SPENCE COUNSELING CENTER, P.C.

 

Important Information about Psychological Services

 

Intro

 

This Important Information, followed by a Consent form, contains information about:

 

●      My professional services

●      The Health Insurance Portability and Accountability Act of 1996 (HIPAA), a federal law that provides privacy protection and patient rights about the use and disclosure of your Protected Health Information (PHI).

 

I am also required to provide you with a Notice of Privacy Practices (Notice), which follows the Consent.  The law requires that I provide you with this information and attain your signature acknowledging that you have received, read, and understand the Consent and Notice.  Please read the Important Information, the Consent, and Notice carefully, and sign each.

 

Psychological Services

 

For psychotherapy and/or psychological services to work successfully, we will have to work together on your issues and problems.  To be successful, you will have to work at talking openly about your thoughts and feelings about the issues that arise in your sessions.  You may have uncomfortable thoughts and feelings, including sadness, anger, and frustration.  Your feelings about me can be an important part of treatment.  Psychotherapy has been shown to have benefits, but there are no guarantees.

 

If medication is a part of your treatment, it is important that you work with the prescribing physician according to the recommended treatment plan.

 

We will begin the work with an evaluation, which lasts from one to three sessions and this will include a diagnosis (if it is required by your use of insurance.)  Psychotherapy is a commitment of time and resources, and it is important for you to be careful in your selection of a therapist.  If you have concerns about your treatment, please bring them up during a session.  If you have continued concerns about working with me, I will kindly help you meet with another professional for a second opinion or to work with you.

 

Sessions and Fees

 

Psychotherapy sessions will last 50 minutes, and often we will meet once each week.  Other arrangements can sometimes be made and we can talk about that.  Once scheduled, a 24 hour notice of cancellation is required, or you will be charged the full fee for the session.  (Your insurance company will not pay for this charge, so you are fully responsible for payment.)  My fee is $115.00 per session.  There will be charges for other professional services as they are required.  Those services include report writing, consultation with other professionals, preparing records or treatment reports, time spent for other requested services (for example, psychological testing), and telephone calls lasting longer than 10 minutes.  If you become involved in legal matters that require my services, you will be required to pay for my professional time, including preparation and travel time, even if I am required to testify by the other party.

 

Availability and Telephone Contact

 

During working hours, I am usually available to answer the phone.  My answering system will take messages 24 hours a day.  I will return calls as soon as possible, but usually the same day, except on weekends or if I am away from the office.  If you have an emergency and cannot reach me, please contact your family physician or go to the nearest emergency room.

 

Confidentiality

 

The law requires that your communications with me be private and protected.  You give Consent for routine use of confidential information; beyond that, I can only release information with written permission, which is called an Authorization.  The Authorization form must follow federal (HIPAA) guidelines to protect your confidentiality and inform you about what will allow me to use and disclose your PHI, and there are times when the Authorization will be required for me to use or disclose your PHI.  Realize that we will only use and disclose the Minimum Necessary Information in every case.  As examples, the Consent authorizes us to use and disclose your PHI to:

 

        ●      Consult with other professional within our office.

        ●      Forward information to our electronic billing firm, that handles our insurance claims.

        ●      Our Business Associates (our attorney, accountant, typist).

        ●      If you are suicidal and/or homicidal and we cannot reach an agreement about that.

        ●      Legal subpoenas often require disclosing of PHI.

        ●      Workmen’s Compensation.

        ●      Child Abuse or vulnerable Adult Abuse.

        ●      The government agency requests information, with the Department of Health and Human Services (the group behind HIPAA) as an example.

        ●      When we are acquiring supervision and/or consultation on your case.

        ●      If you file a lawsuit against me.

 

 

We will always inform you and always get an authorization before use or disclose information to:

 

        ●      Any outside agency requesting information about you (another therapist, for example.)

 

Further information about releasing your PHI is found in the Notice of Privacy Protection in this packet of materials.

 

Records

 

You may examine your records (except in unusual circumstances when I believe that disclosure would physically/emotionally/psychologically harm you) and/or receive a copy of them.  Because the record can be misunderstood, I recommend that you review them with me, or have them forwarded to another mental health professional to review with you.  I am allowed to charge you $.50 per page, along with certain other charges, or the reasonable charges to reproduce the records if the records cannot be routinely copied by a photocopy machine.  If I refuse your request to review your records, you have the right to review, which you can ask further about.

 

In the mental health field, there are two kinds of records or notes.  The standard notes hold information like your diagnosis, treatment plan, length of the session, progress toward goals, and other information.  Psychotherapy notes are a special subset of notes that are kept separate from the standard information and may come directly from our conversations, have my hunches, and include more sensitive information.  Insurance companies cannot request the psychotherapy notes without your given written authorization that complies with HIPAA, and they cannot require these notes as a condition of coverage.  They cannot penalize you for refusing to authorize the release of psychotherapy notes.  You may review and/or receive a copy of the psychotherapy notes, except if I determine that it would not be in your best interest, and there is no appealing that decision.

 

Rights

 

You may request that:

       

        ●      You receive an accounting of disclosures of your record.

        ●      Your records be corrected and amended.

        ●      Restrictions be place on whom the PHI is disclosed.

        ●      You receive information through alternative channels (what address we use or what phone numbers, for example.)

        ●      Any complaints you make about the records will be placed in the record.

        ●      You receive a paper copy of this agreement and the Notice of Privacy Practices.

        ●      You receive a paper copy of my Policy and Procedures.

 

Payment

 

You are expected to pay for services as you receive them.  Other arrangements need to be set up in advance.  If you do not pay for your services, I can use legal resorts to acquire payment from you.  I can use collection agencies, small claims court, and/or an attorney to pursue payment from you.  In all cases, the minimum necessary information will be supplied for the collection of fees.

 

Insurance

 

I will file insurance claims for you if you choose to use insurance as part or all of your payment.  Some insurance contracts require me to be the one to file the claims.  You must understand that you are responsible for the full payment; I will help with the insurance, but ultimately the responsibility of payment rests with you.  I strongly suggest you be an informed consumer and contact your insurance company to find out what part they will take in paying for my services.  Mental health coverage can be different than the medical coverage that your insurance policy provides.  Some plans severely limit psychological services.  You may decide that you will want more treatment than your plan will cover.

 

Your insurance company may require Protected Health Information (PHI) before they will pay any benefits.  Only the minimum amount of information will be revealed to them.  The insurance company is obligated to keep any information given to them confidential.  I can make no guarantees about what they will do with your PHI.

 

Minors

       

If a child is under 19 years of age and not emancipated, the parents have the right to know what is happening in the therapy.  Privacy is important in therapy, so parents are usually requested to allow their child to have confidentiality in the therapy.  General information can be presented to the parents and they may ask for a summary of the treatment.  Any other requests for information about the child will require a signed Authorization from the child.  If there is concern about the child being in danger (suicidal, homicidal, in grave danger), I will first try to get the child to inform the parents, and, if that is not successful, I will notify the parents of my concern.