Common use of Limits of Confidentiality Clause in Contracts

Limits of Confidentiality. Reunification Therapy, when ordered by the Court, is considered a non-confidential process. Any or all notes, electronic correspondence, observations and recommendations may be disclosed to the court by the reunification therapist. They will not be disclosed to the parties without a Court’s order. Additionally, all parties need to sign any and all releases requested by the therapist that are necessary to obtain reports from relevant professionals (e.g. psychiatrist, psychologist, social worker's, teachers school officials, pediatricians, hospitals etc.). This includes past records as well as current records. As a licensed psychologist, I am a mandated reporter and as such there are some situations (not all listed) where I am legally obligated to take action to protect and share information about treatment. For example, if I believe that a child, elderly person or disabled person is being abused, I must file a report with the appropriate state agency. If you and/or a family member/significant other reports to me that you have stated a threat of serious bodily harm to an identifiable person, I am required to take protective actions which include notifying the potential victim, contacting the police, and/or seeking hospitalization for you. If you threaten to harm yourself, I may be obligated to seek hospitalization for you or to contact family members who can help provide protection. Any other laws specific to breaching confidentiality On a regular basis I have peer supervision and consult with a team of professionals about cases. During a consultation, I make every effort to avoid revealing the identity of my patient. The consultant is also legally bound to keep the information confidential. If you don’t object, I will not tell you about these consultations unless I feel that it is important to our work together. Fee Policies: My fees are $250 per hour. The following are also billed at $250 per hour and include: interviewing collateral contacts, appointment cancelled without 2 business day advance, preparing reports, copying files, telephonic, facsimile or electronic correspondence. Court appearances, preparation for court, and travel to and from court are billed at a rate of $350 an hour with a minimum of five hours. A subpoena to court must be received a minimum of seven days in advance of the court date. Upon receipt of the subpoena, that date of appearance is reserved. Even with retraction of subpoena or in the case my presence is not required, minimum payment will still be processed. A retainer of $2500 is required to commence any court ordered/stipulated treatment. It can be paid by credit card or valid check. After commencement of treatment/work when the retainer goes down to $500 it needs to be replenished by $2500. A valid credit card must be on file. You will be advised when your retainer is at $500. Payment of replenishment retainer must be made within 48 hours of advisement. You are welcome to bring a check in or we will xxxx your credit card on file. If you do not respond to the notification, your credit card on file will be charged. Xx. Xxxxxxx has the right to suspend work if fees are not up to date, or she may seek the courts assistance in collection of delinquent fees. You will be responsible for all fees incurred in efforts to collect funds. Please note that to collect fees, personal information will be requested and I must provide the necessary information to obtain collection. There may be occasion where the above fee schedule is changed and this will be written as an amendment to this contract at the end. The retainer will be held until Court determines that Reunification Therapist’s appointment is completed. After this time, if there are funds in the retainer, a credit will be issued. Contacting Me: After the initial appointment is scheduled, correspondence (outside of session) will take place principally by email only. Note all emails are entered into your file and charged at a rate of $250/hour. We want to keep emails to scheduling sessions and/or bare minimum of information. Should you have a concern, it will best to request an appointment. In treatment, I will offer 1 to 2 appointment times and try to reasonably accommodate your families schedule, however, because this is a Court order you will need to come in as requested. If you have a psychiatric/clinical emergency, contact 911 or proceed to the nearest emergency room. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary.

