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 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.
Appears in 2 contracts
Samples: static1.squarespace.com, uploads.documents.cimpress.io
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 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 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 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 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 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.
Appears in 1 contract
Samples: caryneuropsychology.com
Meetings. I Your psychologist normally conduct conducts an evaluation that will last from 1-2 1 to 3 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 your doctor 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 appointment hour is scheduled, you will be expected to pay for it un- less unless you provide 24-24 business 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 PROFESSIONAL FEES Our session fee varies depending on services and durationis $150. 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 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 we charge $500 200 per hour for preparation preparation, travel and attendance at any legal proceedingsproceeding. Contacting Me CONTACTING YOUR PSYCHOLOGIST Due to my our varied work scheduleschedules and the improbability of your doctor answering the phone when with a patient, I am your psychologist is often not immediately available by telephone. While I When doctors are unavailable, the telephone is answered either by our secretaries who know where to reach the doctors, or by voice mail that is monitored frequently. Our staff are in the office Monday through Friday from 8am usually in my office four days a week, I probably will not to 6pm to answer the phone when I am with a clientphones. I Your doctor 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 your psychologist 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 your doctor 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. In most situations, I we 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 • 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 clientthe patient. The other professionals are also legally bound to keep informa- tion the information confidential. If you don’t n'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 my Notice of Psychologist's Policies and Practices to Protect the Privacy of Your Health Information). • We also have a privacy contract with our accountants. As required by HIPAA, we 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, we 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, we may be obligated to seek hospitalization for him/her, or to contact 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 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 treatment, such information is protected by the social workerpsychologist-client patient privilege law. I We 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 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 's compensation claim, I we 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 we are legally obligated to take actions, which I be- lieve we believe are necessary to attempt to protect others from harm harm, and I we may have to reveal some information about a client’s patient's treatment. These situations are unusual in my practice. • If I we 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 and Regulatory Services. Once such a report is filed, I we may be required to provide additional information. • If I have reasonable cause to suspect we 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 we 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 we 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, and we are not attorneys. 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 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 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 we 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 we 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.
Appears in 1 contract
Samples: Services Agreement
Meetings. I normally conduct an evaluation that During our initial meeting(s), the therapist 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 the therapist will usually schedule one 45-minute ses- sion session per week at a time we agree onon (and will usually be 45 minutes in duration), although some sessions may be longer or more frequent. Once SCHEDULING / CANCELLATION POLICY If you need to re-schedule an appointment hour appointment, please let the therapist 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 the therapist 24 hours in advance of your scheduled appointment. If a session is scheduledcancelled with less than 24 hours notice or if you fail a scheduled appointment, you will be expected responsible for the full session fee as indicated in the PAYMENT section below, as insurance would not cover such occurrences. I understand and consent to this cancellation policy (initial and date) PAYMENT Your fee for service is payable by cash or check at each session. The current full fee schedule is as follows: $300 for the initial assessment, $200 for individual sessions, and $240 for couple/family sessions. If for some reason it is easier for you to pay for it un- less you provide 24-hours advanced notice of cancellation. It is important to note on a different schedule, please let the therapist know so 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 mewe can discuss this. If you become involved have a co-pay agreement in legal proceedings that require my participationyour insurance policy, you will be expected responsible for the co-pay at each session. Depending on your insurance plan, The therapist or a designated billing representative may be submitting claims to pay for all your insurance company on your behalf, and your signature below authorizes this to occur, as well as assignment of my professional timepayment to the provider. Information that is released to insurance includes dates of service, including preparation procedure, and transportation costsdiagnosis.Your insurance company also reserves the right to request further information to support necessity of services, even if I am called to testify by another partyand can request treatment plans, session notes, or other information about treatment. 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 You will be available. If you are unable to reach me and you feel that you can’t wait responsible 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 any payment 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 services not covered 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 Any insurance payments will be reflected on your account. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, the unusual circumstance where disclosure is reasonably likely therapist has the option of using legal means to endanger you and/or others secure the payment. This may involve hiring a collection agency or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts going through small claims court which will require 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 therapist 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 contentsdisclose otherwise confidential information. In most circumstancescollection situations, I am allowed to charge the only information the therapist release regarding a copying fee patient’s treatment is his/her name, the nature of 35 cents per page (services provided, and for certain other expenses). The exceptions to this policy are contained in the attached Notice Formamount due. If I refuse your request for access to your Clinical Recordssuch legal action is necessary, you have a right of review, which I its costs 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 Recordthe claim. [They also include in- formation from others provided I understand and consent to me confidentially.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you this payment policy (initial 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:date)
Appears in 1 contract
Samples: Patient 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 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 bill 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 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 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.
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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 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.
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Samples: www.doctorheinsz.com
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 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 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 we decide to proceed with therapy has begunwe would schedule appointments at whatever frequency we decide on (e.g., I will usually schedule one 45-minute ses- sion per week weekly, biweekly, monthly). Sessions are 50 minutes long. PROFESSIONAL FEES As of March 18, 2019 The hourly fee for individual counselling from a registered psychologist is: $200.00. The hourly fee for for family and couples counselling from a registered psychologist is: $230.00. Fees are normally collected at a time we agree on, although some sessions may be longer or more frequentthe end of each session and receipts are available. Once an appointment hour is scheduled, If you will be expected to pay have extended health benefits you can submit your receipts for it un- less you provide 24-hours advanced notice of cancellationdirect reimbursement from your insurer. It is important your responsibility 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. If you are or become involved in legal proceedings that require requiring my participation, participation you will be expected to pay for all of my professional time. The fee for legal reports, including preparation consultation with legal representatives, and transportation costsexpert testimony is $200.00 per hour. Our cancellation policy requires you to provide 48 hours notice. If you miss an appointment without providing notice you may be billed for the missed session. If you miss a scheduled appointment without calling to cancel, any pre-booked appointments may be cancelled without notice by your therapist. Your therapist may request payment for the missed session(s) prior to re-booking new appointments. For clients whose counselling fees are covered by a third party (e.g, WSIB, motor vehicle insurer, Criminal Injuries Compensation etc.) please note that these payers do not pay for missed appointments and you may be responsible for direct payment of session costs for appointments missed or cancelled without sufficient notice. If you are receiving psychological services as part of your accident benefits with a motor vehicle insurer, please note that when your accident benefit claim is settled with your insurer, the insurer is no longer responsible for payment of treatment sessions, even if there are sessions remaining on a preexisting treatment plan. It is your responsibility to inform us regarding any settlement meetings with your insurer so that session fees can be submitted for payment to your insurer. If your file settles and you continue with treatment, you are responsible for the costs of treatment sessions subsequent to the date of settlement. Please note that we reserve the right to pursue unpaid accounts through the use of a collection agency or small claims court. In most collection situations the only information we release regarding a client’s treatment is his/her name, the nature of services provided, and the amount due. 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 to 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 particular problem I will be pleased to determine whether a court would provide you with names of other local professionals. LIMITS OF THERAPY There are some circumstances under which I may choose to terminate therapy. Therapy will be likely to order terminated if there are any verbal or physical threats or acts of violence/harrassment towards myself, the office or my family. I require that you inform me to disclose informationof any legal involvement you may have at the time of our initial meeting. If a government agency This is requesting the information for health oversight activities, important since my file may be requested or I may be required to provide it asked for theman opinion by legal professionals involved in your case. If a client files a complaint you do not disclose this information at the assessment/evaluation stage then I reserve the right to terminate treatment. I reserve the right to terminate treatment if there is pattern of missed or lawsuit against me, I may disclose relevant information regarding that client in order to defend myselfcancelled appointments. If your treatment costs are paid by 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 motor vehicle insurer or the Work- ers’ Compensation Divisionworkplace safety and insurance board, or the client’s employerfunding for treatment is contingent on approval from these insurance sources. There are some situations in which I am legally obligated times when the insurer refuses to take actionspay for further treatment although you may wish to continue. On these occasions, which I be- lieve you can decide if you would like to continue with treatment and pay for treatment yourself. Alternatively, we can help you identify other mental health services whose costs are necessary to attempt to protect others from harm and I may have to reveal some information about a client’s treatmentcovered (e.g., psychiatrist, funded mental health agency). These situations are unusual in my practice. If ACKNOWLEDGMENT 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 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 confidentiallyabove.] 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: scarthmckillop.ca
