Thank you for choosing HWS BEST HEALTH, LLC. This document contains important information about our professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and client rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations. HIPAA requires that we provide you with a Notice of Privacy Practices (the Notice) for the use and disclosure of PHI for treatment, payment, and health operations. The notice, which is available at each office or can be viewed online at www.cdc.gov/phlp/publications/topic/hipaa.html explains HIPAA and its application to your personal health information in greater details. The law requires that we obtain your signature acknowledgment that we have provided you with this information. Although these documents are long and complex, it is important that you read them carefully and that you ask questions you have about the procedures or treatments at any time. When you sign the document, it will also represent an agreement between us unless we have taken action in reliance on it; if there are obligations imposed on us by your health insurer in order to process or substantiate claims made under your policy; of if you have not satisfied any financial obligations you have incurred. If you have any questions or concerns, please feel free to discuss them with us.
SERVICES OFFERED
We will provide services specifically designed to help you, or otherwise provide you with referrals to other professionals. Our clinical and behavioral services consist primarily of individual assessments, individual/group/family counseling for mental health and case management (CPST/TBS) I am hereby authorizing HWS BEST HEALTH, LLC to provide any assessment and treatment (Consent for Treatment).
APPOINTMENTS
Except for rare emergencies, we will see you (or your child) at the scheduled time. We understand that circumstances (such as an illness or family emergency) may arise which necessitate the occasional cancellation of appointments. In these cases, in order to avoid any misunderstanding, we ask that you speak with us personally and give us as much notice as possible to cancel or reschedule. This will allow us to offer your time to another person.
CONFIDENTIALITY, RECORDS, AND RELEASE OF INFORMATION
Psychological services are best provided in an atmosphere of trust. Because trust is so important, all services are confidential except to the extent that you provide us with written authorization to release specified information to specific individuals, or under other conditions and as mandated by Ohio and Federal law and our professional codes of conduct/ethics.
TO PROTECT THE CLIENT OR OTHERS FROM HARM
If we have reason to suspect that a minor, elderly, or disabled person is being abused, we are required to report this (and any additional information upon request) to the appropriate state agency. If we believe that a client is threatening serious harm to him/herself or others, we are required to take protective actions which could include the police, an intended victim, a minor’s parent(s), or others who could provide protection, or seek appropriate hospitalization.
PROFESSIONAL CONSULTATIONS
Counselors routinely consult about cases with other professionals. In so doing, we make every effort to avoid revealing the identity of our clients, and any consulting professionals are also required to refrain from disclosing any information we reveal to them. Unless you object, we do not typically tell clients about these consultations; however, these consultations will be so noted in your Private Health Information. If you want us to talk with or release specific information to other professionals with whom you are working, you will first need to sign an Authorization that specifies what information can be released and with whom it can be shared.
SUPERVISION NOTIFICATION
HWS BEST HEALTH, LLC believes in providing training opportunities for new professionals in the field, from accredited colleges and universities with the highest level of academic standards. At times, your clinician may be under the supervision of another clinician, and you will be notified of this upon intake. This means that your counselor may review your case with the supervisor, or any other supervising licensed professional at or contracted with HWS BEST HEALTH, LLC. You have the right to meet with the supervisor at any given time, and all guidelines for the protection of your Protected Health Information apply. In addition, since we are a training facility, your clinician may, at times, ask for verbal permission for a supervisee to shadow your session, at which time you can grant or deny consent. If you deny consent, this does not impact your access to services and it’s an integral part of your client rights. This serves as written consent for permission for observation. My clinician is under supervision.
PAYMENT FOR SERVICES
If you have a question or objection to fees assessed, objections or inquiries must be made within 60 days of receipt of the relevant invoice in order to allow review and consideration. Inquiries regarding invoices over 60 days will be deemed untimely and payment will be expected for services. Insurance claims are sent electronically as necessary. In addition, we may seek assistance from an outside party in order to collect payment for services. In such cases, any disclosures are limited to the minimum that is necessary to achieve the purpose. The laws and professional standards governing these issues are quite complex, and it is important that we discuss any questions or concerns that you (or your minor child) may have at our first meeting, and as they may arise in the course of our work together. If any of these types of situations arise, we will make every effort to fully discuss it with you before taking any action, and we will limit disclosure of any information to what is necessary. We are not attorneys, however, and you may wish to obtain formal legal consultation if you need specific advice.