Limits of Confidentiality. Reunification TherapyIn general, when ordered the privacy of all communications between a client and psychotherapist is protected by law, and I can only release information about our work to others with your written permission. But there are a few exceptions. In most legal proceedings, you have the Courtright to prevent me from providing any information about your treatment. In some proceedings involving child custody and those in which your emotional condition is an important issue, is considered a non-confidential processjudge may order my testimony if he/she determines that the issues demand it. Any or all notes, electronic correspondence, observations and recommendations may be disclosed to the court by the reunification therapist. They will not be disclosed to the parties without a Court’s order. Additionally, all parties need to sign any and all releases requested by the therapist that are necessary to obtain reports from relevant professionals (e.g. psychiatrist, psychologist, social worker's, teachers school officials, pediatricians, hospitals etc.). This includes past records as well as current records. As a licensed psychologist, I am a mandated reporter and as such there There are some situations (not all listed) where in which I am legally obligated to take action to protect and share others from harm, even if I have to reveal some information about a client’s treatment. For example, if I believe that a child, elderly person person, or disabled person is being abused, I must am required to file a report with the appropriate state agency. If you and/or I believe that a family member/significant other reports to me that you have stated a threat of client is threatening serious bodily harm to an identifiable personanother, I am required to take protective actions. These actions which may include notifying the potential victim, contacting the police, and/or or seeking hospitalization for youthe client. If you threaten the client threatens to harm yourselfhimself/herself, I may be obligated to seek hospitalization for you him/her or to contact family members or others who can help provide protection. Any These situations have rarely occurred in my practice. If a similar situation occurs, I will make every effort to fully discuss it with you before taking any action. I may occasionally find it helpful to consult other laws specific to breaching confidentiality On a regular basis I have peer supervision and consult with a team of professionals about casesa case. During a consultation, I make every effort to avoid revealing the identity of my patient. The consultant is also legally bound to keep the information confidential. If you don’t object, I will not tell you about these consultations unless I feel that it is important to our work together. Fee Policies: My fees 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 at our next meeting. I will be happy to discuss these issues with you if you need specific advice, but formal legal advice may be needed because the laws governing confidentiality are $250 per hour. The following are also billed at $250 per hour and include: interviewing collateral contacts, appointment cancelled without 2 business day advance, preparing reports, copying files, telephonic, facsimile or electronic correspondence. Court appearances, preparation for courtquite complex, and travel to and from court are billed at a rate of $350 I am not an hour with a minimum of five hours. A subpoena to court must be received a minimum of seven days in advance of the court date. Upon receipt of the subpoena, that date of appearance is reserved. Even with retraction of subpoena or in the case my presence is not required, minimum payment will still be processed. A retainer of $2500 is required to commence any court ordered/stipulated treatment. It can be paid by credit card or valid check. After commencement of treatment/work when the retainer goes down to $500 it needs to be replenished by $2500. A valid credit card must be on file. You will be advised when your retainer is at $500. Payment of replenishment retainer must be made within 48 hours of advisement. You are welcome to bring a check in or we will xxxx your credit card on fileattorney. If you do not respond to the notification, your credit card on file will be charged. Xx. Xxxxxxx has the right to suspend work if fees are not up to date, or she may seek the courts assistance in collection of delinquent fees. You will be responsible for all fees incurred in efforts to collect funds. Please note that to collect fees, personal information will be requested and I must provide the necessary information to obtain collection. There may be occasion where the above fee schedule is changed and this will be written as an amendment to this contract at the end. The retainer will be held until Court determines that Reunification Therapist’s appointment is completed. After this time, if there are funds in the retainer, a credit will be issued. Contacting Me: After the initial appointment is scheduled, correspondence (outside of session) will take place principally by email only. Note all emails are entered into your file and charged at a rate of $250/hour. We want to keep emails to scheduling sessions and/or bare minimum of information. Should you have a concern, it will best to request an appointment. In treatment, I will offer 1 to 2 appointment times and try to reasonably accommodate your families schedule, however, because this is a Court order you will need to come in as requested. If you have a psychiatric/clinical emergency, contact 911 or proceed to the nearest emergency room. If I will be unavailable for an extended timerequest, I will provide you with relevant portions or summaries of the name of a colleague to contact, if necessarystate laws regarding these issues.