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 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 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: Patient 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 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 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 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 Typically, an evaluation that will last from 12-2 4 sessions. During this time, we both you and the clinician will decide if I am they are the best person to provide the services you need in order to meet your treatment goals. If therapy has begun, I will Psychotherapy/counseling is usually schedule scheduled as a 45 minute session (one 45-minute ses- sion appointment is equivalent to 45 minutes in duration) once per week at a time we agree onan agreed upon time. However, although some sessions may be longer or more frequentthis can vary depending on individual needs and availability. Once an appointment hour is has been scheduled, you will be expected to pay for it un- less you unless your provide 24-24 hours advanced advance notice of cancellationcancellation (with exceptions being circumstances beyond your reasonable control). It is important to note that insurance companies do not provide reimbursement for cancelled sessionsappointments. If it is possible, another time will be offered to reschedule cancelled appointments. PROFESSIONAL FEES Professional Fees My hourly fee varies depending on fees are determined by the professional licensure of the service provider rendering the services and durationand/or the nature of the clinical work. In addition to weekly ap- pointments, I charge this amount for other professional services A specific list of fees is available upon request. Professionals will generally discuss fees with 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 at the time spent performing any other ser- vices you may request of methe first visit. If you become involved in Services requiring legal proceedings that require my participation, you will be expected to pay involvement invoke fees for all of my professional time, including preparation and transportation costs, even if I am the clinician is called to testify by for 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 CONTACTING YOUR CLINICIAN Clinicians are often not immediately available by telephone, as they are at most times meeting with patients. While I am usually in my The office four days telephone will be answered by a weeksecretary during office hours. If no secretary is available, I probably a voicemail answering service may be used. Every effort will not answer the phone when I am with a client. I will make every effort be made to return your call by on the end of my business day, with the exception of weekends same day you make it. Please provide phone numbers at which you can be reached 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 your clinician 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 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 therapistclinician. In most situations, I can only release information about your treatment can only be released 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 written prior consent. Your signature on this Agreement provides consent for those activities, the activities as follows: I A clinician 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 is made to avoid revealing the identity of my clientthe patient. The other professionals are also legally bound to keep informa- tion the the information confidential. If you don’t object, I you will not tell you be informed about these consultations un- less I feel that unless it is important to our work togetherdeemed important. I All consultations will note all consultations be noted in your Clinical RecordRecords (Which is referenced as the “PHI” in the Notice and Policies and Practices to Protect the Privacy of Your Health Information). Your should be aware that this practice includes other mental health professionals and administrative staff. In most cases, it is necessary 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. This practice has contracts with an various businesses (for example collection agency, etc.) As required by HIPPA a formal business associate contract with this/these business(s), in which it/they promise to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law, has been established. 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 whereby the clinician is 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 protected by the social worker-client privilege privileged communication law. I The clinician cannot provide any information without your (or your personal or legal representative’s) written authorizationauthorizations, or a court order. If you are involved in or are contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me the clinician to disclose information. If a government agency is requesting the information for health oversight activities, I the clinician may be required to provide it for them. If a client files a complaint or lawsuit against methe clinician, I that clinician may disclose relevant information regarding that the 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 employerhim/herself. There are some situations in which I am the clinician is legally obligated to take actions, which I be- lieve he/she believes are necessary to attempt to protect others from harm and I harm. In doing so, the clinician may have to reveal some information about a client’s treatment. These situations are unusual in my practice. If I have reasonable cause the clinician knows or has reason to suspect that a child under 18 years of age, or a mentally retarded, developmentally disabled, or physically impaired individual under the age of 21, 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/ individual, the law requires that I the clinician file a report with Tennessee’s Department of Children’s Servicesthe appropriate government agency, usually the Children Services Agency. Once such a report is filed, I the clinician may be required to provide additional information. If I have the clinician has reasonable cause to suspect believe that an elderly adult is being abused, neglected, or disabled adult presents a like- lihood of suffering serious physical harm and exploited, or is in need a condition which is the result of protective servicesabuse, neglect, or exploitation, the law requires that I file a the clinician report with such belief to the county Adult Protective Services. Once such a report is has been filed, I the clinician may be required to provide additional information. If I the clinician knows or has reasonable cause to believe that a client has been the victim of domestic violence, he/she must note that knowledge or belief and the basis for it is necessary to disclose information to protect against in the client’s record. If the clinician believes 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 and he/she believes that disclosure of certain information may serve to protect that individual, I may be required then the clinician must disclose that information to take protective action. These actions may includethe appropriate public authorities, and/or initiating hospitalization and/or contacting the potential victim, and/or the police professional workers and/or the family of the client’s family. If such a situation arises, I the clinician will make every effort to fully discuss it with you before taking any action and I that will limit my the disclosure to what is necessary. While this written summary of exceptions to of confidentiality should prove helpful in informing you about potential problems, it is important that we you discuss with the clinician any questions or concerns that you may have now or in the future. Professional Records You should The laws governing confidentiality can 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 recordsquite complex, 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 clinicians 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 contentsnot attorneys. In most circumstancessituations where specific advice is required, 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 formal legal advice 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: Clinician Client 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 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 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 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 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. 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 conduct consider the initial 2 to 4 sessions as an “evaluation that will last from 1-2 sessions. period.” 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 per week sessions will be scheduled at a frequency that is mutually agree upon. By mutual agreement, we may change the length and frequency of sessions at any time we agree onduring the course of your therapy. However, although some sessions may be longer or more frequent. Once 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 My hourly fee varies depending on services If it is possible, and duration. In addition to weekly ap- pointments, I charge this amount for other professional services you may need. How- everupon your request, 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 try to find another time to reschedule a missed or check-ins, consulting with other professionals with your permission, prepar- ing of records or treatment summaries, and cancelled session as close to the time spent performing any other ser- vices of your missed appointment, although you may request of mestill be charged for the missed appointment. Xxx also agrees to appear on time for all scheduled sessions. If you become involved in legal proceedings that require my participationhe does not show up for a scheduled session or does not provide 24 hours advance notification for the cancellation of an appointment, you will be expected given your next session free of charge. Upon request and with advance scheduling, Xxx is available to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify conduct therapy sessions by another party. Be- cause of the difficulty of legal involvement, I charge $500 per hour for preparation and phone when your travel or a personal emergency precludes in person attendance at any legal proceedingsan appointment. 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 weekonly during regularly scheduled appointment times. However, I probably will do not answer the phone when I am with a client. When I am unavailable, my telephone is answered by a voice mail that I monitor frequently on weekdays between the hours of 8:00 a.m. and 8:00 p.m. I will make every effort to return your call by within 24 hours (and on the end of my business daysame day whenever possible), with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. It is helpful if you can inform me whether the contact source you are providing me is confidential. 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 staff member 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 Although I do have an e-mail address that is accessible through my website, I do not check e-mail messages with meany specific regularity. Limits I am often away from e-mail access for extended periods of Confidentiality The law protects the privacy of time. Therefore, 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 involving appointment changes or issues 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 distress 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 handled thru my telephone voice mail 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 confidentiallyvia e-mail.] 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.jimstruve.com
Meetings. I normally conduct an evaluation that will last from 1-2 sessions. During this timeIf psychotherapy is initiated, 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 4560-minute ses- sion session per week will typically be scheduled or at a time we agree on, although some sessions may be longer or more frequentother specified intervals as mutually agreed upon. 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. CONTACTING ME Due to my work schedule, I am often not immediately available by telephone. While I am usually in the office between 9:00 a.m. and 5:00 p.m., I typically do not answer the telephone when with a patient. When unavailable, a voice message service is available and messages are checked regularly. Every effort will be made to return your call within 24 hours, with the exception of weekends and holidays. If you are difficult to reach, please inform me of times that you will be available. If you are unable to reach me and feel that you cannot wait for me to return your call, contact your family physician or 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. PROFESSIONAL FEES My hourly session (50 minutes) fee varies depending on services is $200.00. Payment is required at each session. I accept cash, check, credit card (Master Card, Visa, Discover, and durationAmerican Express), and Health Savings Account (HAS) and Flexible Savings Account (FSA). In addition to weekly ap- pointmentsappointments, I charge this amount for other professional services you may need. How- everservices, 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 10-5 minutes, Skype appoint- ments or check-ins, consulting with other professionals with at your permissionrequest, 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 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 Due to the difficulty of significant time incurred with involvement in legal involvementproceedings (e.g., I charge rescheduling other patients), there is a $500 300.00 per hour charge for preparation and attendance at any legal proceedingsproceeding. Contacting Me Due BILLING AND PAYMENTS You will be expected to my work schedulepay for each session at the time it is held, unless agreed otherwise. Payment schedules for other professional services will be agreed to when requested. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I maintain the option of using legal means to secure the payment. This may involve hiring a collection agency, which will require the disclosure of otherwise confidential information. In most collection situations, the only information released regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due. If such legal action is necessary, the costs will be included in the claim. INSURANCE REIMBURSEMENT In order 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 fees. It is important that you determine 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. If it is necessary to clear confusion, I am willing to call the insurance company on your behalf, with your authorization. 