Part 1: General Medical History

This notice describes how information about you may be used and disclosed and how you can have access to this information.

Introduction:

At Kinsler Psychology, we are committed to treating and using your PHI responsibly. This HIPPA Notice describes the personal information we collect and how and when we use or disclose that information. It also describes your rights as they related to your PHI. This HIPPA Notice applies to all PHI as defined by federal regulations.

Understanding Your Health Record/Information:

Each time you visit Kinsler Psychology, a record of your visit is made. Typically, this record contains your symptoms, diagnoses, treatment, and a plan for future care or treatment. This is referred to as your health or medical record and serves as a:

• Basis for planning your care and treatment,
• Means of communicating among the many health professionals who contribute to your care,
• Legal document describing the care you received,
• Means by which you or a third-party payer (i.e., insurance company) can verify that services billed were actually provided,
• Source of information for public health officials charged with improving the health of the State and the nation, as required by law (i.e., reporting child/elder abuse and neglect or domestic violence),
• Basis for disclosing health information to a law enforcement official, for purposes such as identifying or locating an individual, in complying with a court order or subpoena, and other law enforcement purposes,
• Source for public safety. We may disclose health information to appropriate persons in order to prevent or lessen a serious threat to health or safety of a particular person, or the general public, and
• Tool in educating health professionals, source of data for medical research, and tool with which we can assess and continually work to improve the care we render and the outcomes we achieve.

Understanding what is in your record and how your PHI is used helps you to ensure its accuracy, better understand the reasons that others may access your health information, and make more informed decisions when authorizing disclosure to others.

Your Health Information Rights

Although your health record is the physical property of Kinsler Psychology, the information belongs to you. As provided for in federal regulations, you have the right to:

• Obtain a paper copy of this Notice of Health Information Practices upon request,
  Inspect and access your health record,
• Obtain an accounting of disclosures of your health information
• Request communications of your health information by alternative means or at alternative locations,
• Request a restriction on certain uses and disclosures of your information, and
• Revoke your authorization to use or disclose health information, except to the extent that action has already been taken.:

Kinsler Psychology is required to:

• Maintain the privacy of your health information,
• Provide you with a copy of this Notice as to your legal duties and privacy practices with respect to information that is collected and maintained about you,
• Abide by the terms of this Notice,
• Notify you if we are unable to agree to a requested restriction, and
• Accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations.
  We reserve the right to change our practices and to make new provisions effective for all protected health information we maintain. Should our information practices change, we will mail a revised notice to you. We will not use or disclose your health information without your authorization, except as described in this Notice. We will also discontinue using or disclosing your health information after we have received a written revocation of the authorization, according to the procedures included in the Authorization. For More Information or to Report a Problem: If you have any questions or would like additional information, you may contact Kinsler Psychology at (813) 443-4311. You believe your privacy rights have been violated, complaints should also be directed to Kinsler Psychology.

I understand that as a part of my or my family’s health care, Kinsler Psychology originates and maintains paper and/or electronic records describing my health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care or treatment. I understand that this information serves as:

• A basis for planning my care and treatment,
• A means of communication among the many health professionals who contribute to my care,
• A source of information for applying my diagnosis and treatment information to my bill,
• A means by which a third-party payer can verify that services billed were actually provided, and
• A tool for routine healthcare operations, such as assessing quality and reviewing the competence of healthcare professionals.

I have been presented with a copy of Kinsler Psychology's Notice of Privacy Policies detailing how my information may be used and disclosed under Federal and State law. I understand the contents of the Notice. Further, I permit a copy of this Acknowledgement to be used in place of the original and, if applicable, request payment of medical insurance benefits either to myself or to the party who accepts assignments. Regulations pertaining to medical assignment of benefits apply. I understand and have been provided with a Notice of Health Information Practices that provides a more complete description of information uses and disclosures. I understand that I have the following rights and privileges:

• The right to review the Notice prior to signing this Consent,
• The right to object to the use of my health information for directory purposes, and
• The right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or health care operations.