Limits of Confidentiality. Reunification Therapy, when ordered by The law protects the Court, is considered privacy of all communications between a non-confidential processpatient and a psychologist. Any or all notes, electronic correspondence, observations and recommendations may be disclosed to the court by the reunification therapist. They will not be disclosed to the parties without a Court’s order. Additionally, all parties need to sign any and all releases requested by the therapist that are necessary to obtain reports from relevant professionals (e.g. psychiatrist, psychologist, social worker's, teachers school officials, pediatricians, hospitals etc.). This includes past records as well as current records. As a licensed psychologistIn most situations, I am can only release information about your treatment to others if you sign a mandated reporter and as such written Authorization Form. But, there are some situations (not all listed) where I am legally obligated to take action to protect and share information about treatment. For example, if I believe that a child, elderly person permitted or disabled person is being abused, I must file a report with the appropriate state agency. If you and/or a family member/significant other reports to me that you have stated a threat of serious bodily harm to an identifiable person, I am required to take protective actions which include notifying the potential victim, contacting the police, and/or seeking hospitalization for you. If you threaten to harm yourself, disclose information without either your consent or authorization: • I may be obligated occasionally find it helpful to seek hospitalization for you or to contact family members who can help provide protection. Any consult other laws specific to breaching confidentiality On a regular basis I have peer supervision health and consult with a team of mental health professionals about casesa case. During a consultation, I make every effort to avoid revealing the identity of my patient. The consultant is other professionals are also legally bound to keep the information confidential. If you don’t do not object, I will not tell you about these consultations unless I feel that it is important to our work together. Fee Policies: My fees I will note all consultations in your Clinical Record. • If you are $250 per hourinvolved in a court proceeding and a request is made for information about the professional services that I have provided you and/or the records thereof, such information is protected by psychologist-patient privilege law. The following are also billed at $250 per hour and include: interviewing collateral contactsI cannot provide any information without your (or your legally- appointed representative’s) written authorization, appointment cancelled without 2 business day advancea court order, preparing reports, copying files, telephonic, facsimile or electronic correspondence. Court appearances, preparation 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 courtobtaining PHI, and travel I do not have grounds for objecting under state law (or you have instructed me not to and from court are billed at a rate of $350 an hour with a minimum of five hours. A subpoena to court must be received a minimum of seven days in advance of the court date. Upon receipt of the subpoena, that date of appearance is reserved. Even with retraction of subpoena or in the case my presence is not required, minimum payment will still be processed. A retainer of $2500 is required to commence any court ordered/stipulated treatment. It can be paid by credit card or valid check. After commencement of treatment/work when the retainer goes down to $500 it needs to be replenished by $2500. A valid credit card must be on file. You will be advised when your retainer is at $500. Payment of replenishment retainer must be made within 48 hours of advisement. You are welcome to bring a check in or we will xxxx your credit card on fileobject). If you do not respond 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 pursuant to their legal authority, I may be required to provide it for them. • If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself. • If a patient files a worker’s compensation claim, I must, upon appropriate request, disclose information relevant to the notificationclaimant's condition, to the worker’s compensation insurer. There are some situations in which I am legally required to break confidentiality and take actions, necessary to attempt to protect others from harm. • If I have knowledge of a child under 18, or reasonably suspect that a child under 18 that I have observed, has been the victim of child abuse or neglect, the law requires that I file a report with the 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). • If I observe or have knowledge of an incident that reasonably appears to 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 act or omission constituting physical abuse, abandonment, abduction, isolation, financial abuse, or neglect, or reasonably suspects that abuse, the law requires that I report to the appropriate government agency. • If a patient, or a family member, communicates a serious threat by the patient 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 the patient is in such mental or emotional condition as to be dangerous to him or herself, I may be obligated to take protective action, including seeking hospitalization or contacting family members or others, including the police, 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. Professional Records Pursuant to HIPAA, I may keep Protected Health Information about you in two sets of professional records. One set constitutes your credit card on file Clinical Record. It includes information about your reasons for seeking therapy, presenting problems, diagnosis, treatment goals, progress, medical and social history, treatment history, any past treatment records that I receive from other providers, reports of any professional consultations, billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in unusual circumstances in that disclosure would physically endanger you and/or others or makes reference to another person (unless such other person is a health care provider), 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. There will be chargeda copying fee of 25 cents per page. XxIf I refuse your request for access to your Clinical Records, you have a right of review (except for information supplied to me confidentially by others) which I will discuss with you upon request. Xxxxxxx has 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 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 may include 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 you with several new or expanded rights with regard to your Clinical Records and disclosures of PHI. These rights 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 PHI that you have neither consented to nor authorized; determining the location to which PHI disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to suspend work if fees are not up to datea paper copy of this Agreement, or she may seek the courts assistance in collection of delinquent fees. You will be responsible for all fees incurred in efforts to collect funds. Please note that to collect feesattached Notice Form, personal information will be requested and I must provide the necessary information to obtain collection. There may be occasion where the above fee schedule is changed my Privacy Policies and this will be written as an amendment to this contract at the end. The retainer will be held until Court determines that Reunification Therapist’s appointment is completed. After this time, if there are funds in the retainer, a credit will be issued. Contacting Me: After the initial appointment is scheduled, correspondence (outside of session) will take place principally by email only. Note all emails are entered into your file and charged at a rate of $250/hour. We want to keep emails to scheduling sessions and/or bare minimum of information. Should you have a concern, it will best to request an appointment. In treatment, I will offer 1 to 2 appointment times and try to reasonably accommodate your families schedule, however, because this is a Court order you will need to come in as requested. If you have a psychiatric/clinical emergency, contact 911 or proceed to the nearest emergency room. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessaryProcedures.

