I hereby authorize Evergreen Therapy Center or any contractor of Evergreen Therapy Center to furnish the insured’s insurance company all information which said insurance company may request concerning my present circumstances. I hereby assign Evergreen Therapy Center all money to which I am entitled for expenses relating to the services performed from time to time, but not to exceed my indebtedness to Evergreen Therapy Center. It is understood that any money received from the above-named insurance company over and above my indebtedness will be refunded to me when my bill is paid in full. I understand I am financially responsible to Evergreen Therapy Center for charges not covered by my insurance. I further authorize photocopies to be made of this authorization and assignment for attachment to any insurance form, and authorize the insurance company to accept the photocopy. This authorization shall continue and be in effect until revoked, in writing, by me.
In this meeting, the clinician gathered the client's psychosocial history, identified major problems for therapeutic intervention, established preliminary diagnoses, and explained the process of therapy. Clinician explored the nature of the presenting problems, the ways they affect the client, and changes desired by the client. The clinician also reviewed forms related to agency policy and procedures (HIPAA, billing, informed consent, psychotherapy contract, etc.). We needed the entire hour to effectively assess the client's concerns. The client was actively engaged and participated fully in this session.
The responses in the psychosocial history are based on the client's self-report, unless otherwise noted.
Over the past 2 weeks, how much have you been bothered by the following problems?
1-4 Minimal depression, 5-9 Mild depression, 10-14 Moderate depression, 15-19 Moderately severe depression, 20-27 Severe depression.
0 to 4 minimal anxiety/worry, 5 to 9 mild anxiety/worry, 10 – 14 moderate anxiety/worry, 15 – 21 severe anxiety/worry.
DEDUCTIBLES AND COPAYS: Please call the number on the back of your insurance card to be certain psychiatry services are covered. If you have a deductible, you may have to pay all your medical costs until your deductible is reached. After that, you may only have to pay the copay. Please consult your insurance provider to learn more. Psychiatry is $221 for the intake appointment (the first appointment) and follow-up appointments range between $150 to $300 depending on the length and nature of the services required. Psychotherapy (i.e., therapy) is $197 for the intake and $166 for follow-up appointments. If you can’t afford the cost of your appointment, please talk to us about a payment plan. Services provided outside of scheduled appointments, such as completing forms for you, treatment summaries, telephone consultations, etc. is prorated at $40 per 15-minute increment. Fees are due before the start of the session. All fees must be paid before you can reschedule. We require a credit/debit card on file for billing.
PRIVATE PAY: When you private pay, fees are as follows: $221 for the intake appointment (the first appointment) and follow-up appointments range between $150 to $300 depending on the length and nature of the services required. Psychotherapy (i.e., therapy) is $197 for the intake and $166 for follow-up appointments. Fees are due before the start of the session. We require a credit/debit card on file for billing. All fees must be paid before you can reschedule.
HOW DOES PSYCHIATRY WORK? Our goal is to review your needs, determine if medication is appropriate, and then select the best medication for the problems you are experiencing. It is sometimes the case that no medication is needed or appropriate at this time. There is no guarantee, you will be prescribed a medication. We will listen to your feedback but sometimes a medication you think will be helpful may actually not be the best treatment options. Please be open-minded about the psychiatry process. Report your experiences thoroughly and trust your provider to recommend the best treatment options for you.
HOW DOES THERAPY WORK? In the first 2 to 3 sessions, we will meet to establish your main problems, set goals for change, and develop a treatment plan that lays out steps you can take to start getting better. Therapy typically lasts 5 to 20 sessions (typically once a week) but sometimes goes longer and always works toward goals. Therapy is a medical intervention and more than just a place to vent about problems. When we have determined that you have reached your maximum benefits from therapy, we are ethically and professionally required to inform you and together we can set a plan and timeline to end treatment.
MISSED OR CANCELED APPOINTMENTS: Please notify us as soon as possible if you need to cancel or reschedule your appointment. Unless you give us 48-hour notice, and without exception, missed or canceled appointments will incur a $50 fee for the first appointment and the full fee for any appointments after that. Sessions will not be rescheduled until all balances are paid.
TELEPHONE APPOINTMENTS? Insurance often does not reimburse telephone appointments. You will be responsible for any out-of-pocket expenses not covered by insurance for Teletherapy.
