I authorize the release of medical information necessary to process any of my insurance claims, and I authorize payment of medical benefits directly to Angelica Rivas, LCSW for services rendered. I understand and agree that (regardless of my insurance status), I am ultimately responsible for the balance of my account for any professional services rendered as well as any additional collection agency fees should their assistance become necessary. I am aware that I will be charged the insurance allowable rate, or standard fee if private pay for any missed appointments that are not rescheduled or cancelled within 24 hours of the scheduled appointment time. The undersigned agrees, whether he/she signs as a parent, spouse, guarantor, guardian, or client that in consideration of the services to be rendered to the client he/she hereby individual obligates himself/herself to pay the account. Should the account be referred to an attorney for collection, the undersigned shall pay reasonable attorney’s fees and collection expenses.
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
You have the right to:
• Get a copy of your paper or electronic medical record
• Correct your paper or electronic medical record
• Request confidential communication
• Ask us to limit the information we share
• Get a list of those with whom we’ve shared your information
• Get a copy of this privacy notice
• Choose someone to act for you
• File a complaint if you believe your privacy rights have been violated
You have some choices in the way that we use and share information as we:
• Tell family and friends about your condition
• Provide disaster relief
• Include you in a hospital directory
• Provide mental health care
• Market our services and sell your information
• Raise funds
We may use and share your information as we:
• Treat you
• Run our organization
• Bill for your services
• Help with public health and safety issues
• Do research
• Comply with the law
• Respond to organ and tissue donation requests
• Work with a medical examiner or funeral director
• Address workers’ compensation, law enforcement, and other government requests
• Respond to lawsuits and legal actions
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.
Get an electronic or paper copy of your medical record
• You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.
• We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
Ask us to correct your medical record
• You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
• We may say “no” to your request, but we’ll tell you why in writing within 60 days.
Request confidential communications
• You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
• We will say “yes” to all reasonable requests.
Ask us to limit what we use or share
• You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.
• If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.
Get a list of those with whom we’ve shared information
• You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
• We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
Get a copy of this privacy notice
You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
Choose someone to act for you
• If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
• We will make sure the person has this authority and can act for you before we take any action.
File a complaint if you feel your rights are violated
• You can complain if you feel we have violated your rights by contacting us using the information on page 1.
• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
• We will not retaliate against you for filing a complaint.
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.
In these cases, you have both the right and choice to tell us to:
• Share information with your family, close friends, or others involved in your care
• Share information in a disaster relief situation
• Include your information in a hospital directory
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
In these cases we never share your information unless you give us written permission:
• Marketing purposes
• Sale of your information
• Most sharing of psychotherapy notes
In the case of fundraising:
• We may contact you for fundraising efforts, but you can tell us not to contact you again.
How do we typically use or share your health information? We typically use or share your health information in the following ways:.
To Treat You
We can use your health information and share it with other professionals who are treating you.
Example: A doctor treating you for an injury asks another doctor about your overall health condition.
To Run our organization
We can use and share your health information to run our practice, improve your care, and contact you when necessary.
Example: We use health information about you to manage your treatment and services.
To Bill for your services
We can use and share your health information to bill and get payment from health plans or other entities.
Example: We give information about you to your health insurance plan so it will pay for your services.
We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
Help with public health and safety issues
We can share health information about you for certain situations such as:
• Preventing disease
• Helping with product recalls
• Reporting adverse reactions to medications
• Reporting suspected abuse, neglect, or domestic violence
• Preventing or reducing a serious threat to anyone’s health or safety
We can use or share your information for health research.
Comply with the law
We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.
Respond to organ and tissue donation requests
We can share health information about you with organ procurement organizations.
Work with a medical examiner or funeral director
We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
Address workers’ compensation, law enforcement, and other government requests
We can use or share health information about you:
• For workers’ compensation claims
• For law enforcement purposes or with a law enforcement official
• With health oversight agencies for activities authorized by law
• For special government functions such as military, national security, and presidential protective services
Respond to lawsuits and legal actions
We can share health information about you in response to a court or administrative order, or in response to a subpoena.