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 not immediately available by telephonerequire authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to address specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for further therapy after a specified 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 provided to you, including a clinical diagnosis. Sometimes I am usually required to provide additional clinical information such as treatment plans, summaries, or copies of your Clinical Record. In such situations, every effort will be made to release only the minimum information necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in my office four days a weekcomputer. Though all insurance companies claim to keep such information confidential, I probably will not answer have no control over what they do with it once it is received. In some cases, they may share the phone when I am information with a clientnational medical information databank. 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 a copy of a colleague contactany report I submit, if necessaryyou request it. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx By signing this Agreement, you agree that I can provide requested information to communicate your insurance carrier. Once I have all of the information about your insurance coverage, I will discuss what we can expect to accomplish with methe benefits available and what will happen if they run out before you are ready to conclude therapy. Limits of Confidentiality It is important to remember that you always have the right to pay for my services yourself to avoid the problems described above. LIMITS ON CONFIDENTIALITY The law protects the privacy of all the 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 is made 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 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). Disclosures required You should be aware that I practice with other mental health professionals and 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 the same rules of confidentiality. All staff members have been provided 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. If a patient seriously threatens to harm himself/herself or someone else, Texas law provides that a professional may disclose confidential information to collect overdue fees are discussed else- where in this Agreementmedical 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 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 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 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 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 or the Work- ers’ Compensation Division, or the client’s employertreatment 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 age 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 to 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 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/evaluation, 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 or your child’s Clinical Record, Record if you request it in writing. Because You should be aware that pursuant to Texas law, psychological test data are not part of a patient’s record. Given that 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 presence, or have them forwarded to another mental health professional so professional, with whom you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of 35 cents $0.50 per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Formcopied. 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 Notespsychotherapy 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 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 These notes 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 Psychotherapy Notes psychotherapy notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you While insurance companies can request and receive a copy of your Clinical Record, they cannot be sent to anyone else, including insurance companies receive a copy of your psychotherapy notes without your writtensigned, signed Authorizationwritten authorization. Insurance companies cannot require your authorization Authorization as a condition of coverage 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. 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. SIGNED _________________________________________ DATE:____________________ Patient _________________________________________ DATE:____________________ Patient _________________________________________ DATE:____________________
Appears in 1 contract
Samples: Couple 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 45-60- minute ses- sion per week at a time we agree onsession every other week, although some sessions may be longer or more frequentfrequent based on a schedule we have agreed on. Once an For Monday appointments, 24 hours notice is the appropriate time on Friday NOT Sunday. Cancellations with less than 24 hours notice or failure to keep a scheduled appointment hour is scheduled, you will be expected charge at FULL FEE. 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 $250. This session costs more due to the extra time involved in an initial evaluation. My fee for subsequent 60-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. minute sessions are charged at $200, 90-minute sessions are charged at $300. 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 $500 500 per hour for preparation and attendance at any legal proceedingsproceeding with a minimum of 4 hours time which will be due in advance of any appearance by me. Fees for workshops and business consultations will vary depending on the specific requirements. Contacting Me Due BILLING, PAYMENTS, AND INSURANCE You will be expected to my work schedulepay 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. I accept personal check or credit card. If your personal check is returned, you will be responsible for all fees associated with check return. If your account has not been paid for more than 30 days and arrangements for payment have not been agreed upon, I am often 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. By signing this agreement you agree that if collections is required in such a circumstance it will not immediately available constitute a breach of your confidentiality. 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. I will assist you with out-of-network insurance benefits by telephoneproviding receipts with the necessary information for you to submit to your insurance although you will be expected to pay up front. While CONTACTING ME I schedule all my own appointments and get all messages via voicemail. I see clients part time (three days per week). I check my voicemail as my schedule will allow. I do not check voicemail after 7pm Mon through Thurs or on weekends. I do not check email on days I am usually in my office four days a week, I probably will not answer the phone when I am with a clientoff. I will make every effort to return your call by the end of my business day, you back as soon as when I am not with the exception of weekends and holidaysa patient. If you are difficult to reach, please inform me of some times when you will be available. If experiencing a life-threatening emergency or if you are unable to reach me and you feel that you can’t wait for me to until I return your call, contact your family physician, psychiatrist, 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 may practice with another mental health professional and 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 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 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 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) ’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 services related to that claim, I must, upon appropriate request, pro- vide a copy of the client’s record provide appropriate reports to the Labor and Industrial Workers Compensation Commission or the Work- ers’ Compensation Division, or the client’s employerinsurer. 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 under 18 who I have examined is or has been or may be subjected to abuse or the victim of injury, sexual abuse, neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglectdeprivation of necessary medical treatment, the law requires that I file a report with Tennessee’s Department the appropriate government agency, usually the Office of Children’s Child Protective Services. Once such a report is filed, I may be required to provide additional information. If I have reason to believe that any adult patient who is either vulnerable and/or incapacitated and who has been the victim of abuse, neglect or financial exploitation, the law requires that I file a report with the appropriate state official, usually a protective services worker. 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 explicit threat of suffering imminent serious physical harm to a clearly identified or identifiable victim, 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 the patient has the intent and ability 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 personcarry out such threat, I may be required to must take protective action. These actions that 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 may 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 where information puts the other person at risk of substantial harmhas 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 For this reason, I recommend request that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. contents. In most circumstancessituations, I am allowed to charge a copying fee of 35 cents per page that changes annually (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 Process or 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 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 itrefusal. 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 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, upon written request. 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. I understand that as a parent, you are concerned and may want to know about the content of your child’s discussions. It is my experience that a child will progress better in treatment if they know their parent will not know the specific content of the therapeutic discussions. Many times, this is not due to the child wanting to “keep secrets” from the parents, but due to the child being embarrassed, guilty, or otherwise lacking the communication skills. YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ABIDE BY ITS TERMS DURING OUR PROFESSIONAL RELATIONSHIP. __________________________________________________ __________________ Signature of Patient or Legal Guardian Date __________________________________________________ ___________________ Signature of Patient or Legal Guardian Date Parent/Guardian when primary client is adolescent minor: Check boxes and sign below indicating your agreement to respect your adolescent’s privacy: /____/ I will refrain from requesting detailed information about individual therapy sessions with your child. I understand that I will be provided with periodic updates about general progress, and/or may be asked to participate in therapy sessions as needed. /____/ Although I know I have the legal right to request written records/session notes since my child is a minor, I agree NOT to request these records in order to respect the confidentiality of my adolescent’s treatment. /____/ I understand that I will be informed about situations that could endanger my child. I know this decision to breach confidentiality in these circumstances is up to the therapist’s professional judgment and may sometimes be made in confidential consultation with her peer consultants. /____/ I understand that abrupt termination of therapy may render a need to discuss sensitive information pertinent to my child’s treatment needs. I agree to obtain that shared information in person via a parental session with the therapist to discuss possible ongoing needs for my child’s health and wellbeing. Parent Signature ________________________________________ Date__________ Parent Signature ________________________________________ Date__________ Therapist Signature ______________________________________ Date________
Appears in 1 contract
Samples: drsonjabenson.com
