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), federal law that provides privacy protections and client 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. HIPAA requires that I provide you with a
Notice of Privacy Practices (the Notice) for use and disclosure of PHI for
treatment, payment and health care operations. The Notice, which is attached to
this Agreement, explains HIPAA and its application to your personal health
information in greater detail. 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. You should be aware that this Agreement will be in effect for one year
from the date of signing unless you specifically request that it remain in
effect for a shorter time. This contract, or any provision of this contract, can
be revoked by you at any time, except to the extent that I have relied on it.
Psychotherapy is not easily described in general
statements. It varies depending on the personalities of the marriage and family
therapist and client, and the particular problems you are experiencing. There
are many different methods I may use to deal with the problems that you hope to
address. Psychotherapy is not like a medical doctor visit. Instead, it calls
for a very active effort on your part. In order for the therapy to be most
successful, you will have to work on things we talk about both during our
sessions and at home.
Psychotherapy
can have benefits and risks. Since therapy often involves discussing unpleasant
aspects of your life, you may experience uncomfortable feelings like sadness,
guilt, anger, frustration, loneliness, and helplessness. On the other hand,
psychotherapy has also been shown to have many benefits. Therapy often leads to
better relationships, solutions to specific problems, and significant
reductions in feelings of distress. But there are no guarantees of what you
will experience.
Our first few sessions will involve an evaluation of
your needs. By the end of the evaluation, I will be able to offer you some
first impressions of what our work will include and a treatment plan to follow,
if you decide to continue with therapy. 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, money, and energy, so you should
be very careful about the therapist you select. If you have questions about my
procedures, we should discuss them whenever they arise. If your doubts persist,
I will be happy to help you set up a meeting with another mental health
professional for a second opinion.
I normally conduct an evaluation that will last from 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
psychotherapy is begun, I will usually schedule one 50-minute 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 unless you provide 24 hours 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.
My hourly fee is $
. In addition to weekly appointments, I 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. Other services include report
writing, telephone conversations lasting longer than 10 minutes, consulting
with other professionals with your permission, preparation of records or
treatment summaries, and the time spent performing any other 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.
Due to my work schedule, I am often not immediately
available by telephone. While I am usually in my office between 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 an answering machine with voice
mail. I will make every effort to
return your call on the same 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 reach me by pager that number is .
The law protects the privacy of all communications
between a client and a marriage and family 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, 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 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 the
information confidential. If you don’t object, I will not tell you about these
consultations unless I feel that it is important to our work together. I will
note all consultations in your Clinical Record (which is called “PHI” in my
Notice of Marriage and family 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 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 the
professional services I provided to you, such information is protected by the
marriage and family therapist-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,
pursuant to their lawful authority, 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
workers compensation claim, I must, upon appropriate request, disclose
information related to the claim to appropriate individuals, which may include
the client’s employer, the insurer or the Department of Labor and Industry.
There are some situations in which I am legally
obligated to take actions, which I 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 know or have reason
to believe reason a child is being neglected or physically or sexually abused
or has been neglected or physically or sexually abused within the preceding
three years, the law requires that I file a report immediately with the
appropriate government agency, usually the local welfare agency. 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 being or has been maltreated or if I have
knowledge that a vulnerable adult has sustained a physical injury which is not
reasonably explained, the law requires that I file a report immediately with
the appropriate government agency, usually an agency designated by the
county. Once such a report is filed, I
may be required to provide additional information.
§
If I believe that you
present a serious and specific threat of physical violence to another, I may be
required to disclose information necessary to take protective actions. These
actions may include notifying the potential victim, contacting your family or
others who can help provide protection, contacting the police, or seeking your
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. 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.
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, 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, 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 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 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. 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 signed, written Authorization.
Insurance companies cannot require your Authorization as a condition of
coverage nor penalize you in any way for your refusal. You may examine and/or receive a copy of
your Psychotherapy Notes unless I determine that the information they contain
is detrimental to your physical or mental health, or is likely to cause the
client to harm another. If I deny your request to examine your Psychotherapy
Notes, you may select an appropriate third party to whom these notes will be
forwarded. This individual may choose
to disclose these notes to you. In this event, I recommend that you select
another mental health provider to perform this task.
CLIENT RIGHTS
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.
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. [If such legal action is necessary, its costs will be included in
the claim.]
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 clients feel that they need more services after insurance
benefits end. [Some managed-care plans will not allow me to provide services to
you once your benefits end. If this is the case, I will do my best to find
another provider who will help you continue your psychotherapy.]
You
should also be aware that your contract with your health insurance company
requires that I provide it with information relevant to the services that I
provide to you. I am required to provide a clinical diagnosis. Sometimes I am required
to provide additional clinical information such as treatment plans or
summaries, or copies of your entire Clinical Record. In such situations, I will
make every effort to release only the minimum information about you that is
necessary for the purpose requested. This information will become part of the
insurance company files and will probably be stored in a computer. Though all
insurance companies claim to keep such information confidential, I have no
control over what they do with it once it is in their hands. In some cases,
they may share the information with a national medical information databank. I
will provide you with a copy of any report I submit, if you request it. By
signing this Agreement, you 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. [If the
Agreement and Notice are given to clients at the end of the first session and
client is only required to sign the Acknowledgement at the end of the first
session, leaving the Agreement to be signed at the beginning of the second
session] or
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