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Terms and Policy

Cancellation Policy
Cancellation must be made 24 hours in advance or you will be charged for full session rate.
( Type Full Name )
HIPPA Notice
Notice of Policies and Practices to Protect the Privacy of Your Health Information


I. Uses and Disclosures for Treatment, Payment, and Health Care Operations

I may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your consent. To help clarify these terms, here are some definitions:

“PHI” refers to information in your health record that could identify you.

“Treatment, Payment and Health Care Operations”

Treatment is when I provide, coordinate or manage your health care and other services related to your health care. An example would be when I consult with another health care provider, such as your family physician or another psychologist.

Payment is when I obtain reimbursement for your healthcare. Examples are when I disclose your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.
Health Care Operations are activities that relate to the performance and operation of my practice. Examples are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and care coordination.

“Use” applies only to activities within my office such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.

“Disclosure” applies to activities outside of my office, such as releasing, transferring, or providing access to information about you to other parties.

II. Uses and Disclosures Requiring Authorization
I may use or disclose PHI for purposes outside of treatment, payment, or health care operations when your appropriate authorization is obtained. An “authorization” is written permission above and beyond the general consent that permits only specific disclosures. In those instances when I am asked for information for purposes outside of treatment, payment or health care operations, I will obtain an authorization from you before releasing this information.

You may revoke all such authorizations at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) I have relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, law provides the insurer the right to contest the claim under the policy.

III. Uses and Disclosures with Neither Consent nor Authorization
I may use or disclose PHI without your consent or authorization in the following circumstances:

Child Abuse – If I have reasonable cause to believe that a child has been abused, I must report that belief to the appropriate authority.

Adult and Domestic Abuse – 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 that belief to the appropriate authority.

Health Oversight Activities – If I am the subject of an inquiry by the Georgia Board of Psychological Examiners, I may be required to disclose protected health information regarding you in proceedings before the Board.

Judicial and Administrative Proceedings – If you are involved in a court proceeding and a request is made about the professional services I provided you or the records thereof, such information is privileged under state law, and I will not release information without your written consent or a court order.

The privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. You will be informed in advance if this is the case.

Serious Threat to Health or Safety – If I determine, or pursuant to the standards of my profession should determine, that you present a serious danger of violence to yourself or another, I may disclose information in order to provide protection against such danger for you or the intended victim.

Worker’s Compensation – I may disclose protected health information regarding you as authorized by and to the extent necessary to comply with laws relating to worker’s compensation or other similar programs, established by law, that provide benefits for work-related injuries or illness without regard to fault.

IV. Patient’s Rights and Counselor’s Duties
Patient’s Rights:
Right to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of protected health information. However, I am not required to agree to a restriction you request.

Right to Receive Confidential Communications by Alternative Means and at Alternative Locations – You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. (For example, you may not want a family member to know that you are seeing me. On your request, I will send your bills to another address.)

Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI in my mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. I may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed. On your request, I will discuss with you the details of the request and denial process.

Right to Amend – You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. I may deny your request. On your request, I will discuss with you the details of the amendment process.

Right to an Accounting – You generally have the right to receive an accounting of disclosures of PHI. On your request, I will discuss with you the details of the accounting process.

Right to a Paper Copy – You have the right to obtain a paper copy of the notice from me upon request, even if you have agreed to receive the notice electronically.

Counselor’s Duties:
I am required by law to maintain the privacy of PHI and to provide you with a notice of my legal duties and privacy practices with respect to PHI.

I reserve the right to change the privacy policies and practices described in this notice. Unless I notify you of such changes, however, I am required to abide by the terms currently in effect.
If I revise my policies and procedures, I will provide you with a revised notice at your next session.

V. Questions and Complaints
If you have questions about this notice, disagree with a decision I make about access to your records, or have other concerns about your privacy rights, you may contact me at 404-368-5552.

If you believe that your privacy rights have been violated and wish to file a complaint with me/my office, you may send your written complaint to me at 6740 Jamestown Drive, Alpharetta, GA 30005

You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. I can provide you with the appropriate address upon request.

I will not retaliate against you for exercising your right to file a complaint.

VI. Effective Date, Restrictions, and Changes to Privacy Policy
This notice will go into effect on June 1, 2010. I reserve the right to change the terms of this notice and to make the new notice provisions effective for all PHI that I maintain. I will provide you with a revised notice by the time of your next session.
( Type Full Name )
Welcome to my practice. I am glad you are here and I am looking forward to doing some good, productive work together.

This document (the Agreement) contains important information about my professional services and business policies. The Health Insurance Portability and Accountability Act (HIPAA) is 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. 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. While this written summary should prove helpful in informing you about potential problems, it is important that we discuss any specific questions or concerns that you may have. The laws governing confidentiality can be quite complex, it is not possible to cover every eventuality in a document like this, and I am not an attorney. In situations where specific advice is required, one or both of us may wish to obtain formal legal advice.

The law requires that I obtain your signature acknowledging that I have provided you with this information by the end of your first session. Although these documents are long and sometimes complex, it is very important that you read them carefully before the session. We can discuss any questions you have about them at that time.