Meetings. I Evaluation normally conduct an evaluation that will last from 1-2 take place during the first two to four sessions. During this time, we you and your therapist can both decide if I am the best person you are a good match in order to provide the services you need in order to meet your treatment goals. If therapy has Once psychotherapy is begun, I will usually schedule appointments are normally scheduled for one 45-50 minute ses- sion session per week at a time we agree on, although some sessions may be longer or more frequentthat is agreed upon by you and your therapist. Once an appointment hour is scheduled, you will be expected to pay keep that time unless you reschedule with at least 24 hour notice. ATTENDANCE POLICY: Failure to show for it un- less you an appointment without contacting your Xxxxxx Xxxxxxx therapist constitutes a NO- SHOW. If a client has two consecutive NO-SHOWS, Xxxxxx Xxxxxxx staff may remove future appointments from your schedule. At that point Xxxxxx Xxxxxxx may no longer be able to 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 counseling services and durationwill assist with a referral for obtaining counseling services elsewhere. In addition Your therapist may offer 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 participationreschedule appointments; however, you will be expected subject to pay any wait list delays. Cancelling two out of three or three out of five appointments is against Park Xxxxxxx policy and may result in you being removed from the appointment schedule. Xxxxxx Xxxxxxx therapists reserve the right to cancel your appointment if you arrive to the session under the influence of alcohol or drugs, or if you (or those in session with you) are verbally or physically aggressive. This puts safety of clients and Xxxxxx Xxxxxxx therapists at risk. It is your therapist’s discretion to determine whether you might be under the influence of drugs/alcohol or if you are putting safety of others at risk. You are responsible for all paying out of my professional timepocket for the session if your therapist cancels the session due to reasons listed above. (See Xxxxxx Xxxxxxx Financial Policy). Most sessions last between 45 to 50 minutes. Xxxxxx Xxxxxxx has established that in order to provide quality service, including preparation and transportation costs, even if I am called a client is more than 15 minutes late they will be asked to testify by another partyreschedule their appointment. 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 CONTACTING Xxxxxx Xxxxxxx We are often not immediately available by telephone. While I am usually in my office four days a week, I probably will We may not be able to answer the phone when I am we are with a clientpatient. I We do not offer emergency or crisis counseling. If you are experiencing an emergency, we ask that you call 911 or present to the nearest hospital emergency room. For non-emergency concerns or questions, you may call us at 000-000-0000 with a clearly stated return number. We will make every effort try to return your call by the end of my within one business day, with the exception . PROFESSIONAL RECORDS The laws and standards 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 our profession require that you can’t wait we keep treatment records 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 necessary7 years. You may also utilize email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx are entitled 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 receive 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 records unless 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 personseeing them would be emotionally damaging for you, 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 case 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 will be happy to send them to a mental health 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 writingchoice. 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 your therapist’s presence so you that we can discuss the contents. In most circumstancesPatients will be charged an appropriate fee for any time spent in preparing information requests. MINORS If you are under eighteen years of age, I am allowed please be aware that the law may provide your parents the right to charge a copying fee of 35 cents per page (and for certain other expenses)examine your treatment records. The exceptions It is our policy to this policy are contained in the attached Notice Form. If I refuse your request for an agreement from parents that they agree to give up access to your Clinical Recordsrecords. If they agree, your therapist will provide them only with general information about their work together, unless your therapist feels there is a high risk that you will seriously harm yourself or someone else, or that you have been harmed. In this case, he/she will notify them of concern. He/she will also provide them with a right summary of reviewyour treatment when it is complete. Before giving them any information, which I s/he will discuss the matter with you upon request. In additionyou, 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 conversationsif possible, and how they impact your therapy. They also contain particularly sensitive information that do their best to handle any objections you may reveal have with what he/she is prepared to me that is not required to be included in your Clinical Record. [They also include in- formation from others provided to me confidentiallydiscuss.] 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: Outpatient Services Contract
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 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 a fee of $60 if you do not show to the appointment or fail to provide 24-24 hours advanced notice of cancellation. It I ask that you leave a credit card number or un-dated check to cover payment in the event that you do not show for a scheduled session. Checks will be returned upon termination of services. If you are late, you are charged for the full therapy hour even though you may not receive the full 45 minutes. If I am late, you receive your full therapy hour. In order for therapy to be most effective, it is important that once you begin services that you continue to note schedule and attend regular appointments. If a lapse in therapy is necessary for you, I ask that insurance companies you discuss this with me. If you chose to discontinue services, I also ask that you notify me of your intentions. You may do not provide reimbursement for cancelled sessionsthis at any time. Payment and Professional Fees My hourly fee varies depending on services is $125 for the initial diagnostic session and duration$100 for following sessions. Should you fail cancel your appointment 24 hours in advance, or not show to a scheduled session, you will be charged $60. Your signature indicates your promise to not dispute charges (“charge back”) for sessions you have received or no show/cancellation fees. In addition addition, your signature further authorizes the disclosure of information about your attendance/cancellation to weekly ap- pointmentsyour credit card issuer if you dispute a charge. If you are using insurance, I charge this amount you will be responsible for other professional services you may needyour co payment at the beginning of each session. 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 Any charges not covered by insuranceyour insurance or any charges that have not been paid within 60 days are your responsibility. Other services include report writing, telephone conversations lasting longer than 10-10 minutes, Skype appoint- ments or check-ins, consulting with other professionals with per your permissionrequest, prepar- ing preparation of records or treatment summaries, and the time spent performing any other ser- vices service that you may request of me. You will be expected to pay for each session at the time that it is held unless we agree otherwise. I will usually collect payment at the beginning of each session to minimize difficulty in closing at the end of the session. Payment 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, address, phone numbers, the nature of services provided, and the amount due. [If such legal action is necessary, its costs will be included in the claim.] Court Involvement and Subpoenas I do not knowingly accept court-related cases. Your signature serves as your agreement that you are not involved in a court-related case regarding the circumstances in which you are seeking counseling. I am not a custody evaluator and cannot make any recommendations on custody matters. I can refer you to a professional who can provide custody evaluation if needed. Due to the sensitive nature of court related issues, and the time that it will cost me away from my normal work day, you must agree to the following policies before: When working with children of divorced parents, I require a copy of the current, standing court order that demonstrates custodial rights of each parent; or a parenting agreement that has been signed by both parents and a judge before I meet with the child. The parent who is initiating counseling services must have legal authority to make medical decisions for the child. It is your responsibility to inform the other parent of your child’s involvement in counseling if necessary. It is optimal for both parents to participate in the counseling process if possible. I will offer and encourage opportunities for both parents to be involved throughout the counseling process. I ask that my clients waive their right to subpoena me to court for any reason. It is my desire and ethical obligation to preserve the confidentiality and trust that is established in the counseling relationship. Having me and/or my records subpoenaed often damages this. It is in your best interest to know that conducting expert witness testimony is not my area of expertise. I can refer you to another professional who can provide this service if needed. Your signature indicates your agreement to waive your right to subpoena me for this purpose. I will not attend court or deliver my records unless a valid subpoena is issued. If you choose to disregard this waiver and issue me a subpoena, you will be responsible for all charges involved. If you or your child become involved in legal proceedings that require my participationparticipation from another party, you will be expected to pay responsible for all charges. Court related services are not covered by insurance. If I am subpoenaed to appear in court, it will be necessary for me to clear my schedule to be available to attend. I will require at least 24 hours advance notice in order to do this. The charge for me to clear my schedule is $1000, regardless of whether or not I am actually called to appear in court. This includes time spent “on call” or “on standby”. This fee is not refundable even if the case is dismissed or court date is rescheduled. My fee for attending court is $3000 per day regardless of how long I am there or if my professional services are used. The advance payment of $1000 to clear my schedule will apply towards the daily fee if I am indeed required to attend court on that day. Other expenses such a preparation for court, researching, report writing, depositions, travel time, including preparation and communicating with attorneys or other professionals will cost an additional $250 per hour, and is not included in the $3000 per day fee. Other expenses such as transportation costs, even lodging (if more than 90 minutes away from my office), copies, and parking will be charged separately. In the event that I am called to testify by another partymust seek legal consultation regarding any issues involving you or your child, you will be responsible for any charges incurred. Be- cause All payments must be made in advance in the form of the difficulty of legal involvementcash, I charge $500 per hour for preparation and attendance at any legal proceedingsor cashier’s check. Checks will not be accepted. 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 unavailable to answer the phone when calls while I am in session with a client, before 8am, after 8pm, weekends, and on holidays. When I am unavailable, please leave a confidential voicemail for me including your name, phone number you can be reached at, and a brief detailed message. I will make every effort to return your call by the end of my business day, within 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 availableavailable to take a phone call. Please be advised that when I do return your phone call, my number will appear on your caller ID as restricted or unavailable. If you are unable to reach me and you have an emergency situation or do not feel that you can’t are able to wait for me to return your call, please contact your family physicianpsychiatrist, the dial 911, or go to your nearest emergency room and ask for the psychologist or psychiatrist person 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 mePlease understand that contact outside of face-to-face sessions is done on cordless and cellular phones. 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 All conversations via 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 means 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 confidentiallylimited privacy.] 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 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 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 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 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 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 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 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 goalsEach session typically lasts 60 minutes. If you are late for a session, that time is lost from your session. Scheduling presents a special problem in private therapy has begunbecause once a given hour is blocked out for a particular person, I will usually schedule one 45-minute ses- sion per week at a time we agree on, although some sessions may it cannot be longer or more frequentfilled again on short notice. 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, under all circumstances. Services can be obtained via video teletherapy sessions (VSee) when you are not able to come to the office. It is important to note that insurance companies do not provide reimbursement for cancelled sessionssessions but some may for video therapy. 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 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 or within 24 hours, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times and contact information when you will be available. If there is a crisis or an emergency situation and you are unable to reach me and you feel that you can’t wait for me to return (as I am not a critical care service), please utilize your calllocal hospital emergency room, contact your family physicianpolice department, the nearest emergency room and ask for the psychologist or psychiatrist on call, or call 911etc. 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 contact Xx. Xxxxxx via email at xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx at: xxxxx@xxxxxxxxxxxxxxxxxxxxx.xxx. PROFESSIONAL FEES • Initial evaluations (cpt code 90791) are $230.00 per 60-minute session (1-3 sessions). • Follow-up sessions (cpt code 90837) are $200.00 per 60-minute session. • Case Consultations are $230.00 per 60-minute session. PSYCHOLOGICAL ASSESSMENT (Including report preparation): • Personality $1400+, Dissociation $1600+. Fifty (50) % of the above assessment fees are due on the date the testing is initiated, with the remainder due when the results are presented to communicate with meyou. Limits of Confidentiality The law protects the privacy of all communications between You will receive a client and a therapistfinal report. 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 Please do not alter or edit this Agreement provides consent for those activitiesreport in any manner, as follows: I psychological assessment findings 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 togetherbe misinterpreted. I will note all consultations in your Clinical Record. Disclosures required by health insurers or be happy to collect overdue fees are discussed else- where in this Agreement. There are some situations where I am permitted or required prepare an appropriate brief summary report 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 anyoneyour school, including reports to your insurance carrier. Except in the unusual circumstance where disclosure is reasonably likely to endanger you and/or others physician or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the other person anyone else 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 my usual hourly rate. COURT FEES: The rate for all court-involved services is $420.00 per hour, with a four-hour minimum ($1680.00), to your Clinical Recordsbe paid in advance. This includes preparation time, you have travel, and waiting time. PHONE CALLS & EMAIL COMMUNICATION & OTHER SERVICES: At the hourly rate of $200.00, beginning with a right of reviewminimum $60 charge per contact (call, which text, email or other) that is clinical in nature and not brief scheduling or billing matters. Please be advised that I will discuss charge for the time involved in transcribing voice mails and/or transferring emails/texts to medical records. I will charge this amount for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour (rounded up in 5 min increments). Other services include report writing, telephone conversations lasting longer than 5 minutes, texting, emailing, consulting with you upon request. In additionother professionals and family members or friends with your permission, I also keep a set preparation 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 conversationsrecords or treatment summaries, and how they impact your therapy. They also contain particularly sensitive information that the time spent performing any other service 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 confidentiallyrequest of me.] 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: cityparkpsychological.com
