Insurance Information

APPOINTMENTS  
In the event you cannot keep your appointment, 2 business days notice is required. If you miss your appointment or do not cancel 2 business days notice prior to your appointment, you will be charged a $75 fee (increasing by $25 each missed appointment or late cancellation to a max of the full fee per appointment). If you have an appointment on a Monday, you must cancel by Thursday to avoid a fee. For Monday appointments, if you cancel on Saturday or Sunday, you will be charged a late cancellation fee. If you have several standing appointments and you miss two sessions in a row without contacting the office, all future sessions will be cancelled without notice.  You are responsible for remembering your appointments.   

ARRIVAL TIME 
All patients should arrive prior to their appointment start time to confirm current information on file and pay any fees due.  Patients that do not arrive within 10 minutes of their scheduled appointment start time may have their appointment rescheduled and the late fee/no show fee will be assessed to their account.  

FINANCIAL RESPONSIBILITY 
The patient (or guardian) is ultimately responsible for payment of charges for services received from this practice, including those covered by insurance.  As a convenience, this practice will submit claims for reimbursement to your in-network insurance provider; however, all payment responsibility is ultimately the patient’s responsibility. All copays, coinsurance, and/or deductibles are due at time of service. If a minor child/dependent attends an appointment without parent and/or guardian present, payment must be received prior to the appointment.  All patients will be required to keep a valid credit card on file for payment of copays, coinsurance, deductibles, appointment fees not covered by insurance, no show fees, cancellation fees, and/or returned check fees.  See credit card policy for details. 

 

If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, BAPC may use legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require me to disclose otherwise confidential information. In most collection situations, the only information I release regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due.

PATIENT INFORMATION 
The patient is ultimately responsible for letting the office staff know of any change of information.  Please update any and all information as it arises. 

OFFICE HOURS AND PHONE CALLS 
Our office hours are 8:00 A.M. to 4:00 P.M. Monday through Thursday, and on Friday from 8:00 A.M. to 12:00 P.M.  We are closed for holidays and may have modified hours during holidays or staff shortages.  If you call our office and get a recording, please leave a voicemail or text the phone number, and your request will be responded to as soon as possible. For urgent situations, you should call the crisis line at 988.  In life threatening situations, you should go to the nearest emergency room for immediate care or call 911.   Due to your therapist's schedule, they are not immediately available by telephone. You may leave a message with the staff or text the main phone number. Additionally, we have a form you can update your therapist via. Please make it clear to the staff whether you are calling regarding an emergency or non-emergency situation. 

CONFIDENTIALITY 
Treatment information is usually only released after you have given permission by signing a release form.  There may be, however, certain times that the provider would be required by ethics and law to break the confidentiality.  Those situations would be (A) when there is an immediate threat of self-harm or harm to others, (B) when there is suspected or actual abuse and/or neglect of a child, the elderly, and/or an individual with disabilities, and (C) legal court orders to provide information. Additional instances in which confidential information can be released are discussed in our Notice to Patients Regarding Privacy of Health Information.  If such a situation arises, providers will make an effort to discuss it with you. 

With your signature below, you acknowledge that you have read, understand and agree to the above terms. Additionally, I have received, read, and agree with the office’s policies and practices regarding the privacy of my personal health information as described in the Notice to Patients Regarding Privacy of Health Information Practices with the notice of office policies and practices regarding the privacy of my personal health information. 

Bay Area Psychological Consultants is committed to meeting your mental healthcare needs and keeping your insurance and other financial arrangements as simple as possible.  Due to rising administrative costs, we require that ALL patients keep a debit/credit card on file. 

I agree to provide the above practice and/or its designated payment agent with my credit/debit card information. I am responsible for providing the practice with updated credit card information should my card become invalid for any reason.  
 

I authorize the following charges to my Visa, Mastercard, American Express or Discover Card for the following: 

• Late cancellation fees or no show fees.
• Coinsurance/copay/deductibles for services provided.
• The balance of fees denied by my insurance company or not paid by my insurance company within 60 days of date of service up to $250.  I will be contacted by the practice for all balances over $250 and will be responsible for making arrangements for payment of fees exceeding $250.
• Insufficient check amounts plus any insufficient check fees that may be occurred per bad check.  

I authorize Bay Area Psychological Consultants to charge the credit card indicated in this authorization form according to the terms outlined above. If the above noted payment dates fall on a weekend or holiday, I understand that the payments may be executed on the next business day. I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify the business in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. This payment authorization is for the type of bill indicated above. I certify that I am an authorized user of this credit card and that I will not dispute the scheduled payments with my credit card company provided the transactions correspond to the terms indicated in this authorization form.

