disclose information without either your consent contact family members or Authorization: others who can help provide protection. If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatmentthe professional services I provided, such information is protected by the social workerpsychotherapist-client privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client in order to defend myself. If a client files a worker’s 's compensation claim, I must, upon appropriate request, pro- vide a copy of provide any information concerning the client’s record employee's physical or mental condition relative to the Labor and Industrial Commission or the Work- ers’ Compensation Division, or the client’s employerclaim. There are some situations in which I am legally obligated to take actions, which I be- lieve believe are necessary to attempt to protect others from harm and I may have to reveal some information about a client’s 's treatment. These situations are unusual in my practice. If I have reasonable cause to believe that a child I have provided professional services to has been abused or if I suspect that a child dependent adult has been or may be subjected to abuse or neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglectabused, the law requires that I file a report with Tennessee’s the appropriate government agency, usually the Department of Children’s Human Services. Once such a report is filed, I may be required to provide additional information. If I have reasonable cause to suspect that a client communicates an elderly or disabled adult presents a like- lihood imminent threat of suffering serious physical harm and is in need of protective services, the law requires that I file a report with Adult Protective Services. Once such a report is filedto an identifiable victim, I may be required to provide additional informationdisclose information in order to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the client. If I believe that it is necessary a client communicates an imminent threat of serious physical harm to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by the client on him/her- self or another personherself, I may be required to disclose information in order to take protective actionactions. These actions may include, and/or include initiating hospitalization and/or or contacting the potential victim, and/or the police and/or the client’s familyfamily members or others who can assist in providing protection. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Professional Records The laws governing confidentiality can be quite complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. PROFESSIONAL RECORDS You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, re- ports reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure circumstances that involve danger to yourself and others or makes reference to another person (unless-such other person is a health care provider) and I believe that access is reasonably likely to endanger you and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the cause substantial harm to such other person at risk of substantial harmor where information has been supplied to me by others confidentially, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of 35 cents $1.00 per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Records, you have a right of reviewreview except for information supplied to me confidentially by others, which I will discuss with you upon request. In addition, I may also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the con- tents contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also may include in- formation information from others provided to me confidentially.] . These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Patient Rights CLIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include:include requesting that I amend your record; requesting restrictions on what information from your Clinical Records is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights with you. MINORS & PARENTS Clients under eighteen years of age who are not emancipated and their parents should be aware that the law may allow parents to examine their child's treatment records. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is sometimes my policy to request an agreement from parents that they consent to give up their access to their child's records. If they agree, during treatment, I will provide them only with general information about the progress of the child's treatment, and his/her attendance at scheduled sessions. I will also provide parents with a summary of your treatment when it is complete. Any other communication will require your Authorization, unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify your parents of my concern. Before giving your parents any information, I will discuss the matter with you, if possible, and do my best to handle any objections you may have.
Appears in 1 contract
Samples: Service Agreement