Meetings. I Your psychologist normally conduct conducts 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 your doctor 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 appointment hour is scheduled, you will be expected to pay for it un- less unless you provide 24-24 business 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 PROFESSIONAL FEES Our session fee varies depending on services and durationis $160. 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 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 we charge $500 250 per hour for preparation preparation, travel and attendance at any legal proceedingsproceeding. Contacting Me CONTACTING YOUR PSYCHOLOGIST Due to my our varied work scheduleschedules and the improbability of your doctor answering the phone when with a patient, I am your psychologist is often not immediately available by telephone. While I When doctors are unavailable, the telephone is answered either by our secretaries who know where to reach the doctors, or by voice mail that is monitored frequently. Our staff are in the office Monday through Friday from 8am usually in my office four days a week, I probably will not to 6pm to answer the phone when I am with a clientphones. I Your doctor 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 your psychologist 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 your doctor 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. In most situations, I we 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 • 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 clientthe patient. The other professionals are also legally bound to keep informa- tion the information confidential. If you don’t n'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 my Notice of Psychologist's Policies and Practices to Protect the Privacy of Your Health Information). • We also have a privacy contract with our accountants. As required by HIPAA, we 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, we 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, we may be obligated to seek hospitalization for him/her, or to contact 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 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 treatment, such information is protected by the social workerpsychologist-client patient privilege law. I We 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 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 's compensation claim, I we 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 we are legally obligated to take actions, which I be- lieve we believe are necessary to attempt to protect others from harm harm, and I we may have to reveal some information about a client’s patient's treatment. These situations are unusual in my practice. • If I we 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 and Regulatory Services. Once such a report is filed, I we may be required to provide additional information. • If I have reasonable cause to suspect we 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 we 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 we 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, and we are not attorneys. 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 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 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 we 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 we 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.
Appears in 1 contract
Samples: Services Agreement
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 If we decide to continue therapy together, we will last from 1-2 discuss frequency of sessions. During this time, Frequency of sessions can range anywhere between once a month to 2 times per week. Therapy sessions last 50-55 minutes (1 therapeutic hour). Please be on time as I make a point of beginning and ending sessions according to what we both decide if I am the best person to provide the services you need in order to meet your treatment goalshave scheduled. 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 PROFESSIONAL FEES My hourly (55-minute) fee varies depending on is $180 for all psychological services that I provide (including psychological assessments, individual psychotherapy, family, and durationcouple’s therapy). In addition to weekly ap- pointments, This fee is due at the time of service. I charge this amount for other professional services you may need. How- everneed as well, though I will break down the hourly cost if I work for periods of less than one hour. Note that these additional If other services are not covered by insuranceneeded outside of our session meetings, payment is expected for the time used during these services, including travel and waiting time. Other services may 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 (e.g. attendance at school meetings/consultations or legal proceedings), prepar- ing preparation of records or records, treatment summaries, letters, and the time spent performing any other ser- vices service you may request of me. My fees are subject to periodic change, and you will be notified in advance of such changes. Please be aware that additional services such as described above are not typically covered by insurance plans. If you become involved in legal proceedings need to cancel or reschedule a session, you must provide at least 24-hour notice (please review the cancellation policy below). Please note that require my participationinsurance will not reimburse you for this fee. BILLING AND PAYMENTS For psychotherapy, you will be expected to pay for all each session at the time it is held unless we arrange a different payment schedule. I accept cash, check, Venmo (@Xxxx-xxxxxx), or credit/debit/HAS/FSA card. If paying by check, please make the checks out to: Xxxxxxx Xxxxxx. In the event of my a returned check, you will be responsible for any bank fees I have incurred. Payment schedules for other professional timeservices 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, including preparation 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. If such legal action is necessary, its costs will be included in the claim. In most collection situations, the only information I release regarding a patient’s treatment is his/her name, the nature of services provided, and transportation coststhe amount due. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, even if it is important to evaluate what resources you have available to pay for your treatment. I am called not an in-network provider for any insurance plans. Health insurance policies typically include some coverage for mental health treatment. It is recommended that a call be placed to testify Member Services (usually listed on the back of insurance cards) to confirm what coverage is available. If there are out-of-network benefits available, I will happily complete any necessary forms to assist patients in using these benefits and receiving whatever reimbursement is available to them. Please note, however, when using out-of-network coverage, there is often a deductible to be met and payment is due in full by another partythe patient at each session. Be- cause Insurance companies in turn provide some reimbursement of the difficulty of legal involvement, I charge $500 per hour for preparation and attendance at any legal proceedings. Contacting Me Due fee directly 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 clientpatient after the deductible has been met. I will assist with any questions about insurance coverage along the way. Please be aware that even out-of-network insurance will only pay for services that are attended by you. They do not pay in the event of late cancellations or no-shows. CANCELLATION POLICY **Please pay attention to this 24-hour cancellation policy** Once an appointment hour is scheduled, you will be expected to pay for that session in full unless you provide 24-hour advance notice of cancellation. The 24 hours gives me a chance to rearrange the calendar and possibly find another time when we can meet. It also allows time for me to find someone else to fill that hour. The only time I waive this fee is in the event of a medical emergency, such as hospitalization or contagious illness. Please be aware that minor illness and family and/or work conflicts do not excuse you from paying for the session. If you call for a last minute reschedule, I will try to find another time that day to move to (without charging for the missed session). If we cannot find another time that day, you will be charged for the missed session (even though you were not present) and we will then schedule our next session. Keep in mind that insurance will not pay for a missed session. If there is some sort of conflict that arises that prevents you from being in the office, but you could talk on the phone (for example, if you have a minor illness, or if a family member was sick and you were visiting them in the hospital), please let me know and we can do a phone session. Regular fees will apply. Please 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 attend 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 informationsession scheduled. 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 conflict 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 remember how 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 (is and for certain other expenses). The exceptions to this policy are contained consider your emotional and financial investment 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: Outpatient Services 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 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. Our first appointment will be at least a one hour “face-to-face” Consultation intended to clarify your needs as well as to determine whether or not we feel comfortable working with each other. At the end of this meeting, I normally conduct an evaluation will provide you with a personalized packet of questionnaires, that will last from 1I ask you to complete at your home as soon as possible. If you find that completing the forms makes you uncomfortable, please stop immediately and call me to discuss other options. After you receive and complete your personalized packet, please return it to my office, preferably by the postal service or another delivery service if you prefer, deliver it directly to 000 Xxxx Xxxxxx Xxxx at a pre-2 sessions. During this arranged time, we both decide if or carefully fax it to 000-000-0000.. Usually within 48 hours upon receipt of your forms, I am the best person will briefly call you to provide the services you need in order offer some impressions of what our work together will entail. Alternatively, I may feel that it is important for us to meet discuss other treatment options which may better suit your treatment goals. If therapy has begunthat is the case, I will ask colleagues and post on the Pennsylvania Psychological Association List-serve for possible availabilities and options for you without revealing any of your personally identifying information. There are a few occasions when we might decide that there is a need to meet for a few standard sessions to determine your best treatment recommendation thus completing the consultation process. When all is said and done, you should evaluate the information I provide along with your own opinions of whether you feel comfortable working with me. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. Therapy sessions are usually schedule one 45hour-minute ses- sion long sessions, held once per week week, at a time we agree on, although . There may be times when 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 in advance notice of cancellation. It Nevertheless, if we both agree that missing this one appointment was due to circumstances beyond your control, the fee will be waived. If you have questions regarding my procedures, we should address them whenever they arise. If your doubts persist, I will be happy to help direct you to another mental health professional for a second opinion. Usually I will urge you to locate credentialed specialists in CBT at xxxx.xxx and/or xxxxxxxxxxx.xxx. If you have a different psychotherapy modality in mind, I will post your anonymous request on the Pennsylvania Psychological Association List- Serve. PROFESSIONAL FEES My Consultation fee is important to note that insurance companies $225.00 and my hourly session fee is $185.00. As this is exclusively a fee-for-service solo practice, I do not provide reimbursement for cancelled sessions. Professional Fees My hourly fee varies depending have a sliding scale based on services and durationfinancial hard ship needs. 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 10-15 minutes, 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 $500 400.00 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 expensesproceeding). 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: Outpatient Services Contract