Understanding Your Health Record & Information

Federal regulations developed under the Health Insurance Portability and Accountability Act (HIPAA) require that this Practice provide you with this Notice Regarding Privacy of Personal Health Information (PHI). A record of your visit is made each time you visit healthcare providers. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment. This information, often referred to as your health or medical record, serves as a:

· Basis for planning your care and treatment.

· Means of communication among other health professionals who contribute to your care.

· Legal documentation describing the care you receive.

· Means by which you or a third party payer can verify that services billed were actually provided.

· A 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 health information is used helps you:

· Ensure its accuracy.

· Better understand who, what, when, where, and why others may access your health information.

· Make more informed decisions when authorizing disclosure to others.

Our Responsibilities

This Practice is required to:

· Maintain the privacy of your health information.

· Provide you with a notice as to our legal duties and privacy practices with respect to information we collect and maintain about you.

· Abide by the terms of this notice.

· Notify you if we are unable to agree to a requested restriction.

· 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 the new provisions effective for all protected health information we maintain. Should our information practices change, we will inform you.We will not use or disclose your health information without your authorization, except as described in this notice.

Use & Disclosure of PHI in Treatment, Payment, & Health Care

Your Personal Health Information (PHI) may be used and disclosed by this Practice in the course of providing treatment, obtaining payment for treatment, and conducting healthcare operations. Disclosures may be in writing, electronically, by facsimile, or orally. Additionally, the Practice may also use your PHI to remind you of an appointment, inform you of potential treatment alternatives, and inform you of health-related benefits or services that may be of interest to you.

Other Uses or Disclosures Permitted Without Authorization

In addition to treatment, payment, and healthcare operations, this Practice may use or disclose your PHI without your permission or authorization in certain circumstances including:

· When legally required to comply with any federal, state, or local laws that involve disclosure of your PHI.

· When there are risks to public health as permitted or required by law such as for the purpose of preventing or controlling disease, injury, or disability.

· To report abuse, neglect, or domestic violence if it is believed that the patient or others in relationship with the patient is the victim.

· To conduct health oversight activities such as audits, or civil, administrative, or criminal investigations, proceedings, or actions.

· For judicial and administrative proceedings authorized by an order of a court or administrative tribunal.

· For specialized government functions if you have served as a member of the armed forces or in the Department of State and disclosure is requested by you or requested by US military command authorities.

· To deceased patients’ family members as mandated by state law or to a family member or friend that was involved in your care or payment for care prior to death, based on your prior consent.

· In medical emergencies in order to prevent serious harm.

· To close family members or friends directly involved in your treatment based on your consent or as necessary to prevent serious harm.

· For public safety if necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.

· For court proceedings you are involved in. Disclosure typically requires you (or your legal representative’s) written authorization, or a court order, or if a subpoena of which you have been properly notified and you have failed to inform BAPC that you oppose the subpoena. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order BAPC to disclose information.

· If a patient files a complaint or lawsuit against, BAPC may disclose relevant information regarding that patient in order to defend BAPC/the mental health professional.

· For a worker’s compensation claim, and BAPC provides necessary treatment related to that claim, BAPC must upon appropriate request, submit treatment reports to the appropriate parties, including the patient’s employer, the insurance carrier or an authorized qualified rehabilitation provider.

 

Additional Disclosures

The law protects the privacy of all communications between a patient and a provider. In most situations, BAPC can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance consent. Your signature on this Agreement provides consent for those activities, as follows:

• Consultation with other health and mental health professionals about a case. During a consultation, therapist  make every effort to avoid revealing the identity of the client. The other professionals are also legally bound to keep the information confidential. If you don’t object, I will not tell you about these consultations unless I feel that it is important to our work together. Consultations may be noted in your Clinical Record.

• This office has many mental health professionals and administrative staff. In most cases, protected information is shared for both clinical and administrative purposes, such as scheduling, billing and quality assurance. All of the mental health professionals and staff members have been given training about protecting your privacy and have agreed not to release any information outside of the practice without the permission of a professional staff member.

• BAPC has contracts with companies such as accountants, network administrator, data management software company, and insurance/billing clearinghouse. As required by HIPAA, BAPC has formal business associate contracts with this/these business (es), in which it/they promise to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law.

 

Your Health Information Rights

Although your health record is the physical property of the healthcare practitioner or facility that compiled it, the information belongs to you. You have the right to:

· Request a restriction on certain uses and disclosures of your information as provided by 45 CFR 164.522.

· Obtain a paper copy of the notice of information practices upon request.

· Inspect and copy your health record as provided for in 45 CFR 164.524.

