ConfidentialityInformed ConsentAll of our conversations, our work together, your records and any information that you give us are protected by client privilege. That means that the law protects you from having information about you given to anyone without yourpermission. Your privacy is respected, and we intend to honor your privilege. However, there are some limits to your privilege. Here are some exceptions you should understand before we start.
If your counselor believes that there is a risk that you might harm yourself or someone else, we may be required to contact the authorities or another person to give them the opportunity to protect you or the other person. If you report the abuse of children or elderly people, we are required by law to notify the authorities, so they can protect others from harm.
The financial part of our relationship also imposes some confidentiality limits. If you are using insurance or another third-party payer, we must share certain information with them, including (but not necessarily limited to) your diagnosis and the times of your visits. If we submit claims to your managed care company, they may require us to provide additional information such as your symptoms and your progress. You should understand that insurance and managed care information is often stored in national computer databases for an undetermined amount of time.
As counselors, we specialize in treating general adult issues. If your counselor believes that your problems require knowledge that he or she does not have, you may be referred for a consultation with someone with specific training orexperience. We will discuss any such referral with you before we act.
General PoliciesCounseling sessions usually last 50-55 minutes, and we must end each session promptly. Payment is due at the end of your appointment. You will be charged a late cancellation fee if you do not cancel the appointment 24 hours inadvance. Please keep in mind that if you are using insurance they will not cover missed appointments and therefore you will be responsible for the $80.00 fee. In addition, insurance will not cover the time missed if you run late for an appointment. Therefore you may be asked to pay for the missed portion of the session out of pocket.
We check messages throughout the day and whenever possible, we will return the call within the same day. However, if you have an emergency, please call 911 or go to your local emergency room. There may be extended periods of timewhen your counselor will be unreachable due to travel. During that time you may be given the number of another counseling professional to assist in your counselor’s absence.
This information is to help you understand some things about counseling and what you can expect from your time intreatment. If you have any questions or concerns before you begin or at any time, please don’t hesitate to ask so that yourcounselor can explain more fully.
I have read and understand:• The limitations to confidentiality• My HIPAA Rights and was provided with a copy of my rights• General office policies• I am aware that I can access all of these documents at any time online at www.therelationshipexperts.org
Thank you for choosing Relationship Counseling & Psychotherapy Services as your mental health care provider. Carefully review the following information, since your clear understanding of our financial policies is important to ourprofessional relationship. Please inquire if you have any questions about our fees, policies and/or your responsibilities.
• All payment is due in the form of cash, credit/debit, Paypal, or Zelle/Chase Quickpay, or any other electronic payment. This includes copays, co-insurance, deductible payments, and out of pocket fees. All fees must be paid in full at the time of service. We do not allow clients to carry balances. If you have outstanding unpaid fees, this may affect your ability to schedule future appointments.
• Missed appointments that are not canceled or rescheduled at least 24 hours in advance may be subject to alate cancellation fee and will be charged to your card on file. The late cancellation fee is $80.00.
• If you are using an “in-network” insurance to pay for sessions, Relationship Counseling & Psychotherapy Services will file claims on your behalf. If you would like to submit claims to out of network insuranceproviders, it is your responsibility to request a receipt of services from our office manager. Please be advised that your estimated eligibility and benefits are not a guarantee of coverage until the claim is processed. Any fees not covered by your insurance company are your responsibility.
• In the event that you have outstanding fees for services, these fees may be charged to the card listed below.Charges will appear on your card from Relationship Counseling & Psychotherapy Services.
I authorize Relationship Counseling & Psychotherapy Services to charge the following card for payment of servicesrendered under the above conditions.
HIPAA Privacy Authorization Form
Authorization for Use or Disclosure of Protected Health Information
(Required by the Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164)
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
The Health Insurance Portability and Accountability Act (HIPAA) establishes patient rights and protections associated with the use of protected health information. HIPAA provides patient protections related to the electronic transmission of data (“the transaction rules”), the keeping and use of patient records (“privacy rules”), and storage and access to health care records (“the security rules”). HIPAA applies to all health care providers, including mental health care providers. Providers and health care agencies are required to provide patients a notification of their privacy rights as it relates to their health care records.