HEALTH CARE INSURANCE
If we do not file your insurance claim at this time, we will provide you with statements that you may submit to your insurance carrier or complete forms as required by your insurance carrier in order to obtain reimbursement for out-of-network providers. In order to assist you with obtaining reimbursement for our services, your insurance carrier may require that we provide a clinical diagnosis, or additional clinical information such as treatment plans, or copies of your Medical Record. In such situations, we will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Although all insurance companies claim to keep such information confidential, we have no control over what they do with it once they possess this information. By signing this Agreement, you agree that we can provide requested information to your insurance carrier if you choose to file a claim for any services provided. You may request that we do not submit any claims for services provided to your insurance carrier. In this situation, you agree to pay in full for all services rendered and acknowledge that you are financially responsible for any expenses incurred. Payment for such service is required when services are rendered.
PROFESSIONAL RECORDS
You need to be aware that HWS BEST HEALTH, LLC keeps clients’ Protected Health Information in our professional records. This information includes, but not limited to: reasons for seeking our professional services; the impact of any current or on-going problems on concerns; assessment, consultative, or therapeutic goals; progress towards those goals, a medical, developmental, educational, and social history; treatment history; and treatment records that we receive from other providers; reports of any professional consultations; billing records; releases; and any reports that have been sent to anyone, including statements for your insurance carrier and the billing service agency we utilize. Except in unusual circumstances that involve danger to yourself or others, or makes reference to another person (unless such person is a health care provider) and we believe that access is reasonability likely to cause substantial harm to such other person, you or your legal representative may examine and/or receive a copy of your Clinical Record, if you request it in writing. We encourage you to discuss your Clinical Record information with your provider at HWS BEST HEALTH, LLC.
PATIENT RIGHTS
HIPAA provides you with several rights regarding your Clinical Record and disclosures of protected health information. These rights include requesting that we amend your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized.; determining the location to which protected information disclosures are sent; having any complaints you make about our policies and procedures recorded in your records; and the right to a paper copy of the Agreement and our privacy policies and procedures. We are happy to discuss any of these rights with you.
GRIEVANCE POLICY
All clients have the right to file a grievance about the services, or any employee or contractor affiliated with HWS BEST HEALTH, LLC. Clients are provided a copy of the grievance policy for review and additional copies can be provided at the office. All grievances are to be forwarded to the client rights advocate, Jeffrey Bonchek, at 760-310-3611. Given our many professional commitments, we are often not immediately available by telephone. If you need to leave us a message, we will make every effort to return your call promptly (within 24 to 48 hrs with the exception of holidays and weekends). Because of the nature of the services we provide, we do not provide on-call coverage 24 hrs per day, 7 days per week. In emergency or crisis situations, please contact your physician, or call 911 and/or go to the nearest hospital emergency room. Please be advised that due to issues of confidentiality, HWS BEST HEALTH, LLC and its staff and/or agents will not correspond about specific clients via unsecure email or other electronic communication methods outside of our Electronic Health Records system.
CONSENT
Your signature(s) below indicates that you have read the information in this document and agree to be bound by its terms, and that you have received the HIPAA notice form described above or have been offered a copy and declined. Consent by all parents/legal guardians is required.
FINANCIAL AGREEMENT
We are committed to providing you with the best possible care. If you have medical insurance, we are ready to help you receive your maximum allowable benefits. In order to achieve these goals, we need your assistance, and your understanding of our payment policy or Financial Agreement. Payments for services are due at the time services are rendered unless payment arrangements have been approved in advance by our staff. We accept cash, checks, credit or debit cards (through the client portal), and Venmo. We will be happy to help you process your insurance claim form for your reimbursement. You may also elect not to have your claim submitted to your insurance carrier; however, you will be 100% responsible for the fee for services rendered which is payable when the services are rendered. If you elect to have your claim submitted to your insurance carriers, in most instances we may accept the assignment of insurance benefits. It is your responsibility to verify if HWS BEST HEALTH, LLC is a “participating provider” under your insurance plan. HWS BEST HEALTH, LLC will process your insurance claims and invoice any remaining balances owed. The billing agency must also comply with HIPAA regulations. Returned checks (with additional fees applied of $45 for every occurrence) and balances older than 30 days may be subject to additional collection fees and interest charges of 1 ½% per month (or 18% per year). We will gladly discuss your proposed treatment and answer any questions relating to your insurance. You must realize, however, that:
- Your insurance traditionally does not cover expenses for completing forms, making copies, phone calls exceeding five (5) minutes, and other professional services such as special reports, forms, court time, etc. You acknowledge that you are 100% financially responsible for these services. Fees for these services and others vary and will be discussed with you upon request of such services.