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 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 Psychotherapy involves continuous evaluation that will last from 1and re-2 sessionsevaluation to insure we are reaching the goals we set up. During this timeAlthough sessions are usually 55-60 minutes, we both decide if I am the best person to provide the services you need in order to meet your treatment goalsfirst session may be longer. If Group therapy has begunis usually 90 minutes. Once a meeting is scheduled, I will usually schedule one 45-minute ses- sion per week at a be reserving that time we agree onfor us. Because of the nature of psychotherapy, although some sessions may be quite longer or more frequentand there could be a delay in starting a session if the previous session involved a patient in crisis. Once PROFESSIONAL FEES/PAYMENT I am an appointment hour is scheduled, you will be expected to pay Out-Of-Network provider for it un- less you provide 24-hours advanced notice of cancellation. It is important to note that all insurance companies do not provide except Classical (original) Medicare. Medicare patients pay their co-pays if possible at each session. Fees are paid at the time the session is held for all other patients. Checks, credit cards, debit cards and cash are accepted. You should carefully read the section in your insurance coverage booklet that describes mental health services. Or call the Member Services number on the back of your insurance card and get information about coverage for Out- Of-Network providers, deductible amounts, and reimbursement amounts after paying for cancelled sessionsservices of $130.00/session. Professional Fees My hourly fee varies depending on services and duration. In addition If you need to weekly ap- pointmentscancel a meeting/session, I charge this amount for other professional services request you may need. How- ever, I will break down the hourly cost give me as much notice as possible; if I work for periods of its less than one hourbusiness day, or if the session is forgotten or failed, the fee is $50.00 even if you are a Medicare enrolled patient. Note If you are a Classical Medicare patient, you should know that these additional services are not covered by insuranceMedicare requires me to make a good faith attempt to collect co-pays. 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 meMy session fee is $130.00. 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 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 usually not immediately available by telephonephone. While When I am usually in not available, my office four days a week, I probably answering machine will not answer take the phone when I am with a clientcall. I will make every effort to return your call by the end of my business day, as soon as I can with the exception of weekends Fridays, Saturdays, Sundays and holidaysHolidays. If you Although many patients want to use email and text messaging to schedule and change appointments, know that they are difficult to reach, please inform me of some times when you will be availablenot secure systems. 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 psychologist, psychiatrist, social worker or psychiatrist crisis counselor on call. Crisis counselors are on call by phone 24/7. (000-000-0000) Insurance Issues and Confidentiality You should also be aware that your contract with your health insurance company requires that I provide them with your clinical diagnosis. Sometimes I may have to provide additional clinical information, such as treatment plans, progress notes or summaries, or call 911copies of the entire record (in rare cases). If This information will become part of the insurance company files. Though all insurance companies claim to keep such information confidential, I will be unavailable for an extended timehave 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 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 any records 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 are professional recordsYou understand that, they can be misinterpreted and/or upsetting by using your insurance, you authorize me 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 release such information to your Clinical Recordsinsurance company. I will try to keep that information limited to the minimum necessary. Of course, you have a right choice of review, which I will discuss with you upon request. In addition, I also keep a set paying for sessions without involvement of Psychotherapy Notes. These Notes are for my own use insurance and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary without reimbursement 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 confidentiallythem.] 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: drlopresti.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. 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 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
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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 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 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 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 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. 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 1-1 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 beguntreatment is started, I will usually schedule one 45-45 minute ses- sion per week session (one appointment hour of 45 minutes duration) every 2 weeks 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 is $175.00 for the initial evaluation hour, $180.00 for EMDR (90 minute sessions) $140.00 for a regular 60 minute subsequent visit and duration$120.00 for 45 minutes. In addition to weekly ap- pointmentstherapy appointments, 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 with probation, I will provide very general monthly reports on our progress (you will receive copies each month) at no additional charge to you. However, if you request my presence in legal proceedings that require my participationcourt, 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 $500 250.00 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 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 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 during a crisis 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 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 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: Client Services Agreement
Meetings. I normally conduct an evaluation that will last from 1-2 sessions. During this timeour initial visits, you and we both can decide if I am the best person to provide the services you need in order to meet your treatment goalsgoals are services we can provide. If therapy has psychotherapy is begun, I we will usually schedule one 4550-minute ses- sion per week at a time we agree onvisits. These visits will occur on Mondays through Thursdays. When you schedule an appointment, although some sessions may be longer or more frequentit is very important that you plan to keep the appointment. 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 for visits on Tuesdays, Wednesdays, and Thursdays, and four (4) days advance notice of cancellation for visits on Mondays. Additional visits are suspended until you pay for missed appointments. We make exceptions to this rule when a sudden illness or an emergency makes it impossible for you to provide us with the required notice. It is important to note that insurance companies do not provide reimbursement for cancelled sessionsvisits. Professional Fees My hourly fee varies depending on services PROFESSIONAL FEES Our fees are $150 for the initial visit, $110 for 60-minute visits, $1500 for psychological testing with written reports, and duration$60 for 30-minute visits. In addition to weekly ap- pointments, I We charge this amount these amounts 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 including 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, preparation of treatment plans, 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 $500 220 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 weekWhen we are unavailable, I probably will not answer the phone when I am with a clientour telephone is answered by our secretary or voicemail. I 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 reachIn urgent emergencies, please inform me of some times when you will be availablepatients can call 000-000-0000. If you are unable to reach me and your call is not promptly returned or you feel that you can’t cannot wait for me to a return your call, call 911, go to the nearest emergency room, or contact your family physician, the nearest emergency room and ask for the psychologist or psychiatrist on call, or call 911. If I will be we are unavailable for an extended time, I we will provide you with the name names of a colleague other psychologists whom you could 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 we 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 the Acknowledgement Sheet for 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 do not 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 Protected Health Information). 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 staff members have been given training about protecting your privacy and have agreed not to release any information outside of the practice without the psychologist’s permission. We also have a contract with an accounting firm. As required by HIPAA, we have a formal business associate contract with this business in which the firm promises 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 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, 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 treatmentthe professional services that we provided you, such information is protected by the social workerpsychologist-client patient privilege law. I We 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 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 files we are providing treatment for conditions directly related to a worker’s compensation claim, I mustwe may have to submit such records, upon appropriate request, pro- vide a copy to the 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 we are legally obligated to take actions, actions which I be- lieve we believe are necessary to attempt to protect others from harm 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 have we receive information in our professional capacity from a child or the parents or guardian or other custodian of a child that gives us 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 we 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 we 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 servicesto an identifiable victim, 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 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 we will make every effort to fully discuss it with you before taking any action 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 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 us 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 we recommend that you initially review them in my presence, our presence or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to We will 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, as allowed by law. If I we refuse your request for access to your Clinical Recordsrecords, you have a right of review, which I we 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 we 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 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 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, we 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 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 visit at the time of the visit unless you have insurance coverage that requires another arrangement. Payment can be made by cash, check, VISA, or MasterCard. If your check is returned for insufficient funds, we will request immediate payment by cash, credit card, or bank cashier’s check and add an additional $30 “bad check” fee. Additional visits are suspended until you pay for returned checks. 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, and this 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 If you have a health insurance policy, it will usually provide some coverage for mental health treatment. We recommend that you find out what mental health services your insurance policy covers. Read the section in your insurance coverage booklet that describes mental health services and call your plan administrator. If your plan is one with which we have had experience, our secretary may also be helpful as you try to understand your coverage. Please keep in mind that you are responsible for the payment of our fees. Since we are nonparticipating providers with most insurance companies, their payments will be made to you. Our only interaction with your insurance or managed care company is likely to be the completion of treatment plans. It is your responsibility to determine if treatment plans are required and when they are to be submitted. We will complete treatment plans only with you or your representative (if you are a minor) present. All treatment plans must be completed during your visit with us, consequently. As authorizations from insurance companies expire, it is your responsibility to have us prepare new treatment plans. If we are participating providers in your health insurance plan, you have already given our secretary permission by phone to contact your insurance company and verify your benefits. The payment you make at the visit, known as a “copayment,” is specified by the insurance or managed care company. We are responsible for obtaining authorization for your visits and for submitting insurance claims. Your contract with your health insurance company requires that we disclose 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 the Acknowledgement Sheet, you agree that we can provide requested information to your insurance company.