· Amend your health record as provided in 45 CFR 164.528.

· Obtain an accounting of disclosures of your health information as provided in 45 CFR 164.528.

· Request communication of your health information by alternative means or at alternative locations.

· Revoke your authorization to use or disclose health information except to the extent that action has already been taken.

· Be notified if a breach of PHI occurs.

For More Information or to Report a Problem

If you have questions and would like additional information, you may contact the Privacy Officer at our office at the address listed above. If you believe your privacy rights have been violated, you can file a complaint with the Director of Health Information Management or with the Secretary of Health and Human Services. There will be no retaliation for filing a complaint.

With your signature below, you acknowledge that you have received, read, and agree with the office’s policies and practices regarding the privacy of my personal health information as described in the Notice to Patients Regarding Privacy of Health Information Practices with the notice of office policies and practices regarding the privacy of my personal health information.

I authorize Bay Area Psychological Consultants to provide notice to me by telephone or verbally in the event of a breach of my/my child's protected health information (PHI) by Bay Area Psychological Consultants. Such conversation will be documented by Bay Area Psychological Consultants.

Pursuant to the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Final Rule modifying the HIPAA Privacy, Security, Enforcement and Breach Notification Rules, the verbal or telephonic notice provided to me pursuant to this authorization shall not be simply for the administrative convenience of Bay Area Psychological Consultants.

Psychological Testing requires multiple visits to our office. Below is a description of the components of psychological testing and the different types of appointments. 

 

1) Intake - Duration Approximately 45 to 60 minutes:

During this visit your provider will review your current areas of concern and will also gather background information.  If for your child, please bring the child to the appointment. Please also bring the following to your first appointment:

1- A list of all current medications

2- School testing scores 

3- Reports from previous testing assessments or other appropriate medical records (if available)

At this appointment, the psychologist will determine what psychological tests and assessments to order based on your needs. Once this is determined we will be able to give you an accurate quote of the cost of your testing. 

 

2) Testing - Number of appointments and duration varies

For future appointments, psychological tests will be completed. These tests involve answering questions or performing tasks. These tests may be paper and pencil tests, computer based tests, or tests using other objects. These appointments may take anywhere from one hour to several hours.  The psychologist may also order forms for caregivers/teachers to complete. These may need to be done on paper or electronically and can be done outside of the office.  

 Please bring the following to your testing appointment:

1- Glasses and/or hearing aids

2- A sweater or light jacket (to be as comfortable as possible)

3- Snacks and/or a bag lunch (optional)

All tests ordered by the psychologist must be completed in order for the test results and final portion of the psychological assessment. 

 

3) Test Results - Approximately 30 to 60 minutes

During your final appointment, the provider will review your test results and recommendations.  If the patient that is undergoing testing is a minor, only a parent or guardian is required to attend this appointment (but the minor patient is invited to attend as well if appropriate). Results can be faxed with consent to your other treatment providers.  Test results may be delayed if ALL recommended testing is NOT completed prior to 2 weeks before the test results appointment. 

 

Welcome to Bay Area Psychological Consultants. Please take a few minutes to read through this informed consent form to understand more about counseling and get to learn more about the solutions that can address your concerns to get you back on track.

Although these documents are long and sometimes complex, it is very important that you read them carefully before our next session. We can discuss any questions you have about the procedures at that time. When you sign this document, it will also represent an agreement between us. You may revoke this Agreement in writing at any time. That revocation will be binding on me unless I have taken action in reliance on it; if there are obligations imposed on me by your health insurer in order to process or substantiate claims made under your policy; or if you have not satisfied any financial obligations you have incurred.

COUNSELING/PSYCHOTHERAPY

Counseling/psychotherapy is a process carried on between a professional psychologist or masters level clinician (mental health counselor, clinical social worker, or marriage and family therapist), known as counselor or therapist, acting to help a client seeking to learn more about himself or herself, exploring difficulties, and to understand the society that surrounds himself or herself in reaching defined positive goals for a better chance to become a productive member of society.

Psychotherapy varies depending on the personalities of the psychologist and patient and the particular problems you are experiencing. There are many different methods and frameworks a therapist may use to deal with the problems that you hope to address. Psychotherapy calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home. Psychotherapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. On the other hand, psychotherapy has also been shown to have many benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. But there are no guarantees of what you will experience. 

SESSIONS

The first few sessions will involve an evaluation of your needs. During this time, you decide with the therapist if the therapist is the best professional to provide the services that you need in order to meet your treatment goals.

By the end of the evaluation, the therapist will be able to offer first impressions and discuss a treatment plan and goals. The frequency of visits and types of sessions will be a part of this treatment plan. You should evaluate this information along with your own opinions of whether you feel comfortable working with the therapist. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about the therapist's procedures and modalities, please discuss them whenever they arise.