- Your insurance is a contract between you, your employer, and the insurance company. We are not a party to that contract.
- Our fees are generally considered to fall within the acceptable range by most companies, and therefore, are covered up to the maximum allowance determined by each carrier. This applies only to companies who pay a percentage (such as 50% or 80%), of UCR. UCR is defined as usual, customary, and reasonable fees for this region. Thus, most companies consider our fees as usual, customary, and reasonable. This statement does not apply to companies who reimburse based on an arbitrary “schedule” of fees, which bears no relationship to the current standard and cost of care in this area.
- You also understand that your insurance claims may be sent to an outside billing agency. All insurance and patient payments will be directed to HWS BEST HEALTH, LLC only. The billing agency will direct your insurance claim to your insurance company electronically (if available), where it will be reviewed by the insurance staff assigned to review claims. You also understand that your insurance company will obtain the information listed on the insurance claim about your diagnoses and the dates of your mental health treatment sessions. By signing below, and as recorded on the HIPAA consent form, you are giving HWS BEST HEALTH, LLC, and its agents, permission to release all data necessary to your insurance company to determine eligibility and to process your insurance claim electronically, if available. You realize that your insurance company may choose to make this information available to other entities, including other insurance companies. Furthermore, you authorize payment of the mental health/chemical dependency benefits be payable to HWS BEST HEALTH, LLC. You acknowledge signing the HIPAA acknowledgment form and understand your rights and rules regarding the release of Protected Health Information. We also acknowledge that you may discuss any of these confidentiality matters with the Privacy Officer, Lauri Pierce, and any questions regarding the confidentiality of records, the complaint procedure, or other matters pertaining to your review of your Medical Record.
- Clients with commercial or private insurance (not Medicaid or Medicare) are subject to a $45.00 missed appointment fee. Appointments must be canceled or rescheduled no later than 48 hours prior to the scheduled appointment time. Missed appointment fees will automatically be charged to the payment method on file.
- All co-payments and deductibles must be paid at the time of service. This arrangement is part of your contract with your insurance company. Failure on our part to collect co-payments and deductibles from patients can be considered fraud. Please help us in upholding the law by paying your co-payment at each visit. You are responsible for all “non-covered services”, co-pays, deductibles, etc. as indicated by your insurance plan. These amounts must be collected and not waived per your insurance plan requirements.
- Not all services are covered benefits in all contracts. Some insurance companies arbitrarily select certain services they will not cover. We must emphasize that as mental health providers, our relationship is with you, not your insurance company. While the filing of insurance claims is a courtesy that we extend to our patients, all charges are your responsibility from the date services are rendered. We realize that temporary financial problems may affect the timely payment of your account. If such problems do arise, we encourage you to contact us promptly for assistance in the management of your account. If you have any questions about the above information or any uncertainty regarding your insurance coverage, PLEASE don’t hesitate to ask us. We are here to help. THANK YOU.
Being the authorized cardholder, by signing above I understand and agree to the terms set forth in this agreement, agree to pay, and specifically authorize to charge my credit card for the services provided. I further agree that in the event my credit card becomes invalid, I will provide a new valid credit card upon request, to be charged for the payment of any outstanding balances owed.
Payments made for services provided by HWS Best Health, LLC are non-refundable.
The practice may utilize my payment methods on file for any balances, including late cancellation and no-show fees, without additional authorization.