I understand that I may revoke this Consent in writing, except to the extent that the organization has already taken action in reliance thereon. I understand that by refusing to sign the Consent or revoking this Consent, Kinsler Psychology will refuse to treat me, as permitted by Federal regulations. I further understand that Kinsler Psychology reserves the right to change its notice and practices prior to implementation, in accord with Federal regulations. Should Kinsler Psychology change its practices, it will send a copy of any revised notice to the address I have provided by U.S. mail, or email, if I agree. I understand that as a part of Kinsler Psychology’s treatment, payment, or health care operations, it may become necessary to disclose my protected health information to another entity (i.e., insurance, emergency, etc.), and I consent to such disclosure for these permitted uses, including disclosures via fax and email only to appropriate parties.

Please note: This page requires completion if you are utilizing insurance at Kinsler Psychology. Self-Pay patients can skip this page but it will need to be completed if you use insurance here in the future.

Professional Services Assignment: To the extent that fees for professional services rendered to the patient are payable, the undersigned hereby assigns to Kinsler Psychology, and authorizes payment directly for all insurance benefits, including major medical, for professional services rendered to the patient. The undersigned is financially responsible to the service provider for fees not paid pursuant to this agreement.Your insurance and Identification will be copied for our records.

PLEASE NOTE: WE WILL ONLY BILL THE PRIMARY INSURANCE and WE DO NOT ACCEPT MEDICARE OR MEDICAID PLANS.

Acknowledgement: I understand and agree that Kinsler Psychology
1) May at its discretion make contact with an insurance company regarding insurance benefits.
2) Does not in any way guarantee any insurance health benefits.
3) Has not and does not guarantee that the professional services charges are covered by my insurance.

This will authorize Kinsler Psychology to release general medical as well as psychiatric, alcohol, drug abuse, HIV and/or AIDS information from my health record in accordance with Florida Statutes 394.459.90.503, 396.112, and/or 381.609 (3)(F) and Federal regulations (42 CFR Part 2) to the above-named insurance company if necessary for payment of insurance claims. I understand that I have the right to refuse this authorization. If I approve, the facility named above is released from all legal liability that may arise from the release of the information requested.

Prohibition on redisclosure: This information has been disclosed from records whose confidentiality is protected by State/Federal law, which prohibits any further disclosure of such information without the specific written consent of the person to whom such information pertains, or as otherwise permitted by State/Federal law. A general authorization for the release of medical or other information is NOT sufficient for this purpose. This consent is subject to revocation at any time except that the program which is to make the disclosure has already taken action in reliance on it. This authorization will expire when revoked by the patient or guardian.

Text & Email Alerts

Text alerts (for appointments only) are automatically authorized upon starting services at Kinsler Psychology. Please be advised that this service is a courtesy and it should not be the only thing you rely on to remind you and/or your family members of appointments. Immediately after scheduling the appointment, notate it in your calendar. Feel free to call either of our offices to confirm that you have the correct date or to ask for an emailed or printed copy of your upcoming appointments.

Late Cancellations & No-Shows

Because the provider’s time has been reserved exclusively for you and/or your family members, you are required to provide at least 24 hours advance notice if unable to keep the scheduled appointment.

In the event that I do not provide 24 hours advanced notice,
I am financially responsible for the scheduled appointment and I will be charged a $100.00 FEE for a no-show or late cancellation with the provider in our office. Upon prior discussion and agreement, I understand that charges will be added to my account for other professional services rendered (e.g., preparation of letters/reports, review of medical records, etc.) Fees can be waived due to emergency situations/ sickness, please contact as soon as possible (within five business days) so we can let your provider know. 

Psychological Evaluations and Testing:

All patients are required to request testing with a provider and speak with the office manager before being scheduled for testing.

• In the event a patient needs to cancel their appointment, the patient agrees to cancel 24 hours in advance to receive a full refund. If the patient does not cancel within 24 hours of the scheduled appointment, then the patient forfeits the full amount paid for testing up to a maximum of $100. Additionally, if the patient needs to reschedule their appointment, they must do so 24 hours in advance and Kinsler Psychology will transfer the payment to the new appointment.
• For psychological evaluations, until payment is received in full by either yourself or your insurance carrier, no further services will be rendered beyond the initial testing. This means that the tests used as part of the evaluation WILL NOT BE SCORED OR INTERPRETED and NO REPORT WILL BE GENERATED and NO FEEDBACK SESSION WILL BE PROVIDED. Denial of payment by either your insurance carrier and/or yourself will delay these services indefinitely. If your insurance carrier delays and/or denies payment for any reason and you wish to receive these services; you may pay the estimated portion due by your insurance carrier. Once your insurance carrier pays you will be reimbursed by check from Dr. Kinsler & Associates, LLC for any over payments.