• We are required by law to maintain the privacy and security of your protected health information.
• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
• We must follow the duties and privacy practices described in this notice and give you a copy of it.
• We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.
Participation in counseling can result in a number of benefits, including improving interpersonal relationships and resolution of the concerns that led you to seek therapy. Working toward these benefits requires effort on your part and your active involvement, honesty and openness in order to change. We will ask for your feedback and views on progress and other aspects of the therapy and expect you to respond openly and honestly. Sometimes more than one approach can be helpful in dealing with a situation. Remembering or talking about unpleasant events, feelings or thoughts can result in you experiencing considerable discomfort or feelings of anger, sadness, worry, fear, etc. or experiencing anxiety, depression, insomnia, etc. We may challenge some assumptions or perceptions or propose different ways of looking at, thinking about, or managing situations that may feel upsetting or you may feel challenged or disappointed. Attempting to resolve issues that brought you to therapy in the first place may result in changes that were not originally intended. Psychotherapy may result in decisions about changing behaviors, work, substance use, school, or relationships. Sometimes a decision that is positive for one family member is viewed negatively by another family member. Change will sometimes happen quickly, but more often takes time and patience on your part. There is no guarantee that counseling will yield positive or intended results. During the course of therapy, WE may utilize therapeutic approaches according, in part, to the problem that is being treated, your choices, and feedback, and our assessment of what may benefit you. These may include but are not limited to cognitive-behavioral therapy, acceptance and commitment therapy, dialectical behavior therapy, motivational interviewing, system/family, mindfulness-based, or play therapy for clients ages 4-10 years old.
The work with young children is very important and requires specialized training, to make sure to provide the best care to young clients we are currently working towards our Registered Play Therapist (RPT) credential and we are under play therapy supervision. We will ask for a consent to videotape the play therapy sessions which in turn will be viewed for supervision only and be discarded after doing so. The consent form will be discussed during the first session and you have a right to consent or not and the decision will not affect treatment.
All clients sign and agree to confidentiality/HIPAA guidelines that are available for your review indicating that we follow standards as a Licensed Clinical Social Worker to protect the privacy of your personal information. All information is kept private and confidential unless you provide written and specific authorization to share it such as if you need me to speak with your physician or another therapist.
In couples and family therapy, or when members are seen individually, confidentiality does not apply between the couple or among family members. WE will use our clinical judgment when revealing information. WE will not release records to any party unless WE are authorized in writing to do so by all adults who were part of treatment unless compelled to do so by law/valid court order. If coming for family or couple’s therapy, please sign below that you agree to the confidentiality limits and understand that we won’t withhold info between parties involved in treatment.
If you choose to email or text us, please limit the contents to issues such as cancellation or change in appointment time. Email and text messages are not guaranteed confidential. Occasionally we may send you an article or link that might be useful. If you choose to communicate with us this way, you do so understanding that WE cannot guarantee that these modes of communication are confidential. For this and other ethical reason, WE do not accept invitations from current or former clients via any social networking sites such as LinkedIn, Instagram, or Facebook.
On occasion, we may need to consult with licensed professionals regarding our clients when doing so might improve the outcome for the client. The client’s name or other identifying information is never disclosed. The client’s identity remains anonymous and confidentiality is maintained.
Insurance: We are currently paneled with Blue Cross Blue Shield. If you choose to use your insurance, please note that a mental health diagnosis is necessary on the form for reimbursement. We can provide you with a receipt that you can submit to your plan for out of network reimbursement. This is provided on a monthly basis for any sessions occurring over the month but can be requested more or less frequently. You are responsible for thoroughly checking your benefits and what percentage of the fee, if any, you may be reimbursed by your plan.
If you are using a HRA or Health or Flex Saving Account type plan, We can often accept a cc or a check that your plan may use for this purpose.