Limits of Confidentiality. Reunification Therapy, when ordered by the Court, is considered a non-confidential process. Any or all notes, electronic correspondence, observations and recommendations may be disclosed to the court by the reunification therapist. They will not be disclosed to the parties without a Court’s order. Additionally, all parties need to sign any and all releases requested by the therapist that are necessary to obtain reports from relevant professionals (e.g. psychiatrist, psychologist, social worker's, teachers school officials, pediatricians, hospitals etc.). This includes past records as well as current records. As a licensed psychologist, I am a mandated reporter and as such there are some situations (not all listed) where I am legally obligated to take action to protect and share information about treatment. For example, if I If we believe that a childclient presents an imminent danger to his/her health or safety, elderly person or disabled person is being abused, I must file a report with the appropriate state agency. If you and/or a family member/significant other reports to me that you have stated a threat of serious bodily harm to an identifiable person, I am required to take protective actions which include notifying the potential victim, contacting the police, and/or seeking hospitalization for you. If you threaten to harm yourself, I we may be obligated to seek hospitalization for you him/her, or to contact family members or others who can help provide protection. Any other laws specific There are some situations where we are permitted or required to breaching confidentiality On disclose information without either your consent or Authorization: • If you are involved in a regular basis I court proceeding and a request is made for information concerning the professional services that we provided you, such information is protected by the counselor-client privilege law. We cannot provide any information without your written authorization, or a court order. If y xxxx ou are involved in or contemplating litigation, you should conwith your attorney to determine whether a court would be likely to order us to disclose information. • If a government agency is requesting the information for health oversight activities, we may be required to provide it for them. If a client files a complaint or lawsuit against RHEMA Counseling & Support Services, PC or an individual provider within the agency, we may disclose relevant information regarding that client. • If a client files a worker’s compensation claim, and our services are being compensated through workers compensation benefits, we must, upon appropriate request, provide a copy of the client’s record to the client’s employer or the North Carolina Industrial Commission. There are some situations in which we are legally obligated to take actions, which we believe are necessary to attempt to protect others from harm and we may have peer supervision to reveal some information about a client’s treatment. Though these situations are unusual in our practice, we would like to make you aware of them: • If we have cause to suspect that a child under 18 is abused or neglected, or if we have reasonable cause to believe that a disabled adult is in need of protective services, the law requires that we file a report with the County Department of Social Services. Once such a report is filed, we may be required to provide additional information. • If we believe that a client presents an imminent danger to the health and consult with safety of another, we may be required to disclose information in order to take protective actions, including initiating hospitalization, warning the potential victim, if identifiable, and/or calling the police. If such a team of professionals about cases. During a consultationsituation arises, I we will make every effort to avoid revealing the identity fully discuss it with you before taking any action and will limit my disclosure to what is necessary. While this written summary of my patient. The consultant is also legally bound exceptions to keep the information confidential. If you don’t object, I will not tell confidentiality should prove helpful informing you about these consultations unless I feel that potential problems, it is important to our work together. Fee Policies: My fees are $250 per hour. The following are also billed at $250 per hour and include: interviewing collateral contacts, appointment cancelled without 2 business day advance, preparing reports, copying files, telephonic, facsimile that we discuss any questions or electronic correspondence. Court appearances, preparation for court, and travel to and from court are billed at a rate of $350 an hour with a minimum of five hours. A subpoena to court must be received a minimum of seven days in advance of the court date. Upon receipt of the subpoena, concerns that date of appearance is reserved. Even with retraction of subpoena you may have now or in the case my presence future. The laws governing confidentiality can be quite complex, and we are not attorneys. In situations where specific advice is not required, minimum payment will still formal legal advice may be