We will make every effort to collect from your insurance company when applicable. If we are unable to collect from the insurance company or your benefits are exhausted, you as the client are responsible. The client is responsible for all charges not collectible through insurance. We require a 24 hour notice of appointment cancellation. If this is not received, the client is responsible for payment. All accounts 30 days overdue will be charged a 1.5% (per month) service charge.

Privacy Policy

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

1.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 operation purposes with your consent. To help clarify these terms, here are some definitions:

• "PHI" refers to information in your chart that could identify you.
• Treatment is when I provide, coordinate or manage your health care and other services related to your health care. An example of treatment would be when I consult with another health care provider, such as your PCP or another therapist.
• Payment is when I obtain reimbursement for your healthcare. Examples of payment are when I disclose your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.
• Health Care Operations are activities that relate to the performance and operation of my practice. Examples of health care operations are quality assessment and improvement activities, business-related matters, such as audits and administrative services, and case management and case coordination.
• Use applies to activities within my practice, such as sharing, employing, applying, utilizing, examining and analyzing information that identifies you.
• Disclosure applies to activities outside of my practice, such as releasing, transferring or providing access to information about you to other parties.

2. Uses and Disclosures Requiring Authorization

I may use or disclose PHI for purposes outside of treatment, payment and 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 and health care operations, I will obtain an authorization from you before releasing this information. I will also need to obtain an authorization before releasing your psychotherapy notes. "Psychotherapy notes" are notes I have made about our conversation during a private, group, joint or family counseling session, which I have may contact members of your family or other individuals if it would assist in protecting you.

• Workers Compensation: If you file a worker's compensation claim, your records relevant to that claim will not be confidential to entities such as your employer, the insurer and the Division of Worker's Compensation.
• Fees for Services: If necessary, to use a collection agency or other process to collect amounts you owe for services.

When the use and disclosure without your consent or authorization is allowed under sections of Section 164.512 of the Privacy Rule and the state' confidentiality law, this includes certain narrowly defined disclosures to law enforcement agencies, to a health oversight agency (such as HHS or a state department of health), to a coroner or medical examiner, for public health purposes relating to disease of FDA-regulated products or for specialized government functions such as fitness for military duties, eligibility for VA benefits, and national security and intelligence.

4. Patient's Rights and Mental Health Clinician's Duties

Patient's Rights

• Right to Request Restrictions: You have the right to request restrictions on certain uses and disclosures of protected health information about you. However, I am not required to agree to a restriction in regard to your request.
• Right to Receive Confidential Communications by Alternative Means and Alternative Locations: You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations For example, you may not want a family member to know that you are seeing me. Upon your request, I will send your bills to another address.
• Right to Inspect and Copy: You have the right to inspect or obtain a copy (or both) of PHI in my mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. I may deny your access to PHI under certain circumstances, but in some cases, you may have the decision reviewed. On your request, I will discuss with you the details of the amendment process.
• Right to Amend: You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. I may deny your request. On your request, I will discuss with you the details of the amendment process.
• Right to an Accounting: You generally have the right to receive an accounting of disclosures of PHI for which you have neither provided consent nor authorization (as described in Section 3 of this Notice On your request, I will discuss with you the details of the accounting process.
• Right to a Paper Copy: You have the right to obtain a paper copy of the notice from me upon request, even if you have agreed to receive the notice electronically.

When we examine, diagnose, treat, or refer you we will be collecting what the law calls. Protected Health Information (PHI) about you. We need to use this information here to decide on what treatment is best for you and to provide treatment to you. We may also share this information with others who provide treatment to you or need it to arrange payment for your treatment or for other business or government functions.

 By signing this form you are agreeing that you have read and understand our Notice of Privacy Policies and you are agreeing to let us use your information here and send it to others in accordance with our written policies. Please make sure you have read and understand our Privacy Policies above before signing this consent form.

 In the future we may change how we use and share your information and so may change our Notice of Privacy Policies.

If you are concerned about some of your information, you have the right to ask us not to use or share some of your information for treatment, payment, or administrative purposes. You will have to tell us what you want in writing. Although we will try to respect your wishes, we are not required to agree to these limitations. However, if we do agree, we promise to comply with your wish.

I have had the opportunity to read this statement of policy and understand its meaning and consent to receiving services based on this understanding.

My choice has been voluntary and I understand that 1 may terminate therapy at any time.

I understand that there is no assurance that I will feel better. Because psychotherapy is a cooperative effort between myself and my therapist, I will work with my therapist in a cooperative manner to resolve my difficulties.

I understand that during the course of my treatment, material may be discussed which may be upsetting in nature and that this may be necessary to help me resolve my problems.

I understand that confidentiality of records collected about me will be held or released in accordance with state laws regarding confidentiality of such records and information.

I understand that state and local laws require that my therapist report all cases of abuse or neglect of minors or the elderly.

I understand that state and local laws require that my therapist report all cases in which there exists a danger to self or others.

I understand that there may be other circumstances in which the law requires my therapist to disclose confidential information.

I have read and had explained to me the basic rights of individuals who undergo treatment. These rights include:

1. The right to be informed of the various steps and activities involved in receiving services.
2. The right to confidentiality under federal and state laws relating to the receipt of services.
3. The right to humane care and protection from harm, abuse, or neglect.
4. The right to make an informed decision whether to accept or refuse treatment.
5. The right to contact and consult with counsel and select practitioners of my choice and at my expense.

I understand that my therapist may disclose any and all records pertaining to my treatment to representatives of my insurance company (and to my primary care physician), if such disclosure is necessary for claims processing, case management, coordination of treatment, quality assurance, or utilization review purposes, I understand that I can revoke my consent at any time except to the extent that treatment has already been rendered or that action has been taken in reliance on this consent, and that if I do not revoke this consent, it will expire automatically one year after all claims for treatment have been paid as provided in the benefit plan. 1 have read and understand the above.