TELEPSYCHIATRY: If engaging in Telehealth the laws that protect the confidentiality of your medical information also apply to Telehealth. Please be aware there are risks affiliated with Telehealth. Some (but not all) include the possibility that, despite responsible efforts, the transmission of your medical information could be disrupted or distorted by technical failures and the storage of your medical information could be accessed by unauthorized persons.
CONFIDENTIALITY: All information discussed in sessions and in the written records pertaining to our sessions are confidential and may not be revealed to anyone without your written permission, except when required by law. Some (but not all) of the circumstances where disclosure is required by law are as follows: when there is a reasonable suspicion of child, dependent, or elder abuse or neglect; when a client presents a serious and immediate danger to self or others; or is so impaired he/she cannot meet basic self-care needs; when there is a legitimate court order to provide such information.
EMERGENCIES: We will try our best to help you during a crisis but we do not provide emergency services. The services you are receiving are outpatient therapy and not emergency services. If you have a crisis that requires immediate attention or thoughts of suicide, please reach out for help using one of the following: dial 911, go to your local hospital ER, or dial the suicide hotline at 1-800-273-8255.
LITIGATION LIMITATION: Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to many matters which may be of a confidential nature, it is agreed that should there be legal proceedings (such as, but not limited to divorce and custody disputes, injuries, lawsuits, etc.), neither you (client) nor your attorney, nor anyone else acting on your behalf will call on me to testify in court or at any other proceeding, nor will a disclosure of the psychotherapy records be requested. I may modify this requirement at my discretion.
Notice of Privacy Policies and Practices to Protect the Privacy of Your Health Information
THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
This Notice of Privacy Practices is provided to you by law as a requirement of the Health Insurance Portability and Accountability Act (HIPAA). Please retain the entirety of this form for your records. Privacy is a very important concern for all those who come to this office. It is also complicated, because of the many federal and state laws and our professional ethics. If you have any questions, please contact Evergreen Therapy Center to discuss further.
I. DISCLOSURES FOR TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS
We may disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your consent.
II. USES AND DISCLOSURES REQUIRING AUTHORIZATION
We 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 we are asked for information for purposes outside of treatment, payment and health care operations, we will obtain an authorization from you before releasing this information. We will also need to obtain an authorization before releasing your psychotherapy notes. “Psychotherapy Notes” are notes we have made about our conversation during a private, group, joint, or family counseling session, which we have kept separate from the rest of your medical record. These notes are given a greater degree of protection than PHI.
You may revoke all such authorizations at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) we have relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, and the law provides the insurer the right to contest the claim under the policy.
III. LIMITS OF CONFIDENTIALITY
We may use your PHI without your consent or authorization in the following circumstances:
Child Abuse: If we know, or have reasonable cause to suspect, that a child is abused, abandoned, or neglected by a parent, legal custodian, caregiver or other person responsible for the child's welfare, the law requires that we report such knowledge or suspicion to the Iowa Department of Human Services.
Abuse of Elderly or Disabled Adult: If we know, or have reasonable cause to suspect, that a vulnerable adult (disabled or elderly) has been or is being abused, neglected, or exploited, we are required by law to immediately report such knowledge or suspicion to the Iowa Department of Human Services.
Health Oversight: If a complaint is filed against me with the Iowa Department of Health on behalf of the Board of Psychology, the Department has the authority to subpoena confidential mental health information from me relevant to that complaint.
Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made for information about your diagnosis or treatment and the records thereof, such information is privileged under state law, and we will not release information without the written authorization of you or your legal representative, or a subpoena of which you have been properly notified and you have failed to inform us that you are opposing the subpoena or a court order. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. You will be informed in advance if this is the case.
Serious Threat to Health or Safety: When you present a clear and immediate probability of physical harm to yourself, to other individuals, or to society, we are required by law to communicate relevant information concerning this to the potential victim, appropriate family member, or law enforcement or other appropriate authorities.
Worker’s Compensation: If you file a worker's compensation claim, we must, upon request of your employer, the insurance carrier, an authorized qualified rehabilitation provider, or the attorney for the employer or insurance carrier, furnish your relevant records to those persons.