NOTICE OF HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT ACKNOWLEDGEMENT FORM
I hereby acknowledge that I was given or made available to me the Health Insurance Portability and Accountability Act (HIPAA) and can access an electronic copy of the Health Insurance Portability and Accountability Act at the office or at: www.cdc.gov/phlp/publications/topic/hipaa.html CLIENT BILL OF RIGHTS As a person receiving services, you have the right to:
(1) The right to be treated with consideration and respect for personal dignity, autonomy and privacy;
(2) The right to reasonable protection from physical, sexual or emotional abuse, neglect, and inhumane treatment;
(3) The right to receive services in the least restrictive, feasible environment;
(4) The right to participate in any appropriate and available service that is consistent with an individual service plan (ISP), regardless of the refusal of any other service, unless that service is a necessity for clear treatment reasons and requires the person's participation;
(5) The right to give informed consent to or to refuse any service, treatment or therapy, including medication absent an emergency;
(6) The right to participate in the development, review and revision of one's own individualized treatment plan and receive a copy of it;
(7) The right to freedom from unnecessary or excessive medication, and to be free from restraint or seclusion unless there is immediate risk of physical harm to self or others;
(8) The right to be informed and the right to refuse any unusual or hazardous treatment procedures;
(9) The right to be advised and the right to refuse observation by others and by techniques such as one-way vision mirrors, tape recorders, video recorders, television, movies, photographs or other audio and visual technology. This right does not prohibit an organization from using closed-circuit monitoring to 5122-26-18 3 observe seclusion rooms or common areas, which does not include bathrooms or sleeping areas;
(10) The right to confidentiality of communications and personal identifying information within the limitations and requirements for disclosure of client information under state and federal laws and regulations;
(11) The right to have access to one's own client record unless access to certain information is restricted for clear treatment reasons. If access is restricted, the treatment plan shall include the reason for the restriction, a goal to remove the restriction, and the treatment being offered to remove the restriction; (12) The right to be informed a reasonable amount of time in advance of the reason for terminating participation in a service, and to be provided a referral, unless the service is unavailable or not necessary;
(13) The right to be informed of the reason for denial of a service;
(14) The right not to be discriminated against for receiving services on the basis of race, ethnicity, age, color, religion, gender, national origin, sexual orientation, physical or mental handicap, developmental disability, genetic information, human immunodeficiency virus status, or in any manner prohibited by local, state or federal laws;
(15) The right to know the cost of services;
(16) The right to be verbally informed of all client rights, and to receive a written copy upon request; 6 (17) The right to exercise one's own rights without reprisal, except that no right extends so far as to supersede health and safety considerations;
(18) The right to file a grievance;
(19) The right to have oral and written instructions concerning the procedure for filing a grievance, and to assistance in filing a grievance if requested;
(20) The right to be informed of one's own condition; and,
(21) The right to consult with an independent treatment specialist or legal counsel at one's own expense.
NOTICE OF RIGHTS ACKNOWLEDGEMENT FORM
I hereby acknowledge that I was given or made available to me my Rights.
RISKS AND BENEFITS OF THERAPY
People decide to start therapy for a wide variety of reasons. Whatever the reason, though, it usually boils down to wanting better – or at least wanting to feel better. Therapy can be very effective in helping people accomplish just that. Therapy can be a place to learn about yourself, to gain perspective, and to learn new ways of thinking about and interacting with the world. Because of this, therapy isn’t generally thought of as a “risky” kind of thing to do. Even though it’s much more likely that therapy will be beneficial, it does bring about a certain amount of risk that should be considered – if for no other reason than to understand that it might not be easy. I’ll first outline what a few of those risks are and then close with the benefits (that I think highly outweigh the potential of any risks involved).
Risks:
1 – Therapy can sometimes make you feel worse (initially) – the therapy process often involves discussing events from your past or other things in your life that are difficult to talk about. This can bring up unwanted feelings and emotional pain that may linger beyond the therapy session and into your week. On top of that, digging deep into emotional issues and painful memories can bring up things you’ve forgotten about and would rather not think about. The good news is that the discomfort involved often means that some real healing is taking place. Emotional pain sometimes gets worse before it gets better.
