404-245-5797
(As required
by HIPAA and the State of Georgia)
This document contains important information about our professional services
and business policies. It also contains summary information about the Health
Insurance Portability and Accountability Act (HIPAA), which is a federal law
that provides new privacy protections and new client rights with regard to the
use and disclosure of your Protected Health Information (PHI). HIPAA requires that
I provide you with a Georgia Notice Form about the use and disclosure of your
Protected Health Information for treatment, payment and health care operations.
I have copies of our Georgia Notice Form for you to take or simply review. The
Georgia Notice Form explains the HIPAA law and its application to your personal
health information in greater detail. The law also requires that I obtain your
signature acknowledging that I have provided you with this information at your
first session. Although these documents are long and sometimes complex, it is
very important that you read them carefully. We can discuss any questions you
have about the information, and then I will ask you to sign this Agreement.
When you sign this document, it will 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.
PSYCHOLOGICAL SERVICES:
Psychotherapy is not easily described in general statements. It varies
depending on the personalities of the psychotherapist 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. 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.
SESSIONS: Individual sessions are
customarily 50 minutes, including time spent scheduling appointments and paying
fees. Longer or more frequent sessions can be arranged as necessary. Once an
appointment hour is scheduled, you will be expected to pay for it unless you
provide 24 hours advance notice of cancellation. It is important to note that
insurance companies do not provide reimbursement for cancelled sessions so the
total cost of the session is your responsibility.
PROFESSIONAL FEES: My hourly fee is $80 per session, unless otherwise
agreed upon. 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 15 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. Please note that fees paid
for psychological services are eligible for inclusion in your medical expense
deduction on your income tax. Your extended health benefit plan may provide you
reimbursement for fees paid for psychological services. You may request a
receipt for each payment, which you should retain for income tax or other claim
purposes.
CONTACTING ME: I have a 24-hour
confidential voice mail box (404-245-5797), at which you may leave a message. I
do not use a beeper, but I do check for messages regularly and will return
calls as promptly as possible. 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. If you need more immediate attention, you have several options: call
a friend or another member of your support network; call your psychiatrist (if
you have one) or your primary care physician; contact your local county mental
health center, go to the nearest emergency room, dial 911. If I will be
unavailable for an extended time, I will provide you with the name of a
colleague to contact, if necessary.
LIMITS ON CONFIDENTIALITY: The law
protects the privacy of all communications between a client and a
psychotherapist. 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 written advance consent for activities such as those
outlined below:
· You should be aware that I may consult with other mental health professionals
about cases. 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.
·
Disclosures required by health insurers or to collect overdue fees are
discussed 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 your written Authorization:
· If you are involved in a court proceeding and a request is made for
information concerning my professional services, such information is protected
by the psychotherapist-client 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 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, furnish copies of all
medical reports and bills.
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 your treatment. These situations are
unusual in my practice.
· If I have reason to believe that a child has been abused, the law requires
that I file a report with the appropriate governmental agency, usually the
Department of Human Resources. Once such a report is filed, I may be required
to provide additional information.
· If I have reasonable cause to believe that a disabled adult or elder person
has had a 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 Human
Resources. Once such a report is filed, I may be required to provide additional
information.
· If I determine that a client presents a serious danger of violence to another,
I may be required to take protective actions. These actions may include
notifying the potential victim, and/or contacting the police, and/or seeking
hospitalization for the client.
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.
PROFESSIONAL RECORDS: You should be
aware that, pursuant to HIPAA, I keep clinical records on you. Most of this
constitutes your Protected Health Information. It may include information such
as 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 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 cause
substantial harm to such other person, 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, 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.
CLIENT RIGHTS: HIPAA provides you
with several new or expanded rights with regard to your clinical record and
disclosures of Protected Health Information. These rights 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 the Georgia Notice Form. 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 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 fee adjustment or payment installment plan. I will
provide an invoice if you request one.
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 may provide some coverage for mental health
treatment. At this time, I am not on any company’s lists of approved providers.
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 their computer. In some
cases, they may share the information with a national medical information
databank. As with many medical conditions, a history of treatment might affect
the purchase of new insurance in the future. 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.
DISCONTINUATION OF TREATMENT: Either
of us may elect to discontinue treatment at any time. It is desirable to have a
final closing session if a decision to discontinue treatment is made. If the
decision to discontinue is made, I will be glad to provide you with names of
other referral sources if you so desire.
YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO
ITS TERMS AND ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE SEEN A COPY OF
THE HIPAA GEORGIA NOTICE FORM DESCRIBED ABOVE. IF YOU HAVE ANY QUESTIONS,
PLEASE ASK.
I voluntarily request services, accept the policies
sated above, and acknowledge the full responsibility of all fees incurred.
SIGNATURE OF CILENT OR GAURDIAN OF CLIENT UNDER 18 DATE
PRINTED NAME OF CLIENT FEE