 

Insurance Claims

Direct insurance assignment is currently accepted from several major insurance companies. For clients with other insurance, Kinsler Psychology will gladly provide documentation of treatment for clients seeking insurance reimbursement for out-of-network benefits. Payment is due at the time services are rendered unless special arrangements have been made. For psychotherapy, financial hardships will be considered on an individual basis. We accept credit, debit, and HSA cards only. We do not accept checks or cash. As a courtesy, we will estimate your insurance portion and process your claims for you. You will be required to pay your estimated patient portion on the day services are rendered, prior to the start time of your session. Not all services are a covered benefit in all contracts. Authorizations are based on medical necessity and are not a guarantee of payment by your insurance company. Insurance companies determine “medical necessity” for services provided at the time the claim is received and reviewed by them. Regardless of what the insurance company tells you or Kinsler Psychology at the time of the eligibility check, payment rendered is based on the claim, which is ultimately up to your insurance company. Please note that claims may take up to one month to process. The cost of your appointment will be determined by the information detailed on the returning claim. If there are concerns about the cost of your session it is always recommended to contact your insurance company and discuss your coverage. Patient responsibility includes that portion identified by your insurance company as well as any claims that are denied payment for any reason. 

PROVIDER CONTROLLED SUBSTANCE PRESCRIPTION POLICY

Please note: This policy MUST be signed to receive medication management services at this practice.

What is the meaning of a controlled drug?

A drug or other substance that is tightly controlled by the government because it may be abused or cause addiction. The “control” applies to the way the substance is made, used, handled, stored, and distributed. Controlled substances include opioids, stimulants, depressants, hallucinogens, and anabolic steroids.

What is the intent of this policy?

To provide access to safe and effective controlled substances for legitimate patients in need of treatment, while minimizing the risk for development of addiction in patients through improved prescribing and dispensing practices. Improvement of patient outcomes and quality of life is sought through reduction of under treatment, overtreatment, and inappropriate use of controlled substances. Advancement of evidence-based approaches to identify, monitor, treat, and follow up with patients suffering from addiction, in addition to focused education and training of practitioners in recommended controlled substance prescribing and dispensing practices and administration of rescue medication (i.e. naloxone) are all critical aspects to patient treatment.

The policies of Kinsler Psychology are in compliance with the Florida Boards of Medicine, Nursing and Pharmacy and take into consideration the recommendations of the CDC, DEA, and model policies on the use of controlled substances from the Federation of State Medical Boards. Patients on controlled substance treatments are required to sign a Controlled Substance Agreement.

Some of the conditions of this agreement are:

1. New Patients: For the first three (3) months, patients prescribed controlled substances will be seen on a bi-weekly or monthly basis. Once stable and after treatment for three (3) consecutive months, the prescribing provider may recommend 2-3-month follow-up appointments. However, this will only be scheduled with the proper documentation by the provider.
2. Pharmacies do not allow controlled substance prescriptions to be “called in”. Only non-controls can be “called in” for renewal. Prescriptions will be electronically sent to the pharmacy (aka e-prescribed) or in emergency situations (i.e., systems or internet down) the prescription will need to be picked up at the office & brought to the pharmacy.
3. If prescriptions are needed to be picked it can only be by the patient whose name is on the controlled medicine, unless we have a signed Release of Information form noting a specific family member/friend can pick up the prescription on behalf of the patient, ID will be required. Minors are not able to pick up prescriptions for parents.
4. Patients should submit requests for refills with a minimum of seven (7) days before the medication will run out to give their provider enough time to respond to the request (the pharmacy may be out of that medication or an authorization may be needed. These extra steps take time. Last minute requests may be detrimental to your care.)
5. We will not provide early refills or provide replacement of lost or stolen medication. If there is any suspicious behavior including frequent or early refill requests, multiple “lost/stolen” prescriptions or constantly switching pharmacies, we have the right to  terminate the Controlled Substance agreement and refuse further prescription requests.
6. Prescriptions are given for only one (1) month at a time for a 30-day supply, so a new prescription will need to be written each time. Therefore, no 90 days’ supply of controlled substances will be provided.
7. Patient will take this medication only as prescribed and will not change the dosage amount or frequency without authorization from the prescribing provider.
8. Patient-Provider relationship is terminated if regularly scheduled appointments are not kept or the prescribed treatment plan is not followed (a copy can be requested from the front desk personnel).
9. Patient is required to confirm by signature that they have not given any false health facts and are not seeking treatment under false pretense.
10. Patient is required to release Dr. Kinsler & Associates, LLC/Kinsler Psychology from any liability related to their misuse of the controlled substance prescribed.                                                         