processedneeded. A retainer CLIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of $2500 protected health information. These rights include requesting that we amend your record; requesting restrictions on what information from your Clinical Records is required disclosed to commence 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 court ordered/stipulated treatment. It can be paid by credit card or valid check. After commencement of treatment/work when the retainer goes down to $500 it needs to be replenished by $2500. A valid credit card must be on file. You will be advised when complaints you make about my policies and procedures recorded in your retainer is at $500. Payment of replenishment retainer must be made within 48 hours of advisement. You are welcome to bring a check in or we will xxxx your credit card on file. If you do not respond to the notification, your credit card on file will be charged. Xx. Xxxxxxx has records; and the right to suspend work if fees a paper copy of this Agreement and our privacy policies and procedures. We are not up happy to datediscuss any of these rights with you. In addition, or she may seek you will receive a copy of these rights in RHEMA Counseling & Support Services, PC’s Notice of Privacy Practices. We reserve the courts assistance in collection right to revise the terms of delinquent feesthis Notice and make the new Notice effective for all medical information that we maintain. A copy of these revisions will be posted online at xxx.xxxxxxxx.xxx. You will be responsible for all fees incurred in efforts to collect funds. Please note that to collect feesmay also obtain a copy from our office located at 0000 Xxxxxxxx Xxxxx, personal information will be requested and I must provide the necessary information to obtain collection. There Xxxxxx, XX 00000 or you may be occasion where the above fee schedule is changed and this will be written as an amendment to this contract at the end. The retainer will be held until Court determines that Reunification Therapist’s appointment is completed. After this time, if there are funds in the retainer, request a credit will be issued. Contacting Me: After the initial appointment is scheduled, correspondence copy by calling (outside of session919) will take place principally by email only. Note all emails are entered into your file and charged at a rate of $250/hour. We want to keep emails to scheduling sessions and/or bare minimum of information. Should you have a concern, it will best to request an appointment. In treatment, I will offer 1 to 2 appointment times and try to reasonably accommodate your families schedule, however, because this is a Court order you will need to come in as requested. If you have a psychiatric/clinical emergency, contact 911 or proceed to the nearest emergency room. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary000- 0000.

Limits of Confidentiality. Reunification TherapyIn general, when ordered the privacy of all communications between a client and psychotherapist is protected by law, and I can only release information about our work to others with your written permission. But there are a few exceptions. In most legal proceedings, you have the Courtright to prevent me from providing any information about your treatment. In some proceedings involving child custody and those in which your emotional condition is an important issue, is considered a non-confidential processjudge may order my testimony if he/she determines that the issues demand it. Any or all notes, electronic correspondence, observations and recommendations may be disclosed to the court by the reunification therapist. They will not be disclosed to the parties without a Court’s order. Additionally, all parties need to sign any and all releases requested by the therapist that are necessary to obtain reports from relevant professionals (e.g. psychiatrist, psychologist, social worker's, teachers school officials, pediatricians, hospitals etc.). This includes past records as well as current records. As a licensed psychologist, I am a mandated reporter and as such there There are some situations (not all listed) where in which I am legally obligated to take action to protect and share others from harm, even if I have to reveal some information about a client’s treatment. For example, if I believe that a child, elderly person person, or disabled person is being abused, I must am required to file a report with the appropriate state agency. If you and/or I believe that a family member/significant other reports to me that you have stated a threat of client is threatening serious bodily harm to an identifiable personanother, I am required to take protective actions. These actions which may include notifying the potential victim, contacting the police, and/or or seeking hospitalization for youthe client. If you threaten the client threatens to harm yourselfhimself/herself, I may be obligated to seek hospitalization for you him/her or to contact family members or others who can help provide protection. Any These situations have rarely occurred in my practice. If a similar situation occurs, I will make every effort to fully discuss it with you before taking