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HIPAA/OUTPATIENT CONTRACTS

This document contains important information about my professional services and
business policies. It also contains:
1) A summary information about the Health Insurance Portability and
Accountability Act (HIPAA). This is a federal law that provides privacy
protections and patient rights with regard to the use and disclosure of Protected
Health Information (PHI) for the purposes of treatment, payment and health care
operations. The law requires that I obtain your signature acknowledging that I
have provided you with this information. You will find this on pages 2-3.
2) An Agreement for Outpatient Services. Although this document is long, it is very
important that you read it and we discuss any questions you may have. When you
have signed this document, it will be an agreement between us regarding your
treatment. 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, or if
you have not satisfied any financial obligations you have incurred to me.
HIPAA Client Information Privacy Practices
Limits on Confidentiality The law protects the privacy of all communications between a
client and a licensed psychologist. 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.
- I may at your request provide other insurance providers with data to process claims or
other transactions, including information necessary for workers' compensation claims, or
short or long term disability and in order for you to receive reimbursement for treatment
from me.
- I may provide a collection agency with the necessary information to collect overdue bills.
This is discussed in the Outpatient Contract.
There are some situations where I am permitted or required to disclose information
without either your consent or authorization, as follows:
● 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
psychologist-patient privilege law. I cannot provide any information without your
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 you file a complaint or lawsuit against me, I may disclose relevant information
regarding you in order to defend myself.
● If you threaten to harm yourself, I may be obligated to seek hospitalization for you, or
to contact family members or others who can help provide protection.
● If I have reasonable cause to suspect child abuse or neglect, or elder abuse or neglect,
the law requires that I file a report with the appropriate government agencies. Once
such a report is filed, I may be required to provide additional information.
● If you communicate a threat of physical violence against a reasonably identifiable
third person and you have 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 include notifying the potential victim, or if the victim is a
minor, her/his parents and the relevant social services agency, contacting the police,
and/or seeking hospitalization for 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. 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.
Patient Rights
HIPAA provides you with several rights with regard to your clinical records and
disclosures of protected health information (PHI). You have the right to
● request that I amend your record; (I may deny your request under certain
circumstances)
● request restrictions on what information from your clinical records is disclosed to
others;
● request an accounting of most disclosures of PHI that you have neither consented to
nor authorized;
● determine the location to which and means by which protected information is sent to
you
● have any complaints you make about my policies and procedures recorded in your
records; and,
● the right to have a paper copy of this agreement.
If you are concerned that your privacy rights may have been violated, you may also
submit a written complaint to the U.S. Department of Health and Human Services. I will
provide the address upon request.
Your signature below indicates that you acknowledge the receipt of this notice of my
office’s privacy practices.
Signature
Outpatient Services Agreement
Psychological Services:
Psychotherapy is not easily described in general statements. It varies depending on the
personalities of the psychologist and patient, 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 session(s) will involve an evaluation of your needs. By the end of the at least
the first session, 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 in 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.
Additionally, if I feel that I am not the mental health professional best suited for your
needs, I reserve the right to begin terminating services and assist you in finding a
provider that is suitable to your particular needs.
Meetings:
I normally conduct an evaluation that will last from 1-3 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 psychotherapy is begun, I will usually schedule one
45-minute session per week at a time we agree on. Therapy is a long-term process for
which we are setting aside time to meet together and progress. It is possible that a given
session may not last the full 45-minutes depending on what transpires.
Because of the difficulty in filling time slots that suddenly open, once an
appointment is scheduled, you will be expected to pay for it unless you provide 24
business hours advance notice of cancellation, that is, 1 business day. This
late-cancel fee will be waived only if you and I both agree that the situation
warrants an exception. Also, with sufficient advance notice, I may be able to
reschedule your session that week. If the session can’t be reasonably rescheduled
within a week, you are responsible for the cost of the session.
Professional Fees:
In addition to (usually) weekly appointments, I charge for other professional services you
may need, though in such cases 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. 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.
Because of the difficulty of legal involvement, and the opportunity cost of scheduling that
time, I charge $500 per hour for preparation and attendance at any legal
proceeding.
Contacting Me:
Due to my work schedule, I am often not immediately available by telephone. While I
am usually in my office between 11:00 a.m. and 7 p.m., I probably will not answer the
phone when I am with a patient. When I am unavailable, my telephone is answered by a
confidential voicemail service. I monitor messages frequently. I will make every effort
to return your call on the same day you make it. If you are difficult to reach, please
inform me of some times when you will be available and preferred phone numbers for me
to call. If you are unable to reach me (which may happen on weekends when I may not
be available) and feel that you can't wait for me to return your call, contact your family
physician or the nearest emergency room and ask for the psychologist or psychiatrist on
call. If I will be unavailable for an extended time, I will provide you with the name of a
colleague to contact, if necessary.
Billing and Payments
Payment and/or co-payments are expected at the end of each session. In cases of financial
hardship, I am usually willing to negotiate a fee adjustment.
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. In most
collection situations, the only information I release regarding a client's treatment is
her/his 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 charge $25.00 for returned checks to
cover the additional re-billing administrative time.
Insurance Reimbursement
If you use insurance, you should learn from them the details of your mental health
benefits: pre-authorization requirements, coinsurance amounts, deductibles and
limitations on coverage. It is your responsibility to know what your coinsurance/deductible/coverage and benefits are. I do not always have the time to
contact your insurance company and find out this information. Please be aware that many
commercial plans have a deductible amount. It is your responsibility to know this
information and that this fee is covered by you. In the event that you have a deductible,
most psychotherapy sessions will cost between $65.00 to $89.00 and evaluations
anywhere from $500.00 to $2,000.00. If you have a Medicaid policy and it expires, you
will be responsible for any unpaid balance.
If the maximum number of sessions reimbursable by your plan is small and that is a
factor in how long you are willing to be in treatment, discuss that with me in the initial
sessions so we can take that into consideration in planning your treatment. Many issues
respond to short-term treatment, but others can take longer. Also, the insurance company
and/or my billing service can err in the processing of claims. You are responsible for
monitoring the payment of your benefits.
You should be aware that most insurance companies require you to authorize me to
provide them with a clinical diagnosis. Sometimes I have to provide additional clinical
information such as treatment plans or summaries, or copies of the entire record (in rare
cases). 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.
Professional Records:
The laws and standards of my profession require that I keep treatment records. You are
entitled to receive a copy of your records, or I can prepare a summary for you instead.
Because these are professional records, they can be misinterpreted and/or upsetting to
untrained readers. If you wish to see your records, I recommend that you review them in
my presence so that we can discuss the contents. Patients will be charged an appropriate
fee for any professional time spent in responding to information requests. All records
requests must be made in writing, including your reasons for the request, and I will
respond to most requests within 30 days.
Your signature below indicates that you have read the information in this document and
agree to abide by its terms during our professional relationship.
Signature