CONTROLLED SUBSTANCE AGREEMENT

The State of Florida has laws governing the prescription of controlled substances. The drugs include all opioids (i.e., codeine, hydrocodone, oxycodone), sleeping aids, benzodiazepines (i.e., Valium, Xanax, Ativan) and ADHD medications (i.e., Concerta, Metadate CD, Ritalin, Adderall, Vyvanse).
To comply with Florida law, I acknowledge and agree to the following:

1. Prescriptions for controlled substance medications can only be written for a 30-day supply.
2. I will not use any illegal controlled substances (i.e., cocaine).
3. I will not share, sell, or trade my medication with anyone.
4. I will safeguard my medicine from loss or theft. Lost or stolen prescriptions, written or filled, will not be replaced.
5. I will use my medicine at a rate no greater than the prescribed rate and that the use of my medicine at a greater rate will result in my being without medication for a period of time. If requested by my
   provider, I will bring all unused medicine to every office visit.
6. I must be seen by my provider no less than every two (2) months to continue to get my controlled medications.
7. I agree that refills of my prescriptions will be made only at the time of an office visit or during regular office hours. No refills will be available during evenings or on weekends.
8. I will submit to a blood or urine test within one week of when requested by my provider to determine my compliance with these policies. Failure to comply may result in delay of prescription and or termination.
9. I will communicate fully and truthfully with my provider about the character and intensity of my psychological condition and how well the medicine is helping with my condition.
10. I acknowledge controlled substance medications have inherent risks associated with their use. These risks include but are not limited to the following: physical dependence, psychological dependence, potential for overdose and potential for withdrawal syndrome.
11. I understand the provider will run a report on the Florida Prescription Drug Monitoring Program (E-FORCSE) periodically to verify that I am receiving controlled substances from only one prescriber & only one pharmacy.
12. I will obtain all psychiatric controlled medicines only from one provider means that If I see another provider who gives me a controlled substance medicine (for example, a dentist, a doctor from the Emergency Room or another hospital, etc.) I must bring this medicine to this office in the original bottle, even if there are no pills left, so it can be documented in my chart. I also have the option to request my records be forwarded to this office by completing a Release of Information form.
13. I agree to comply with the terms of this agreement. I understand that my provider has the right to discontinue prescribing me controlled substance medications and discharge me from care If I do not cmply with the terms of this agreement.

To the following Individual/Facility:

We are requesting  your consent for the observation and/or recording of your psychotherapy sessions. This practice, supervised by  Licensed Clinical Psychologist Kimberly Kinsler, Psy.D, LCSW and/or Licensed Clinical Psychologist Jelyn Young, Ph.D., aims to enhance the quality of our clinical services and support the professional development of our clinicians.

Purpose of Observation and Recording:

Observing and recording clinical sessions allows for:

• Detailed and accurate records of therapy sessions.
• High-quality self-supervision and consultation.
• Enhanced supervision with other professionals.

The recordings will be used strictly for clinical and educational purposes, with every effort made to ensure patient confidentiality.

Your Rights:

• Your consent or refusal will not affect your status as a patient in any way.
• You are under no obligation to consent and are not subject to any pressure to do so.
• You can withdraw your consent at any time without any impact on your treatment.

Confidentiality:

• All recordings are confidential and will not become part of your permanent medical record.
• Recordings will be destroyed after their intended use is completed.
• Observers and viewers are bound by the ethical standards of the American Counseling Association, American Psychological Association, American Board of Clinical Social Work, and the governing bodies within the state of Florida.

By signing below, you agree to the observation and/or recording of your psychotherapy sessions. These recordings will be used to improve the quality of your therapy and assessment, for consultations with expert clinicians, and for the training of professional colleagues. No recording or observation will be done without your prior knowledge.