PATIENT CONSENT AND AUTHORIZATION
Consent to Treatment:
I hereby consent to receive mental health treatment from Northampton Center for Couples Therapy (hereafter referred to as NCCT). I understand that my consent is voluntary. I also understand that I do not have to accept any treatment option NCCT offers and that I may withdraw my consent at any time.
I accept that working toward change may involve experiencing difficult and intense feelings, some of which may be painful, in order to reach therapy goals. I understand that the changes I make will have an impact on my partner and on others around me. I accept that such changes can have both positive and negative effects and agree to clarify and evaluate potential effects of changes before undertaking them [This is especially true if dependent children are involved]. On the other hand, therapy 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.
I understand that standard treatment sessions are 90 minutes in length, but that exceptions may occur.
I also understand that there are circumstances in which couples therapy may not be the best treatment option. Such circumstances may include when there is active substance abuse, domestic violence, emotional abuse, or mental health problems that are not stable and/or untreated. I further understand that NCCT may choose at any time to discontinue services in the event that any of these circumstances are present, and at such time all fees paid to NCCT to date (regardless of duration of treatment) are nonrefundable. I understand that in such circumstances NCCT will make a good faith effort to provide me with alternative referrals for treatment, but that ultimately it is my responsibility to seek out and pursue treatment.
Couples Therapy and Release of Medical Records:
I understand in order for any therapy information or medical records to be released, both members of the couple must provide written authorization. If some individual sessions may help the process of couples therapy, what I say in those individual sessions will be considered to be a part of the medical record.
I also understand that information discussed in couples therapy is for therapeutic purposes and is not intended for use in any legal proceedings involving the couple. I agree not to subpoena my therapist to testify for or against either party or to provide records in a court action.
I understand that our communications are private and protected by law. Because of laws protecting confidentiality, in most situations my therapist cannot share information about our work without my permission. However, there are certain specific limits to confidentiality. I fully understand these limits below.
Communication and Availability:
Due to my therapist’s work schedule, my therapist is often not immediately available by telephone. When my therapist is unavailable, an automated voice mail answers his/her telephone. My therapist will make every effort to return my call on the same day I make it, with the exception of weekends and holidays. If I will be difficult to reach, I will inform my therapist of some times when I will be available. In a life-threatening emergency, I will call 911 or go to the nearest Emergency Room.
I understand that email is not a secure medium for communication and my therapist’s preference is that I contact him/her by phone. However, if I choose to contact my therapist using email, I am doing so with the full understanding that my therapist cannot guarantee the safety and security of that communication, despite NCCT taking all possible action to protect my privacy. I also acknowledge that email occasionally disappears or is delayed and that my therapist may never receive an email that I send.
I hereby give consent for Northampton Center For Couples Therapy to communicate and send me personal health information through text messaging to my mobile telephone number listed on my intake form. According to HIPAA (Health Insurance Portability and Accountability Act) guidelines, I am aware of the risks of unencrypted text messaging and must give consent in order to send and receive information via text message. Cellular services do not use encryption, which means that a third party may be able to access the transmitted information.
I understand that I am responsible for full payment of all fees for services provided by NCCT regardless of whether there is insurance coverage. If I have insurance, I understand that I am responsible for knowing the specific terms and limits of my insurance coverage, and that I am ultimately responsible for full payment of fees. Furthermore, unless prior arrangements are made, I agree to pay any self-pay fees, copayments, and/or coinsurance amounts at the end of each session.
Assignment of Benefits and Release of Information:
I hereby assign and transfer over to NCCT, all of my rights, title and interest to my medical reimbursement benefits under my insurance policy. I authorize the release of any medical information needed to determine benefits, including medical, psychiatric and/or substance abuse (drug or alcohol) information. This authorization shall remain in effect until written notice is given by me revoking this authorization. I certify that the information given is correct. I understand that this assignment and authorization does not relieve me of my obligation to pay any bills not covered by my insurance policy; or of any balance due after payments by my insurance policy. I agree to pay any balance due in full no later than 30 days of statement, unless other arrangements have been made in advance.
