AGREEMENT REGARDING CONSENT TO TREATMENT, POLICIES, SERVICES & FEES
If there is an emergency during therapy where I become concerned about your personal safety, or the safety of another, I will do whatever I can legally do to prevent you from injuring yourself or others and to ensure that you receive the proper medical care. For this purpose, I may call your emergency contact person listed on your information form or 911.
HEALTH INSURANCE & CONFIDENTIALITY OF RECORDS
Disclosure of confidential information may be required by your health insurance carrier or HMO/PPO/MCO/EAP in order to process claims. If you so instruct, I will provide the minimum necessary information to the carrier. Once submitted, I have no control over, or knowledge of, what insurance companies do with this information or who has access to this information.
Sometimes patients become involved in litigation while they are in therapy or after therapy has been completed. If you or an opposing attorney are consideringrequesting disclosure of the records, I will do my best to discuss with you the risks and benefits of doing so. As noted in this document, you have the right to review your own psychotherapy records anytime.
I consult regularly with other professionals regarding certain cases. Your identity remains completely anonymous and confidentiality is fully maintained.
E–MAILS, CELL PHONES, TEXTS, COMPUTERS, AND FAXES
To protect the confidential information of clients, I use HIPAA compliant platforms for telehealth video sessions, emails and forms completion. I do not store client information on my computer and I keep client personal files securely behind two locks. When you communicate with me using unencrypted e-mail, text, e-fax or phone message, it is assumed your information and identity have the potential to be intercepted.
RECORDS AND YOUR RIGHT TO REVIEW THEM
Both the law and the standards of my profession require that I keep treatment records for at least 7 years. I retain clinical records as long as is mandated by Wisconsin law. As a client, you have the right to review or receive a summary of your records at any time.
The preferred method to contact me between sessions or for logistical communication such as rescheduling or cancellation is 1) email, 2) voicemail. I may be reached via email email@example.com or by phone at 1-262-372-1309. I will return your call/email as soon as I am able.
If an emergency situation arises, please call 911. Take note that I check voicemail and email intermittently and cannot be reached immediately.
HEALTH INSURANCE & SELF-PAYMENT
Please keep in mind that all charges are the responsibility of the client regardless of your insurance coverage. I will be happy to file your claims with your insurance carrier. However, if the insurance hasn’t’ paid within 60 days, I will expect you to work with your insurance company to receive reimbursement. If no payment has been received within 90 days of the date of service, you will be billed for the full service rendered.
It is my policy to bill clients directly for professional services that may not be billed to insurance. For example, clients will be charged for phone calls and reports necessary for collateral contacts such as physicians, attorneys, and schools. This policy also applies to therapeutic and emergy phone consutlations with clients or their family members. Clients will be billed at the my normal hourly rate, in 15-minute increments.
My practice is committed to providing the best treatment for my clients and I charge what is usual and customary for our area. You are responsible of payment regardless of any insurance company’s arbitrary determination of usual and customary rates.
All clients are responsible to provide Jennifer Van Rossum, LPC – 5Peaks, LLC with accurate insurance information and to contact me should coverage be changed. I am not responsible for any changes in your health insurance benefits.
If you prefer to not go through your insurance, do not have insurance or I am an out-of-network provider, therapeutic services will be provided at self-pay rates in which all charges are your personal financial responsibility.
If you have financial concerns or encounter changes in your financial situation during the course of therapy, I will be glad to work with you in reaching a mutually beneficial payment arrangement.
CREDIT CARD ON FILE
Payment is to be made at the time of service. I give Jennifer Van Rossum, LPC - 5Peaks, LLC permission to keep my credit card information on file in order to facilitate payments for my co-pay, co-insurance, deductible or other charges incurred in each visit. I understand that my card will not be charged without my knowledge. Although payment is due at the time of service, I understand that in addition to the credit card on file, I have the option of paying with cash or check.
Unless canceled, at least 24 hours in advance, my policy is to charge for missed appointments at the rate of a normal office visit. You will be billed/charged directly. Insurance carriers do not assume any financial responsibility for failed appointment charges.
THE PROCESS OF THERAPY/EVALUATION AND SCOPE OF PRACTICE
Participation in therapy can result in a number of benefits to you, including improving interpersonal relationships and resolution of the specific concerns that led you to seek therapy. Working toward these benefits, however, requires effort on your part. Psychotherapy requires your active involvement, honesty, and openness in order to change your thoughts, feelings and/or behaviors. Remembering or talking about unpleasant events, feelings or thoughts can result in you experiencing discomfort or strong feelings such as anger, sadness, worry or fear. This is perfectly normal and my role is to help guide you through this discomfort and help you attempt to resolve issues that brought you to therapy in the first place.