IV. CLIENT’S RIGHTS AND PROVIDER'S DUTIES
Right to Request Restrictions - You have the right to request restrictions on certain uses and disclosures of protected health information about you. You also have the right to request a limit on the medical information I disclose about you to someone who is involved in your care or the payment for your care. If you ask me to disclose information to another party, you may request that I limit the information I disclose. However, I am not required to agree to a restriction you request. To request restrictions, you must make your request in writing, and tell me: 1) what information you want to limit; 2) whether you want to limit my use, disclosure or both; and 3) to whom you want the limits to apply.
Right to Receive Confidential Communications by Alternative Means and at 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. You may also request that I contact you only at work, or that I do not leave voicemail messages.) To request alternative communication, you must make your request in writing, specifying how or where you wish to be contacted.
Right to an Accounting of Disclosures - 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 III of this Notice). On your written request, I will discuss with you the details of the accounting process.
Right to Inspect and Copy - In most cases, you have the right to inspect and copy your medical and billing records. To do this, you must submit your request in writing. If you request a copy of the information, I may charge a fee for costs of copying and mailing. I may deny your request to inspect and copy in some circumstances. I may refuse to provide you access to certain psychotherapy notes or to information compiled in reasonable anticipation of, or use in, a civil criminal, or administrative proceeding.
Right to Amend - If you feel that protected health information I have about you is incorrect or incomplete, you may ask me to amend the information. To request an amendment, your request must be made in writing, and submitted to me. In addition, you must provide a reason that supports your request. I may deny your request if you ask me to amend information that: 1) was not created by me; I will add your request to the information record; 2) is not part of the medical information kept by me; 3) is not part of the information which you would be permitted to inspect and copy; 4) is accurate and complete.
Right to a Copy of this Notice - You have the right to a paper copy of this notice. You may ask me to give you a copy of this notice at any time. Changes to this notice: I reserve the right to change my policies and/or to change this notice, and to make the changed notice effective for medical information I already have about you as well as any information I receive in the future. The notice will contain the effective date. A new copy will be given to you or posted in the waiting room. I will have copies of the current notice available on request.
Complaints: If you believe your privacy rights have been violated, you may file a complaint. To do this, you must submit your request in writing to my office. You may also send a written complaint to the U.S. Department of Health and Human Services.
We are required by law to maintain the privacy of PHI and to provide you with a notice of our legal duties and privacy practices with respect to PHI. We reserve the right to change the privacy policies and practices described in this notice. Unless we notify you of such changes, however, we are required to abide by the terms currently in effect. If we revise our policies and procedures, we will provide you with the revised policy in person or by mail at the address you provide.
This notice will go into effect on March 1, 2018. We reserve the right to change the privacy policies and practices described in this notice. Unless we notify you of such changes, however, we are required to abide by the terms currently in effect. If we revise our policies and procedures, you will be notified about those changes in your next office visit, by telephone communication, or by mail.
Patient’s Acknowledgment of Receipt of Notice of Privacy Practices
Please sign, print your name, and date this acknowledgment form.
I have been provided a copy of Evergreen Therapy Center’s “Notice of Privacy Practices.” We have discussed these policies, and I understand that I may ask questions about them at any time in the future. I consent to accept these policies as a condition of receiving mental health services.
This form gives Evergreen Therapy Center permission to text or email you about appointments and information regarding your care. If you do not wish to communicate by text or email, leave this form unsigned.
Please note that email and texting is a convenient form of communication, but it is not a secure form of communication and confidentiality cannot be absolutely guaranteed. If this is a concern, please call 319-853-8762.
I consent and give permission for my provider and other staff at Evergreen Therapy Center to communicate with me by email or text regarding various aspects of my care, which may include, but shall not be limited to, diagnoses, treatment plans, recommended interventions, appointments, and billing.
I understand that email and text messaging are not confidential methods of communication. I further understand that, because of this, there is a chance that email and text messages regarding my care might be read by someone else.
In signing my name below, I acknowledge that I am giving my informed consent to receive psychiatric treatment at Evergreen Therapy Center. Psychiatric treatment consists of diagnostic services and medication management. Should I desire psychotherapy only or I am not considering psychiatric medications, I should not agree to or attend this appointment.