Court Action Policy and Fees:
Clients are discouraged from having The Northampton Center for Couples Therapy subpoenaed or requesting records for the purpose of litigation. We are trained as clinical social workers, marriage and family therapists and mental health counselors and our work and therapeutic philosophy comes from non-adversarial positions. We have not been trained forensically or with the expertise to appear in court. We are unable to guarantee that any testimony that we are required by law to give will be solely in your favor. We can only testify to the facts of the case and our professional opinion.
If any clinician at The Northampton Center for Couples Therapy is to receive a subpoena then the attorney or office staff will need to call our office and set up a time for the subpoena to be served during office hours. We request a minimum of 72 hours notice of any Court appearance so that schedule changes for our clients can be made within a reasonable time frame.
Please note: if a subpoena is received without a minimum of 72 hour notice there will be an additional $300 express charge.
Court action fees are as follows:
All fees are doubled if the clinician from The Northampton Center for Couples Therapy is scheduled to go out of town.
If a clinician is subpoenaed and the case is reset with less than 72 hour notice prior to the beginning of the day of the scheduled subpoena and or testimony is not given then the client will be billed $1,000.
Bills for court related actions are presented to clients on a weekly basis and payment is expected upon receipt. A zero balance will need to be kept at all times.
My signature below acknowledge that I understand and accept the terms and conditions of this authorization and agreement.
If I am unable to keep an appointment, I agree to notify NCCT at least 24 hours in advance of my scheduled visit.
I understand that I will be charged the full session rate for all sessions cancelled with less than 24 hour notice.
I also understand that this fee is not covered by insurance.
NCCT recognizes that circumstances arise when I might need to miss more than one appointment during the course of a month. NCCT is able to hold my designated slot as a courtesy for up to 4 weeks.
If I miss more than one appointment within a month for any reason, I will be charged a $130 fee (per week) so that my slot can be held.
Note: This fee will be charged regardless of advanced notice duration. NCCT cannot offer this benefit for more than 4 weeks.
Additionally, a signed credit card release form must be on file OR I will need to pay for the reserved sessions in advance. Failure to do so will result in my slot no longer being held in reserve for me.
My signature below acknowledge that I understand and accept the terms and conditions of this policy. If the patient is a minor child, an appropriate guardian must sign below. Such signature acknowledges that this authorization and agreement applies to the minor child.
THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
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:
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. I will also need to obtain an authorization before:
You may revoke all such authorization (of PHI or Psychotherapy Notes) 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.
Uses and Disclosures with Neither Consent nor Authorization
I may use or disclose PHI without your consent or authorization in the following circumstances:
Patient’s Rights and Therapist’s Duties
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 413.586.2300 for additional information. If you believe that your privacy rights have been violated and wish to file a complaint with me, you may send your written complaint to our Security Officer at 40 Main Street, Suite 206, Florence, MA 01062. You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. Our Security Officer can provide you with the appropriate address upon request. You have specific rights under the Privacy Rule. I will not retaliate against you for exercising your right to file a complaint.
Other Uses of PHI in Healthcare
Business Associates - There are some jobs I hire other businesses to do for me. In the law, they are called Business Associates. Examples may include a copy service to make copies of your health records or a billing service to print, mail, and follow-up on my insurance claims for reimbursement, to mail patient bills, and/or to contact your insurance company regarding benefits, eligibility, and authorization. These business associates need to receive some of your PHI to perform their jobs properly. To protect your privacy they have agreed in a signed contract to safeguard your information.
The effective date of this notice is April 14, 2003.
THE SIGNATURE BELOW INDICATES THAT I HAVE RECEIVED A COPY OF THE NOTICE OF PRIVACY PRACTICES FROM NCCT:
The Northampton Center for Couples therapy (NCCT) and its Billing Agency* are authorized to keep my signature on file and charge my account for any balances due from NCCT services rendered to me or my family not covered by my insurance plan. I understand that this authorization will remain in effect until NCCT has received written notification from me of its termination in usch time and manner to afford NCCT a reasonable opportunity to act on it.
(If applicable) I am also authorizing NCCT and its Billing Agency to use the above listed credit card for my partner/spouse for all balances on their account as well. I know that this is in addition to the balances on my account. My signature above authorizes NCCT to apply balances from my spouse/partner's account although my spouse/partner's name is not on the credit card being used at this time.