any action. I may occasionally find it helpful to consult other laws specific to breaching confidentiality On a regular basis I have peer supervision and consult with a team of professionals about casesa case. During a consultation, I make every effort to avoid revealing the identity of my patient. The consultant is also legally bound to keep the information confidential. If you don’t object, I will not tell you about these consultations unless I feel that it is important to our work together. Fee Policies: My fees 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 at our next meeting. I will be happy to discuss these issues with you if you need specific advice, but formal legal advice may be needed because the laws governing confidentiality are $250 per hour. The following are also billed at $250 per hour and include: interviewing collateral contacts, appointment cancelled without 2 business day advance, preparing reports, copying files, telephonic, facsimile or electronic correspondence. Court appearances, preparation for courtquite complex, and travel to and from court are billed at a rate of $350 I am not an hour with a minimum of five hours. A subpoena to court must be received a minimum of seven days in advance of the court date. Upon receipt of the subpoena, that date of appearance is reserved. Even with retraction of subpoena or in the case my presence is not required, minimum payment will still be processed. A retainer of $2500 is required to commence any court ordered/stipulated treatment. It can be paid by credit card or valid check. After commencement of treatment/work when the retainer goes down to $500 it needs to be replenished by $2500. A valid credit card must be on file. You will be advised when your retainer is at $500. Payment of replenishment retainer must be made within 48 hours of advisement. You are welcome to bring a check in or we will xxxx your credit card on fileattorney. If you do not respond to the notification, your credit card on file will be charged. Xx. Xxxxxxx has the right to suspend work if fees are not up to date, or she may seek the courts assistance in collection of delinquent fees. You will be responsible for all fees incurred in efforts to collect funds. Please note that to collect fees, personal information will be requested and I must provide the necessary information to obtain collection. There may be occasion where the above fee schedule is changed and this will be written as an amendment to this contract at the end. The retainer will be held until Court determines that Reunification Therapist’s appointment is completed. After this time, if there are funds in the retainer, a credit will be issued. Contacting Me: After the initial appointment is scheduled, correspondence (outside of session) will take place principally by email only. Note all emails are entered into your file and charged at a rate of $250/hour. We want to keep emails to scheduling sessions and/or bare minimum of information. Should you have a concern, it will best to request an appointment. In treatment, I will offer 1 to 2 appointment times and try to reasonably accommodate your families schedule, however, because this is a Court order you will need to come in as requested. If you have a psychiatric/clinical emergency, contact 911 or proceed to the nearest emergency room. If I will be unavailable for an extended timerequest, I will provide you with relevant portions or summaries of the name state laws regarding these issues. Communication between your behavioral health provider(s) and your primary care physician (PCP) may be important to ensure the continuity of care and that all care is complete, comprehensive, and well-coordinated. I however, I will not do so without your consent. HIPPA CONSENT TO USE OR DISCLOSE INFORMATION FOR TREATMENT, PAYMENT AND HEALTHCARE OPERATIONS Federal regulations (HIPPA) allow me to use or disclose Protected Healthcare Information (PHI) from your records in order to provide treatment to you, to obtain payment for the services I provide, and for other professional activities known as “healthcare operations”. Nevertheless, I ask your consent in order to make this permission explicit. The Notice of Privacy Practices describes these disclosures in more detail. You have the right to review the Notice of Privacy Practices before signing this consent. I reserve the right to revise my Notice of Privacy Practices at any time. You may ask me to restrict the use and disclosure of certain information in your record that otherwise would be disclosed for treatment, payment, or health care operations; however, I do not have to agree to these restrictions. If I do agree to a colleague restriction, that agreement is binding. You may revoke this consent at any time by giving written notification. Such revocation will not affect any action taken in reliance on the consent prior to contactthe revocation. This consent is voluntary; you may refuse to sign it. However, I am permitted to refuse to provide healthcare services if necessarythis consent is not granted, or if the consent is later revoked. I hereby consent to the use or disclosure of my Protected Health Information as specified above.