At the beginning of treatment, I will share with you my understanding of the problem, a potential treatment plan, therapeutic objectives and possible outcomes of treatment. I see our work together as a partnership, so if you ever have any questions about the course of your therapy, please let me know.
Termination of therapy can occur with any of the following:
I don’t believe I would be a good therapeutic fit for your needs. In such a case, I will give you referrals to 3 other providers.
If you don’t believe I am helping you in your therapy needs, you have the right to terminate therapy at any time. In such a case, I will also give you referrals to 3 other providers.
If treatment goals have been met and sufficient progress has been made in which you feel therapy is no longer needed.
AUDIO OR VIDEO RECORDING
Unless otherwise agreed to by all parties beforehand, there shall be no audio or video recording of therapy sessions, phone calls, or any other services provided by me.
In principle, I do not use search engines to look up information about clients. In extreme situations that involve your wellbeing and safety, such as when I have reason to suspect that you might be in a crisis or danger, exceptions might be made. In these cases, searching the internet for pertinent information in an attempt to find alternative ways to contact you might be necessary to ensure your welfare. These extraordinary incidents would be fully documented and discussed with you when possible.
SOCIAL MEDIA POLICY
I take issues of confidentiality and privacy, as well as healthy boundaries relating to the therapeutic relationship, very seriously. In order to protect the right for privacy, safeguard the confidentiality of information shared between you and me and maintain clear therapeutic boundaries, I do not engage with clients in any way on any social networking sites.
Clients are automatically subscribed to the 5Peaks Monthly Newsletter so that they can stay up to date on 5Peaks news, changes, events and classes. Clients can opt-out at anytime.
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THE INFORMATION. PLEASE REVIEW CAREFULLY:
I am required by the Health Insurance Portability & Accountability Act of 1996 (HIPAA) to provide confidentiality for all medical/mental health records and other individually identifiable health information in my possession. This Notice is to inform you of the uses and disclosures of confidential information that may be made by Jennifer Van Rossum, LPC – 5Peaks, LLC, and of your individual rights and Jennifer Van Rossum, LPC – 5Peaks, LLC legal duties with respect to confidential information.
Ways in which I may use and disclose your protected Health information:
I may use and disclose at my discretion your medical records for each of the following purposes only: treatment, payment and health care operations.
● Treatment means providing, coordinating or managing mental health care and related services.
● Payment means activities such as obtaining payment for the mental health care services I provide for you
from your insurance or another third party payer.
● Health care operations include the business aspects of running a practice.
I may contact you to provide appointment reminders or other services that may be of interest to you. I will disclose your protected health information to any person you identify that is involved in payment for your care.
I will use and disclose your protected health information when required by federal, state or local law. There are certain situations in which as a therapist I am required by ethical standards to reveal information obtained during therapy to persons or agencies even if you do not give permission. These situations are as follows: (a) If you threaten grave bodily harm or death to yourself or another person, I am required by ethical standards to inform the intended victim and/or appropriate law enforcement agencies; (b) if you report to me your knowledge of physical or sexual abuse of a minor child or of an elder (over 65) or any sexual conduct/contact with a minor, I am required by law to inform the appropriate child welfare or social agency which may then investigate the matter; (c) if I am required by a court of law (court order) to turn over records to the court or if I am ordered to testify regarding those records.
Any other uses and disclosures will be made only with your written authorization. You will be provided with an authorization form upon request. A separate form will be needed for each request for release of information. The authorization for release of records is valid until it expires or is revoked. You may revoke authorization in writing and I am required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization.
CONFIDENTIALITY: All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your written permission except where disclosure is required by law.
MINORS: All information pertaining to minors will be released to their parents or legal guardians upon their request, unless it would seriously affect the therapeutic process. The adult accompanying a minor and the parents (or guardians of the minor) are responsible for full payment (regardless of divorce decree if applicable).
WHEN DISCLOSURE IS REQUIRED OR MAY BE REQUIRED BY LAW
Some of the circumstances where disclosure is required or may be required by law are:
where there is a reasonable suspicion of child, dependent, or elder abuse or neglect
where a client presents a danger to self, to others, to property, or is gravely disabled
when a client's family member communicates to me that the client presents a danger to others
If you present your mental status as an issue in litigation, the defendant may have the right to request my psychotherapy records and/or testimony
I have read the above Office Policies, Privacy Practice, General Information, Informed Consent for Psychotherapy carefully. I understand them and agree to comply with them. My electronic signature serves as my agreement.