Welcome to Heart and Solutions, LLC: A Strength Based Counseling Agency. 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 patient rights about the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. Although these documents are long and sometimes complex, it is very important that you understand them. When you sign this document, it will represent an agreement between us. We can discuss any questions you have when you sign or at any time in the future. 

Therapy and BHIS counseling are built on a relationship between people that works, in part, because of clearly defined rights and responsibilities of each person.  As a client in therapy or BHIS counseling, you have certain rights and responsibilities that are important for you to understand.  There are also legal limitations to those rights that you should be aware of.   This agency and your provider have corresponding responsibilities to you as well.  These rights and responsibilities are described in the following sections.

Therapy and BHIS counseling has both benefits and risks.  During the therapy or BHIS process, you may experience uncomfortable feelings such as sadness, guilt, anxiety, anger, frustration, loneliness, and helplessness.  The process of therapy or BHIS often requires discussing the unpleasant aspects of your life, and these feelings can occur as a result.  Even though there are risks, therapy or BHIS has been shown to have benefits for many individuals who undertake it.  Therapy or BHIS can lead to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress, and resolutions to specific problems.  There are no guarantees about the specific outcomes.  Therapy and BHIS require a very active effort on your part.  In order to be most successful, you need to work on things we discuss outside of the therapy or BHIS sessions.

The first 2-4 sessions will involve a comprehensive evaluation of your specific needs.  At the end of the evaluation, your therapist will be able to offer initial impressions of what your work might include.  Then you will discuss treatment goals and create a treatment plan.  You should evaluate this information and make your own assessment about whether you feel comfortable working with your therapist.  If you have questions about procedures, please discuss them with your therapist as they arise.  If your doubts persist, we will help you set up a meeting with another mental health professional upon request.

Heart and Solutions, LLC has a legal and ethical obligation to obtain your informed consent before initiating services with a Heart and Solutions graduate counseling internship student. 

The student intern  is completing an internship  through their university under the supervision of a faculty member. While completing internship hours at Heart and Solutions, the internship student will also be under the supervision of their Heart and Solutions supervisor who will provide weekly supervision and case consultation. Additionally, the internship student will receive on-site mentoring from Heart and Solutions’ staff and all clinical documentation completed by the internship student will be reviewed by Heart and Solutions. 

If you have any questions or concerns, please feel free to contact Heart and Solutions at 1-800-531-4236.

Therapy appointments will generally be 54-60 minutes in duration, once per week at a time we agree on.  Some sessions may be more or less frequent as needed based on your individual needs.  Therapy appointments may be scheduled for 38-45 minutes based on insurance coverage, school schedule, or developmental abilities of the client.  Behavioral Health Intervention sessions are one hour of individual session and one hour of family session per week.  If more than two children in the same household participate in BHIS services, they may have less family time per child.

 The time scheduled for your appointments is assigned to you and you alone.  If you need to cancel or reschedule a session, we ask that you provide us with 24 hours’ notice.  If it is possible, your therapist will try to find another time to reschedule the appointment.  In addition, you are responsible for coming to your session on time; if you are late, your appointment will still need to end on time.  Heart and Solutions team members reserve the right to end a session, phone call, or services if they feel unsafe in any way.

Unless otherwise prohibited by law, you are allowed to cancel your appointment with less than 24-hour notice (“late cancel”) or miss your appointment (“no show”) only once before Heart and Solutions reserves the right to charge a fee of $20.00 for subsequent “late cancels” and “no shows”. This fee will be billed to the patient. This fee is not covered by insurance and must be paid prior to your next appointment.

If you do not attend your scheduled session and provide no notice three times within a three-month period, you will be placed on standby status.  Standby status means that you will only be able to schedule with your provider for a session to occur within 24 hours.  If you are on standby status and you “no-show” or cancel, you will be discharged and referred to another provider for services.  You may contact us to resume services after three months.  You are able to return to good standing by completing three consecutive sessions while on standby status.

• Letter writing fee to you or to any outside entity on your behalf: $35.00 per letter
• Returned Ceck Fee: $25.00
• Appearance in court after being subpoenaed: $200.00 per hour
• Preparation time for subpoena (including phone calls with attorney): $200.00 per hour
• Travel time to court if subpoenaed: $200.00 per hour

If you anticipate becoming involved in a court case, we recommend that you discuss this fully with your provider before you waive your right to confidentiality. If your case requires your provider’s participation, you will be expected to pay for the professional time required even if another party compels your provider to testify. It is important to note that insurance companies will not pay for these kinds of services, and so the responsibility is yours.