2 – Therapy can promote change. You might be wondering why this is considered potentially risky. Let me explain. Therapy often promotes personal development and positive changes that impact all areas of life. As we grow and change, relationships change. We make moves and do things differently. Although the goal is for improved functioning and healthier relationships, this change can bring about resistance from others. Decisions made during the therapy process might mean having to make hard decisions about your career, friendships, and intimate relationships. Change – even good change – can be difficult and bring about a whole new set of challenges to work through.
3 – As you begin the process of self-discovery, you might not always like what you find. Learning about yourself can be hard. As you take a self-inventory, explore strengths/weaknesses, and take accountability for who you are as a human being, you sometimes gain insights that are difficult to accept. The positive in all of this is that the difficult insights gained are necessary for understanding oneself and what needs to be done to make appropriate changes.
4 – You might hear things you don’t want to hear. An important element of therapy, at least in my opinion, is that of honesty. Just as honesty is important for the role of the client, it is important for the Therapist to be honest about observations (and questions they are asked) in order to help one grow. This might mean being challenged and having to hear things that bring up a certain level of discomfort and resistance.
5 – You might not find the right Therapist right away. One of the things I emphasize regularly in my blogs is the crucial importance of finding the right Therapist – one that you feel comfortable with and that has an approach (and the knowledge) to competently deal with the issues you are wanting to resolve. Although there’s a lot we can do to improve the chances of finding the right therapist before we make an initial appointment, we don’t always know for sure if we’ve found the right fit until after the first couple of sessions. By then, you may have already shared a lot about yourself and your story. It can be daunting to think about having to start all over again. This, unfortunately, prevents some people from going back to therapy. You can read more here about how to find the best Therapist for you.
6 – You might REALLY like your therapist. It’s important that you like the person you’re working with, that you can relate to them on some basic levels, and that you feel comfortable with them. What’s the problem with liking your therapist, you might ask? Well, through the process of therapy, you build a kind of unique relationship with your therapist that may be unlike any other relationship in your life. You might share about yourself at depths you haven’t with anybody else in your life and build a sort of lasting connection. Because resolving issues that eventually lead to the end of therapy is typically the goal, this means that at some point the relationship will probably end. For some people, this brings about a sense of loss. Fortunately, as you prepare to end the process of therapy, this is something that can be discussed and gradually prepared for.
Benefits:
• Improved mood
• Increased Self-Esteem and Confidence
• Better relationships
• Increased ability to achieve goals
• New and improved perspectives and ways of thinking about the world
• Increased ability to deal with stress
• Resolution of past issues
• Greater self-awareness
• Improved health
• Cathartic Relief by having a neutral person to talk to
• Decreased anxiety and depression
• Increased sense of meaning, purpose, and fulfillment
• Improved ways of coping with life’s difficulties
• Better sleep
• Increase in good habits and decrease in bad habits
• Resolution of shame, guilt, and regret
• Potential to conquer fears
• Higher career satisfaction
• Increased assertiveness
• Better ability to manage anger in a healthy way I hereby acknowledge that I was made aware of the potential risks and benefits of therapy and the risks/benefits listed are by no means an “all-inclusive” list.
TELEHEALTH SERVICES INFORMED CONSENT
What is Telehealth? “Telehealth” means, in short, a provision of mental health services with the provider and recipient of services being in separate locations, and the services being delivered over electronic software. Services delivered via telehealth rely on a number of electronic, often Internet-based, technology tools. These tools can include videoconferencing software, email, text messaging, virtual environments, and specialized mobile health (“mHealth”) apps. HWS BEST HEALTH, LLC provides telehealth services through doxy or Zoom business. The modality used will be documented in each note. You will need access to internet service, and will be sent a direct link to enter our virtual “waiting room.” If you have any questions or concerns about the above tools, please address them directly to your provider so you can discuss their risks, benefits, and specific application to your treatment.
Benefits of receiving services via telehealth:
• Receive services at times or in places where the service may not otherwise be available.
• Receive services in a fashion that may be more convenient and less prone to delays than in-person meetings.
• Receive services when you are unable to travel to the service provider’s office.
• The unique characteristics of telehealth media may also help some people make improved progress on health goals that may not have been otherwise achievable without telehealth.