We accept cash or check, (either is preferred) or VISA, Discovery, Amex, or Mastercard. Please fill out the form for credit card use that all clients complete even if they intend to usually use cash or a check. This allows use as a back up if you forget your payment or for a late fee.
Regular therapy sessions are 50 min. which is considered a therapeutic hr. Session fees are $110 for individuals and for couples/family therapy. We also offer 85 min sessions if a longer session is indicated or requested. Fee is $170. These may work best for stuck couples, clients who want a jump start on the process, or those who cannot attend on a weekly or regular basis. If requested, the initial session can be one of these longer versions if appropriate and agreed to ahead of scheduling.
Please have payment ready so as not to use your session time writing checks, etc.
Late Cancellation:If you need to reschedule, please call us as soon as possible. Unlike doctors who can overbook and may spend 15 min. per patient, therapists need to block a full hr. Since We hold a spot for you making it unavailable to another client, if less than 24 hrs. is provided or you do not show to the appointment you will be charged $110. All reschedules or cancellations need to be done through confirmed communication so sending an email is not acceptable. We may make an exception to the late fee based on the circumstances and/or if we are able to reschedule to another time that same week.
If coming for couples counseling and one member is unable to attend, sometimes it’s appropriate for the other member to attend to continue progress or to work on individual issues. Check with us about this.
Due to the nature of the therapeutic process and that it often involves making a full disclosure with regard to many matters which may be of a confidential nature, you agree that should there be legal proceedings (such as, but not limited to divorce and custody disputes, injuries, lawsuits, etc.), neither you (client) nor anyone else acting on your behalf will call on us to testify in court or at any other proceeding. However, if our appearance at court is required by law and you signed a release form allowing this, our fee is $1,100 per day and must be paid in full 30 days prior to the expected court date.
Most clients come weekly. Committing to and prioritizing that time is ideal. Occasionally, people attend therapy more often. Others may reduce frequency once things improve. Longer sessions are an option for those looking to get a jump start or if there’s a need for more intensive work for a set period of time. Extended sessions can be helpful for busy clients or couples who have trouble coming in weekly or who need or request more focused work.
Sometimes it becomes clear that a different approach or level of care is best or necessary. If We initiate terminating therapy with you, it will be because WE feel that WE are not able to be helpful or a higher level of care is indicated. Our ethics and license requires that WE have our clients’ needs as primary in treatment planning. If We no longer feel that we are the right resource for you, we will offer referrals to other sources of care, but cannot guarantee that they will accept you or how they’ll approach your treatment needs. Once you have stopped attending you are no longer under our care and our therapeutic relationship will be ended unless you reinitiate treatment with us.
Ending therapy well is important. Length of counseling varies and is up to the client, however, please let us know if you feel ready to complete this course of counseling so that we can have 1-2 wrap up sessions to solidify gains you’ve made and to discuss recommendations to maintain progress. Often when we approach ending clients choose to switch to monthly sessions for 3 months then reassess if they are ready to end or continue less frequently. WE are open to working with you to find what is best. Except in rare and/or potentially dangerous circumstances, we leave it up to you to contact us to request an appointment. If we do not hear from you after a period of one month, we will close your case which will mean we are no longer responsible for your counseling.
At times, phone contact is necessary between sessions. Clients are encouraged to keep phone contacts brief, if possible, and to address issues during your regular therapy session. If you need to speak with us between sessions, please call 678-753-2527. Your call will be returned as soon as possible. We are not an emergency mental health clinic, so if an emergency requires immediate attention, you agree to call the National Suicide Hotline at 800-784-2433 or 911, or the GA Crisis and Access Line (GCAL) at 800-715-4225, or go to a hospital emergency room.
I understand that ALAS adheres to the privacy practices outlined in the HIPPA National Providers policy. ALAS will provide you with a copy of HIPPA notice at our first appointment.
I HAVE READ, UNDERSTAND, AND AGREE TO ALL THE ALAS OFFICE POLICIES