Appears in 1 contract
Samples: www.cerioandceriopsych.com
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 a late cancellation/no show fee of $50.00 unless you provide 24-24 hours advanced advance notice of cancellation. Monday appointments must be cancelled by Friday at 4:00 p.m. in order to avoid a late cancellation fee. It is important to note that insurance companies do not provide reimbursement for cancelled sessions. Professional Fees PROFESSIONAL FEES My hourly fee varies is $100 to $250, depending on what services and durationare utilized. 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 preparation. Attendance at any legal proceedingsproceeding is charged by the service and not by the hour. Contacting Me Due to my work schedule, CONTACTING ME When I am often not immediately available unavailable, my telephone is answered 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 clientvoice 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 my home number.] 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 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 there is an 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 a patient threatens to harm himself/herself, I am 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 will 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 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 actual threat of physical violence against a clearly identified or disabled adult presents reasonably identifiable victim or a like- lihood 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 filedspecific violent act, 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 am 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 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 Business 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 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 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 Business 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)) for any subsequent copies. 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 NotesRecords. These Notes Records are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes Records vary from client to client, they can include social history, the con- tents contents of our conversations, my analysis of those conversations, goals and diagnosis and how they impact on your therapy, as well as, progress. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Business Record. [They also include in- formation information from others provided to me confidentially.] . These Psychotherapy Notes Records are kept separate from your Clinical Business Record. Your Psychotherapy Notes Records 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. 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, 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
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 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 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 charged $50 if you provide cancel without providing 24-hours advanced hour 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 $150 for the initial session; $130 for each session thereafter. 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 $500 200 per hour for preparation and attendance at any legal proceedingsproceeding. Contacting Me Please keep in mind that payment for services is due at the time of service. 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. 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 the end of my next 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 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 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 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 1-2 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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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 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 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. 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 appropri- ate, 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 of- fice, 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. My initial counseling session is $140.00. If I am a preferred provider with your insurance company, you will pay only the co-pay. I will bill your insurance for my portion of the fee. Otherwise, you will be expected to pay for the full fee. I also bill if you are using your EAP (employee assistance program benefits) so you do not pay. 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: 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 $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 We normally conduct an evaluation that will last from 1-2 to 4 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 is begun, I we will usually schedule one 45-50 minute ses- sion session per week at a time we agree on, although some sessions may be longer or more frequentvary in length 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 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, we will try to find another time to reschedule the appointment.] PROFESSIONAL FEES Our hourly fee varies typically ranges from $80-140 per session, depending on the provider and the services and durationprovided. 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 a typical 45-50 minute hour. Note that these additional services are not covered by insurance. Other services include report writing, telephone 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 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 typically charge $500 175 per hour for preparation and attendance at any legal proceedingsproceeding.] Some providers offer a sliding scale fee or discounted rate for out-of-pocket fees for individuals who do not have insurance coverage for services. Contacting Me Ask your provider if they participate in this option if you are interested. A discount fee application is available in the client manual. CONTACTING US Due to my our work schedule, I am we are often not immediately available by telephone. While I am we are usually in my our office four days a weekduring working hours, I we probably will not answer the phone when I am we are with a client. I When we are unavailable, our telephone is answered by an answering service [machine, voice mail, or by our office staff] that we monitor frequently, or who knows where to reach us. 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 can call the provided emergency number(s).] 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 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 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 therapisthealth professionals. In most situations, I we can only release your private health information (PHI) 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 we may need to use or disclose your PHI without your authorization or consent. Your signature on this Agreement provides consent Please read “Notice of Policies and Practices for those activities, as follows: I may occasionally find it helpful to consult other health Privacy of Protected Health Information” for detailed policies and mental health profes- sionals about a caseprocedures regulated by HIPAA. During consultation, I make every effort to avoid revealing the identity PROFESSIONAL RECORDS The laws and standards 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 professions require 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 typically includes information about your reasons for seeking therapyservices, 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 we 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 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 to we will charge a copying processing fee of 35 and 50 cents per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I we refuse your request for access to your Clinical Recordsrecords, you have a right of review, which I we will discuss with you upon request. In addition, I some providers may also keep a set of Personal Psychotherapy Notes. These Notes 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 Personal Psychotherapy Notes vary from client to client, 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 information from others provided to me us confidentially.] These Personal Psychotherapy Notes are kept separate from your Clinical Record. Your Personal Psychotherapy Notes are usually 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 MINORS AND LEGAL GUARDIANS Clients under 16 or17 years of age who are not emancipated and their legal guardians should be aware that the law may allow legal guardians to examine their child’s treatment records. Because privacy in therapy is often crucial to successful progress, particularly with teenagers, it is sometimes our policy to request an agreement from 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. We will also provide guardians 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 guardians of our concern. Before giving guardians 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 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 be willing to negotiate a fee adjustment or payment installment plan.] If your account has not been paid for more than 90 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 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. We will fill out forms and provide you with several new 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 clients feel that they need more services after insurance benefits end. [Some managed-care plans will not allow us to provide services to you once your benefits end. If this is the case, we will do our best to find another provider who will help you continue your services.] 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 expanded rights 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 regard 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 the “Informed Consent for Services,” you agree that we can provide requested information to your Clinical Records 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 disclosures of protected health informationwhat will happen if they run out before you feel ready to end your sessions. These rights include:It is important to remember that you have the right to pay for our services yourself to avoid the problems described above [unless prohibited by contract].
Appears in 1 contract
Samples: www.ablewellnesscenter.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 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 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 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 or 60-minute session (one appointment hour of 45-minute ses- sion 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 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 fees for sessions of different lengths of time are listed on services the back of the Information Form, which you will be asked to complete and durationsign. 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 billable services include report writing, telephone conversations lasting longer than 10-minutesconversations, Skype appoint- ments or check-insemail time, 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; this fee will increase substantially per hour if I retain counsel. Contacting Me CONTACTING ME Due to my work schedule, I am often not immediately available by telephone. While Even when I am usually in my office four days a weekoffice, 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 try to return your call by the end of my call, particularly if urgent, within one 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, physician or the nearest hospital 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. This Authorization Form will remain in effect for a length of time you determine. In most cases, it cannot exceed 60 days. 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: • You should be aware that I may occasionally find it helpful to consult practice with other health and mental health profes- sionals about a caseprofessionals and that I employ administrative staff. During consultationIn most cases, I make every effort need to avoid revealing share protected information with these individuals for both clinical and administrative purposes, such as scheduling, billing and quality assurance. All of the identity of my client. The other 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 legally bound have contracts with businesses such as bookkeepers, accountants and computer consultants. As required by HIPAA, I have a formal business associate contract with these businesses, in which they promise to keep informa- tion confidentialmaintain 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 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 a copy of the clientpatient’s record to the Labor D.C. Office of Hearings and Industrial Commission Adjudications, the patient’s employer or the Work- ers’ Compensation Division, or the client’s employerinsurer. 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 reason to suspect that a child has 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 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 anyoneactions, including reports to your insurance carrier. Except in notifying individuals who can protect the unusual circumstance where disclosure is reasonably likely to endanger you and/or others patient 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 confidentiallyinitiating emergency hospitalization.] 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 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 fees which may depend upon factors such as length of appointment or who provides services. 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 $500 400 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: 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.