Risks of receiving services via telehealth:
• Telehealth services can be impacted by technical failures, may introduce risks to your privacy, and may reduce your service provider’s ability to directly intervene in crises or emergencies. Here is a non-exhaustive list of examples: Internet connections and cloud services could cease working or become too unstable to use Cloud-based service personnel, IT assistants, and malicious actors (“hackers”) may have the ability to access your private information that is transmitted or stored in the process of telehealth-based service delivery.
• Computer or smartphone hardware can have sudden failures or run out of power, or local power services can go out. Interruptions may disrupt services at important moments, and your provider may be unable to reach you quickly or using the most effective tools. Your provider may also be unable to help you in person. There may be additional benefits and risks to telehealth services that arise from the lack of in-person contact or presence, the distance between you and your provider at the time of service, and the technological tools used to deliver services. Your provider will assess these potential benefits and risks, sometimes in collaboration with you, as your relationship progresses. Assessing Telehealth’s Fit For You Although it is well validated by research, service delivery via telehealth is not a good fit for every person. Your provider will continuously assess if working via telehealth is appropriate for your case. If it is not appropriate, your provider will help you find in [1] person providers with whom to continue services. Please talk to your provider if you find the telehealth media so difficult to use that it distracts from the services being provided, if the medium causes trouble focusing on your services, or if there are any other reasons why the telehealth medium seems to be causing problems in receiving services. Raising your questions or concerns will not, by itself, result in the termination of services. Bringing your concerns to your provider is often a part of the process. You also have a right to stop receiving services by telehealth at any time without prejudice. If your provider also provides services in person and you are reasonably able to access the provider’s in-person services, you will not be prevented from accessing those services if you choose to stop using telehealth. Your Telehealth Environment You will be responsible for creating a safe and confidential space during sessions. You should use a space that is free of other people. It should also be difficult or impossible for people outside the space to see or hear your interactions with your provider during the session. If you are unsure of how to do this, please ask your provider for assistance. For additional information on how to get your space and technology set up before your first session, please visit https://personcenteredtech.com/tmh/clients/ Our Communication Plan At our first session, we will develop a plan for backup communications in case of technology failures and a plan for responding to emergencies and mental health crises. In addition to those plans, your provider has the following policies regarding communications:
• The best way to contact your provider between sessions is via phone. Your provider will respond to your messages with 24-hours or the next business day. Please note that your provider may not respond at all on weekends or holidays. Your provider may also respond sooner than stated in this policy. That does not mean they will always respond that quickly. Our work is done primarily during our appointed sessions, which will generally occur during 8am – 5pm.
• Contact between sessions should be limited to pertinent information that cannot wait until your next session.
• Confirming or changing appointment times or billing questions are to be addressed with the administrative staff.
• Please note that all textual messages you exchange with your provider, e.g. emails and text messages, will become a part of your health record.
• Your provider may coordinate care with one or more of your other providers. Your provider will use reasonable care to ensure that those communications are secure and that they safeguard your privacy. Your Security and Privacy Except where otherwise noted, your provider employs software and hardware tools that adhere to security best practices and applicable legal standards for the purposes of protecting your privacy and ensuring that records of your healthcare services are not lost or damaged. As with all things in telehealth, however, you also have a role to play in maintaining your security. Please use reasonable security protocols to protect the privacy of your own healthcare information. For example: when communicating with your provider, use devices and service accounts that are protected by unique passwords that only you know. Also, use the secure tools that your provider has supplied for communications. Recordings Please do not record video or audio sessions without your provider’s consent. Making recordings can quickly and easily compromise your privacy, and should not be done so. Our Safety and Emergency Plan As a recipient of telehealth-based services, you will need to participate in ensuring your safety during mental health crises, medical emergencies, and sessions that you have with your provider. Your provider will require you to designate an emergency contact and provide permission to communicate with this person about your care during emergencies, which you were requested to do upon intake. Your provider will also develop with you a plan for what to do during mental health crises and emergencies and a plan for how to keep your space safe during sessions. If you need additional mental health services, please dial 211 or text 4HOPE to 741741 or if you are having an emergency or crisis, please dial 911 or go to your nearest emergency room.