FEES. In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. Fees are charged on a per session basis. We may directly bill your insurance company by informing us of the details. Below are some of our most frequest charges and fees. 

Psychologists

First Session/Intake $250
Therapy Session (53 minutes +) $175
Psychological Testing - Varies based upon testing ordered (Estimated cost is typically $1500 to $2500)

Master's Level Clinicians (LMFT, LCSW, LMHC)

First Session/Intake $200
Therapy Session (53 minutes +) $150

No Show/Late Cancellation Fees

$75 for first and increases by $25 each additional no show/late visit

Administration Fees

Letters/Forms - $25 and up
Copies of Records - $1/page, first 25 pages and then $0.25/page after

Legal Fees -  Starting at $250 per hour for preparation and attendance

Phone calls over 10 minutes 

 

PROFESSIONAL RECORD

The laws and standards require providers keep Protected Health Information about you in your Clinical Record. The Clinical Record includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that are set for treatment, progress towards those goals, your medical and social history, your treatment history, any past treatment records received from other providers, reports of any professional consultations, your billing records. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, we recommend have them forwarded to another mental health professional. In most circumstances, I am allowed to charge a copying fee of $1.00 per page, up to $25.00, then $.25 per page thereafter (and for certain other expenses). BAPC may withhold copies of your records until payment of the records fees has been made. If your provider refuses your request for access to your records, you have a right of review, which the therapist will discuss with you upon request.

 

MINORS & PARENTS

Patients under 18 years of age who are not emancipated and their parents should be aware that the law may allow parents to examine their child’s treatment records. Children between 13 and 17 may independently consent to (and control access to the records of) diagnosis and treatment in a crisis situation. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, and parental involvement, is also essential, it is usually our policy to request an agreement with minors [13 and over] and their parents about access to information. This agreement provides that during treatment, the therapist will provide parents with only with general information about the progress of the treatment, and the patient’s attendance at scheduled sessions.  Before giving parents any information, the therapist will discuss the matter with the child, if possible, and do their best to handle any objections he/she may have. For the safety of your children, please do not leave children unattended in the waiting room. We are not responsible for any financial disputes or agreements between any absent parent and custodial parent. The parent whom signs consent for treatment will be financially responsible.

  

DUAL RELATIONSHIPS

Therapy never involves sexual or any other dual relationship that impairs your therapist's objectivity, clinical judgment or can be exploitative in nature. Your counselor will assess carefully before entering into a non-sexual and non-exploitative dual relationship with clients. It is important to realize that in some communities, particularly small towns, military bases, university campuses, church/religious
communities, multiple relationships are either unavoidable or expected. Your counselor will never acknowledge working with anyone without his/her written permission. Many clients have chosen their therapist because they knew him/her before they entered therapy with him/her, and/or are personally aware of his/her quality of work for their level of service. Nevertheless, your therapist will discuss with you the often-existing complexities, potential benefits and difficulties that may be involved in dual or multiple relationships. Dual or multiple relationships can enhance trust and therapeutic effectiveness but can also detract from it and often it is impossible to know which ahead of time. It is your responsibility to advise your therapist if the dual or multiple relationships become uncomfortable for you in any way. Your therapist will always listen carefully and respond to your feedback and will discontinue the dual relationship if she/he finds it interfering with the effectiveness of the therapy/counseling or your welfare and, of course, you can do the same at any time.

SOCIAL MEDIA

As a policy of the Center therapists do not accept friend requests from current or former clients on social networking sites, such as Facebook. Adding clients as friends on these sites and/or communicating via such sites is likely to compromise their privacy and confidentiality. For this same reason, clients shouldnot communicate with therapist on any interactive or social networking websites

Introduction

Teletherapy is the delivery of psychotherapy services using interactive audio and visual electronic systems, when you (the patient) and the behavioral services provider are not in the same physical location. You (the patient) must still be located in the state in which the provider is licensed. 

Privacy/Confidentiality

1. We have carefully selected a video-conferencing platform, called doxy.me, which incorporates state-of-the-art security protocols, such as encryption, to protect the confidentiality of your audio and visual data (e.g.: video-stream, contact info 2. You can find more information about Zoom at doxy.me. 3. Doxy.me meets the legal (HIPAA) requirements for confidentiality. We also follow all other necessary record-keeping protocols, as usual, to meet HIPAA requirements.