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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 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.
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Samples: twelchpsychologist.com
Meetings. I normally conduct an evaluation evaluation, which may or may not include formal psychological testing, 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 one 45-50- minute ses- sion session (one appointment hour of 50 minutes duration) per week or every other week at a time we agree on, although some sessions may be longer or more or 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 cancellationcancellation or unless I can fill the open slot with another patient. A appointment scheduled for Monday must be cancelled by noon on Friday to avoid having to pay for the session. 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 duration. is $175.00 (or $3.00 discount for check or cash.) In addition to weekly ap- pointmentsappointments, I charge this amount for other professional services you may need. How- ever, 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-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 or your representative 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 complexity and liability of legal involvement, I charge $500 200 per hour for preparation for and attendance at participation in any legal proceedingsproceeding. Contacting Me Due to CONTACTING ME Because I spend most of my work scheduleday in session with patients, I am not often not immediately available by telephone. While I am usually in my office four days a weekoffice, Monday through Thursday and on some Fridays, I probably will do not answer the phone when I am with a clientpatient. The best time to reach me is often between noon and 2:00 PM or between 7:00 and 7:30 PM. When I am unavailable, you may leave a message on my confidential voicemail. I will make every effort to return your call by the end of my business daywithin 24 hours, with the exception of Fridays, weekends and holidays. If you are also 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 physicianphysician or Highlands Behavioral Health at 000-000-0000. If your emergency is life threatening, call 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. 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 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 employ administrative staff. In most cases, I need to share protected information with these individuals for both clinical and administrative purposes, such as, billing, filing, 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 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 either 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 am required to provide it for them. If a client patient files a complaint or lawsuit against me, I may will 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, or toward a specific location, 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 must make every an effort to fully discuss it with you before taking any notify such person or location; and/or notify an appropriate law enforcement agency; and/or take other appropriate action and I will limit my disclosure to what is necessaryincluding seeking hospitalization of the patient. 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 Colorado has a psychotherapist-patient privilege which means mental health professionals cannot be asked about your reasons for seeking therapy, a description any knowledge gained during the course of therapy without the consent of the ways in which your problem impacts your life, your diagnosis, person to whom the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past testimony relates (C.R.S. 00-00-000 (g). This privilege extends to treatment records that I receive from other providers, re- ports including psychotherapy notes. Juvenile patients in particular require the privacy protection provided by the psychotherapist-patient privilege due to the sensitive nature 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 children's mental health care provider(Xxxx v. People, 927 P.2d 1315, 1321 Colo. 1996.) is referenced and I believe disclosing that information puts While patients have the other person at risk of substantial harm, you may right to submit in writing a request to examine and/or receive a copy of your the Clinical Record, if you request it in writing. Because these are professional records, they records and can be misinterpreted and/or upsetting to untrained readers. For this reasonIf I believe disclosure of records may cause psychological harm to the patient, I recommend that may instead provide you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss with a written summary of the contents. In most circumstances, I am allowed to charge a copying fee of 35 cents per page records (and for certain other expensesC.R. S. 25-1-802 (1) (a). 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 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. You also have a right to inquire about my professional training and credentials and you are always welcome to do so. In summary, I am a psychologist, licensed in the state of Colorado since 1997. I completed a master's degree in counseling and general psychology at the University of West Florida in 1991 and a doctorate in professional psychology at the University of Denver in 1995. I hold a bachelors degree in Social Work and English Literature. My training at the University of Denver was approved by the American Psychological Association as was my pre-doctoral internship site at Indiana University Counseling and Psychological Services. I specialize in family systems, child, couple, and family therapy, trauma recovery, and psychological testing. I have been trained in Eye Movement Desensitization Reprocessing (EMDR) since 2000 and continue to study and implement this therapy technique. I also pursue continuing education in variety of areas, particularly trauma recovery, divorce-related matters, and clinical applications of neurobiology and the field of epigenetics. You are entitled to request information about the methods of therapy, techniques used, probable duration of therapy if known, and the fee structure. You may seek a second opinion from another therapist or terminate therapy at any time. The practice of licensed or registered persons in the field of psychotherapy is regulated by the Mental Health Licensing Section of the Division of Registrations. The Board of Psychologist Examiners can be reached at 0000 Xxxxxxxx, Xxxxx 0000, Xxxxxx, Xxxxxxxx 00000, (000) 000-0000. In a professional relationship, sexual intimacy is never appropriate and should be reported to the board that licenses, registers, or certifies the licensee, registrant or certificate holder. Regulatory requirements applicable to mental health professionals: a Licensed Clinical Social Worker, a Licensed Marriage and Family Therapist, and a Licensed Professional Counselor must hold a masters degree in their profession and have two years of post-masters supervision. A Licensed Psychologist must hold a doctorate degree in psychology and have one year of post-doctoral supervision. A Licensed Social Worker must hold a masters degree in social work. A Psychologist Candidate, a Marriage and Family Therapist Candidate, and a Licensed Professional Counselor Candidate must hold the necessary licensing degree and be in the process of completing the required supervision for licensure. A Certified Addiction Counselor I (CAC I) must be a high school graduate, and complete required training hours and 1,000 hours of supervised experience. A CAC II must complete additional required training hours and 2,000 hours of supervised experience. A CAC III must have a bachelor’s degree in behavioral health, and complete additional required training hours and 2,000 hours of supervised experience. A Licensed Addiction Counselor must have a clinical master’s degree and meet the CAC III requirements. A Registered Psychotherapist is registered with the State Board of Registered Psychotherapists, is not licensed or certified, and no degree, training or experience is required. 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 ((C.R. S. 25-1-802 (1) (a). Because privacy in psychotherapy is often crucial to successful progress, it is my policy to request an agreement from parents that they consent to give up access to their child’s records. 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, except in the case of very young children. Upon written request, 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 to release records, unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify the parents and/or appropriate authorities 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 beginning of each appointment, with a check or in cash, unless we agree otherwise. (Credit card payment is not preferred but can be arranged if necessary). Fees for other services will be billed in increments of tenths of an hour. In circumstances of unusual financial hardship, I may be able to negotiate a temporary fee adjustment or temporary installment plan. If your 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. 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. Your signature below indicates that you have read this agreement and agree to abide by all of its terms, including waiver of access to a child patient's records, and also serves as an acknowledgement that you have received the HIPAA notice form described above. Signature Date Printed Name ADULT INFORMATION FORM Please answer as openly and fully as you reasonably can. All information will be held in confidence.
Appears in 1 contract
Samples: camdencounseling.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 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 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 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 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 that meet with clients once a week or more if needed. Eventually, the sessions are spread out to once every two weeks, once a month, etc. This is done to ensure long-term change. Each session will last from 1for approximately 50 minutes. We both commit to being punctual for our meetings so that we can make the most of the time I have with the client. If re-2 sessions. During this timescheduling is necessary, we both decide if I am the best person you are required to provide the services me with a 24 hour advance notice. Each time 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 reschedule without a time we agree on, although some sessions may be longer or more frequent. Once an appointment 24 hour is scheduledadvance notice, you will be expected required to pay for it un- less you provide 24-hours advanced notice of cancellation. It is important to note a fee that insurance companies do not provide reimbursement for cancelled sessionsmatches your regular rate. Professional Fees My hourly Our decided upon fee varies depending on services and durationper session is due by cash or check made out to myself at the time of service. 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-minutesconversations, 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 90 per hour for preparation and $90 per hour for attendance at any legal proceedingsproceeding. 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. If such legal action is necessary, its costs will be included in the claim. Contacting Me Due to I can most easily be reached through 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 email account at xxxxx@xxxxxxxxxxxxxxxxxx.xxx or phone when I am with a clientat 000-000-0000. I will make every effort to return your phone call by the end of my business dayor email within 24-48 hours, with the exception of weekends and holidays. If you are difficult to reachWhile email communication is welcome, please inform me be warned regarding your confidentiality; internet email is not a secured medium and privacy cannot be ensured. In case of some times when you will be available. If you are unable an emergency, please call 911, the 24 hour crisis hotline at 000-000-0000, 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 mental health clinician 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 answer 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 therapy related 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 confidentiallythrough online communication.] 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: setfreeplaytherapy.com