This Patient Notification of Privacy Rights informs you of your rights. Please carefully read this Patient Notification. It is important that you know and understand the patient protections HIPAA affords you as a patient.
In mental health care, confidentiality and privacy are central to the success of the therapeutic relationship; therefore, I will do all we can do to protect the privacy of your mental health records. If you have questions regarding matters discussed in this Patient Notification, please do not hesitate to ask.
I. PreambleRecords are kept documenting your care as required by law, professional standards, and other review procedures. HIPAA clearly defines what kind of information is to be included in your “designated medical record” or “case record” as well as some material, known as “Psychotherapy Notes” which is not accessible to insurance companies and other third-party reviewers. HIPAA provides privacy protections about your personal health information, which is called “protected health information (PHI)” which could personally identify you. PHI consists of three (3) components: treatment, payment, and health care operations.
Treatment refers to activities/sessions I provide, coordinate or manage your mental health care service or other services related to your health care. Examples include a counseling session or communication with your primary care physician about your medication or overall medical condition.
Payment is when Relationship Counseling & Psychotherapy Services obtains reimbursement for your mental health care or other services related to your health care.
Health care operations are activities related to my performance such as quality assurance. The use of your protected health information refers to activities my agency conducts for scheduling appointments, keeping records, and other tasks related to your care. Disclosures refer to activities you authorize such as the sending of your protected health information to other parties (i.e., your insurance company).
II. Uses and Disclosures of Protected Health Information Requiring AuthorizationIf you request Relationship Counseling & Psychotherapy Services to send any of your protected health information of any sort to anyone outside my office, you must first sign a specific authorization to release information to this outside party. A copy of that authorization form is available on the website and upon request. In recognition of the importance of the confidentiality of conversations between therapist and patients in treatment settings, HIPAA permits keeping “psychotherapy notes” separate from the overall “designated medical record”. “Psychotherapy notes” are the therapist’s notes “recorded in any medium by a mental health provider documenting and analyzing the contents of a conversation during a private, group, or joint family counseling session and that are separated from the rest of the individual’s medical record.” “Psychotherapy notes” are private and contain information about you and your treatment.
III. Uses and Disclosures Not Requiring Consent or AuthorizationBy law, protected health information may be released without your consent or authorization under the following conditions:
• Suspected or known child abuse or neglect
• Suspected or known sexual abuse of a child
• Adult and Domestic abuse
• Judicial or administrative proceedings (i.e. you are ordered here by the court)
• Serious threat to health or safety (i.e. “Duty to Warn” and Threat to National Security)
V. Patient’s Rights and Our DutiesYou have a right to the following:
• The right to request restrictions on certain uses and disclosures of your protected health information which I may or may not agree to but if I do, such restrictions shall apply unless our agreement is changed in writing
• The right to receive confidential communications by alternative means and at alternative locations. For example, you may not want forms mailed to your home address so I will send them to another location of your choosing.
• The right to inspect and copy your protected health information in the designated record and any billing records for as long as protected health information is maintained in the record.
• The right to insert an amendment in your protected health information, although the therapist may deny an improper request and/or respond to any amendment(s) you make to your record of care.
• The right to an accounting of non-authorized disclosures of your protected health information.
• The right to a paper copy of notices/information from Relationship Counseling & Psychotherapy Services, even if you have previously requested electronic transmission of notices/information.
• The right to revoke your authorization of your protected health information except to the extent that action has already been taken.
For more information on how to exercise each of these aforementioned rights, please do not hesitate to ask for further assistance on these matters.
Relationship Counseling & Psychotherapy Services is required by law to maintain the privacy of your protected health information and to provide you with a notice of your Privacy Rights and our duties regarding your PHI. Relationship Counseling & Psychotherapy Services reserves the right to change its privacy policies and practices as needed with these current designated practices being applicable unless you receive a revision of these policies when you come for future appointment(s). Our duties in these matters include maintaining the privacy of your protected health information, to provide you with a notice of your rights and our privacy practices with respect to your PHI, and to abide by the terms of the notice unless it is changed and you are so notified.
VI. Complaints· The right to have oral or written instructions for filing a grievance.
· The right to file a grievance is not time-limited. If you need assistance in filing a grievance or want further information, please For more information see:
Changes to the Terms of this Notice:
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.