Benefits of Teletherapy

1. Teletherapy improves access to care: a. It can enable you to be seen by a provider at your usual healthcare office when the provider is at a different location b. It can enable you to be seen by a provider when you are not able to leave your home due to medical illness, mobility issues, or other unavoidable circumstance. However, you must still be physically present in the state which services are typically rendered. 2. Teletherapy allows for more timely and/or efficient evaluation and treatment. 3. Teletherapy facilitates obtaining the expertise of a distant specialist.

Possible Risks

As with any procedure, there are potential risks associated with the use of teletherapy. These risks include, but may not be limited to: a. In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate treatment by the provider. b. Delays in evaluation and treatment could occur due to deficiencies or failures of the equipment. c. In very rare instances, security protocols could fail, causing a breach of privacy of personal health information. d. Misunderstandings can happen even when meeting in person. But the more limited the information (e.g.: as when not meeting in person) the higher the likelihood of misunderstanding or missing some cues.

Necessary Equipment

1. You would need a device through which to conduct teletherapy – which includes a screen, microphone, video-camera, and speaker. a. This can be done by PC, Mac, iOS, or Android; on a computer, laptop, tablet or smart phone. b. You may utilize a device for a screen and have audio through an audio line synchronously. 2. Larger stationary screens and high-definition cameras are recommended. 3. Access to your personal email address and/or cell phone number which was provided to the office. You will typically receive the appropriate links and access instructions for teletherapy via text message.

My Rights:

• I understand that the laws that protect the privacy and confidentiality of health information also apply to teletherapy.
• I understand that the teletherapy platform used by Bay Area Psychological Consultants is encrypted to prevent the unauthorized access to my private health information.
• I have the right to withhold or withdraw my consent to the use of teletherapy during the course of my care at any time. I understand that my withdrawal of consent will not affect any future care or treatment, other than stopping teletherapy. I also understand that my Bay Area Psychological Consultants provider has the right to withhold or withdraw his/her consent for the use of teletherapy during the course of my care at any time.
• I understand that all rules and regulations which apply to the practice of psychology or mental health counseling or clinical social work in the state of Florida also apply to teletherapy.

Communication With My Insurance Company:

• I understand that I have already authorized Bay Area Psychological Consultants to communicate with my insurance company when I signed the new patient paperwork.
• I understand that teletherapy may not be covered by my insurance company, and I am responsible for services not covered by my insurance company.
• If my insurance company asks for proof of medical necessity or visit, I understand and consent that my provider may submit to my insurance company:
  • A letter explaining why teletherapy is necessary
  • Copies of intake, encounter notes, review of progress

My Responsibilities:

• I will not record any teletherapy sessions without written consent from my Bay Area Psychological Consultants provider. I also understand that all Bay Area Psychological Consultants providers will not record any of our teletherapy sessions without my prior additional written consent.
• I will inform my Bay Area Psychological Consultants provider if any other person can hear or see any part of our session before the session begins.  My Bay Area Psychological Consultants provider will inform me if any other person can hear or see any part of our session before the session begins.
• I understand that I must first be a patient of a Bay Area Psychological Consultants provider to be eligible for teletherapy services from my Bay Area Psychological Consultants provider.
  • In other words, I understand that I need to meet with a Bay Area Psychological Consultants provider at least once in person, in order to be eligible for teletherapy services from that provider.
• I agree to contact emergency personnel (911) on the recommendation of my Bay Area Psychological Consultants provider should my condition place my own health, or the health of another, at risk.
• I understand that I must disclose my physical location to my Bay Area Psychological Consultants provider at the beginning of our teletherapy session for both billing and safety reasons.

Communication Via Email and Text Message:

The email address that I authorize Bay Area Psychological Consultants and my provider to use for guidelines on accessing the teletherapy session is as written below.

Treatment of Minors/Persons with Guardianship:

For a minor or person with a legal guardian, consent for telehealth must be provided by a legal guardian. For the first session conducted via teletherapy, a guardian must be present for the first part of the session. For future sessions, a guardian is not required to be present.

Patient Consent to the Use of Teletherapy:

I have read and understand the information provided above regarding teletherapy, have discussed it with my Bay Area Psychological Consultants provider, and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of teletherapy in my care and authorize Bay Area Psychological Consultants to use teletherapy in the course of my assessment and treatment.

I understand that completion of this form does not guarantee that I will have the ability to have appointments with my provider via teletherapy.  Each patient will be considered for teletherapy on a case by case basis by their provider.

By completing these forms, this is NOT a guarantee of being accepted as a patient of Bay Area Psychological Consultants.  All data submitted will be carefully reviewed by our team.  You will be contacted within 5 business days to confirm or decline availablity of services.  If you have not been contacted within 5 business days, please feel free to reach out to us at 850-729-0303 within business hours.