When you sign this document, it represents 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 upon it, if there are obligations imposed on me by your health insurer in order to process or substantiate claims already made under your policy, or if you have not satisfied any financial obligations to me which you have already incurred.

Counseling is not easily described in general terms. It varies depending on the personalities of 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.

Counseling 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 in between.

Counseling 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, counseling 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. 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 entail. You should evaluate this information along with your own opinions of whether you feel comfortable working with me. Therapy involves a commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about me or my work, we should discuss them as they arise.

We will usually schedule one 50-minute session per week, although sometimes sessions may be longer or more frequent.

Once an appointment is scheduled, you will be expected to be here for it or to provide 24 hours advance notice of your absence. If you cancel an appointment without sufficient notice, or if you simply fail to appear for an appointment, you will be billed for it. The fee for the first missed appointment is $50. The fee for second and subsequent missed appointments is my full fee.

Due to the nature of my work, I am usually not immediately available by telephone. While I am generally in my office between 9 a.m. and 5 p.m., I do not answer the phone. I check messages daily, however, and make every effort to return calls within one business day. If you are going to be difficult to reach, please inform me of some times when you will be available. It is also always a good idea to leave your last name (as I may have more than one person with your first name!) and your telephone numbers with area codes. Speak slowly and distinctly. Give your name and number up front, in case you get cut off.

If, and only if, you have a bona fide mental health emergency, by which I mean your mental state is such that you represent imminent danger to yourself or to someone else, you should call me on my cell phone at 404.368.5552.
If you are unable to reach me and feel that you can’t wait for me to return your call, you have several options. You may contact your psychiatrist, family physician, or the nearest emergency room and ask for the mental health provider on call. If you are pretty sure that you will require hospitalization, you can go ahead and call The Ridgeview Institute at 770.434.4568. In a life-threatening emergency, of course, you should call 911 and request the police and/or an ambulance.

Whenever I will be unavailable for an extended time, I will provide you with the name of a colleague to contact.

You should be aware that I will keep a written record of our work. This record includes your reasons for seeking therapy, your medical and social history, your treatment history, how your problem affects your life, my diagnosis, the goals for treatment, your progress, records from other providers, consultations, billing records, and reports.
Psychotherapy Notes contained in a file separate from your Clinical Record include the contents of our conversations, my analysis of those conversations, and how they affect your therapy.

Except in circumstances involving potential harm to you or to another person, you (or your legal representative) may examine and receive a copy of your Clinical Record upon written request. These records can be misinterpreted by and be upsetting to you. For this reason, I recommend that we initially review them together, or you could have them forwarded to another mental health professional so you can discuss the contents with him or her. Your record may reflect thoughts I have had about your situation which I have not yet shared with you: Therapeutic interventions are effective only when correctly timed. Therefore, I caution you against requesting to see your record: In my experience, whatever your concern is it can probablybe dealt with to your satisfaction without opening your records. We should always try discussing your concerns first, and let reading the chart be our last resort.

I charge $1.00 per page for copying, and I bill you for insuring and mailing your record. If I refuse your request for access to your records, you have a right of review, which I will discuss with you upon request.

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 minor client or s/he and I agree otherwise. Because privacy in psychotherapy is ESPECIALLY crucial to successful progress with teenagers, it is my policy to require an agreement from parents that they consent to give up their access to their son or daughter’s records. I will provide general information about the progress of a teen’s treatment and his/her attendance at scheduled sessions—and nothing else. I will also provide parents with a summary of their son/daughter’s treatment when it is complete. Any other communication will require the teen’s authorization, unless I feel that that s/he is in danger or is a danger to someone else, in which case of course I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the minor client, if possible, and do my best to handle any objections s/he may have.

My fee range is $100-125 per 50 minute session.

Payment is due for each session at the end of the hour, unless we agree otherwise in advance.

If you have a health insurance policy, it will usually provide some coverage for mental health treatment. However, you are ultimately responsible for payment of my fees. It is therefore very important that you find out exactly what mental health services your insurance policy covers before we get started, in order to avoid any unpleasant surprises.
Obtaining insurance reimbursement requires that I disclose PHI, including your diagnosis and sometimes treatment plans, summaries, or even copies of your entire record. In such situations, I release only the minimum information about you that is necessary for the purpose requested. However, this information will become part of the insurance company files and will probably be stored in a computer with all the attendant security risks. Some companies place your information in a national medical databank. I have no control over what they do with it once it is in their hands. You may therefore decide, and I recommend that you do, to pay for therapy yourself to keep your privileged information within the confines of this office.

My signature below indicates that I have read and understand the information in the Counselor-Patient Services Agreement and agree to abide by its terms during our professional relationship. MY SIGNATURE BELOW ALSO SERVES AS AN ACKNOWLEDGEMENT THAT I HAVE RECEIVED, READ, AND UNDERSTAND THE HIPAA NOTICE FORM DESCRIBED ABOVE.
( Type Full Name )