Although intern services are provided free of charge to the client, we retain the right to impose any late/cancellation and no-show fees associated with services. Interns are mandated to fulfill a specific number of clinical hours to meet their degree requirements, and client cancellations can impact these hours. You will not incur the $20 late/cancellation or no-show fee if you provide a notice of 24 hours or more.

If you have a health insurance policy, it may provide some coverage for mental health treatment.  Our billing service will assist you in filing claims.  You are responsible for obtaining information about your covered benefits.  This includes determining if we are in or out of network, copays, patient responsibility, prior authorizations, deductibles, and all other plan details or limits to coverage.  You are responsible for notifying us if/when your coverage changes.  Please direct any inquiries about your coverage to your insurance company.

Patient responsibility invoices are mailed to you and are due monthly.  You may pay your balance in our Cedar Rapids office via cash, check, or credit card.  You can also pay using a credit card over the phone or by mailing a check or credit card authorization form to our PO Box.  In the Cedar Rapids office, co payments and private pay balances are due at the time of service.  If you refuse to pay your debt, we reserve the right to use an attorney or collection agency to secure payment, as well as to refer you to services with another provider.

If we are not a participating provider for your insurance plan, you will be considered a private pay client.  You may request a receipt for your payments, which you can submit to your insurance company for reimbursement.  Please note that not all insurance companies reimburse for out-of-network providers.  If you prefer to use a participating provider, we will refer you to another agency.

By signing our informed consent form, you agree that you have disclosed all of your insurance coverages and that if you have Medicare as your primary coverage, you have disclosed this.  By signing this agreement, you agree that if you have not disclosed Medicare as your primary insurance coverage and your claims are denied because you have this coverage, you are responsible for payment in full.

Unless otherwise prohibited by law, in the event that you fail to pay the charges of Heart and Solutions, Heart and Solutions will pursue legal remedy for the full invoice of charges and you shall be liable for all costs incurred by Heart and Solutions as a result of these collection efforts, including, but not limited to, attorney fees and collection agency costs, whether or not litigation is initiated.  Heart and Solutions is not responsible for the confidentiality of text messages, voice calls, emails, or voicemails sent to the intended recipient utilizing the contact information provided.

Coverage from alternative funding sources such as grants, regional funding, crime victims, wrap-around services, etc. are not considered guaranteed payment and do not negate client financial responsibility.

Our Private Pay rates are the same as our insurance rates, however a cash-discount is offered for bills paid within 90 days of the invoice. Heart and Solutions can not offer private pay cash discounted rates to clients who are paying for services due to deductible or patient responsibility from insurance. If payment is not made within 90 days of service, you will be responsible for the full amount and we reserve the right to end services and refer you to another agency.

Please be advised that if you file for bankruptcy and include any outstanding balance with Heart and Solutions, you will be discharged from our services. This means that upon the discharge of your bankruptcy, you will not be eligible to return to or receive services from Heart and Solutions in the future.

Heart and Solutions is fully committed to working with you to address any outstanding balances and to set up manageable payment arrangements.

Heart and Solutions employees may request your permission to transport clients for various purposes. This will always be done with your consent and knowledge unless the provider must transport the client for emergency purposes. Heart and Solutions requires all employees to hold a current and valid driver’s license and car insurance. Heart and Solutions is not liable for any accidents that occur while transporting clients.

Heart and Solutions’ providers may not be immediately available by telephone, are not crisis intervention workers, and are not on call outside of work hours. You are welcome to leave a message on their confidential voicemail and your call will be returned at their earliest convenience. If you feel you cannot wait for them to return your call or if you feel unable to keep yourself safe, 1) Call 911 and ask to speak to the mental health worker on call, 2) Go to your local hospital Emergency Room. Your provider will make every attempt to inform you in advance of planned absences, and will provide you with the name and phone number of the mental health professional covering their practice when applicable. Heart and Solutions team members do not engage with their clients on social media.

Heart and Solutions and its providers will not confirm or deny knowledge of you as a client without your written consent. If you see your provider outside of the session, your provider will not acknowledge you unless you acknowledge them first. If you have a dual relationship with your provider or with another Heart and Solutions team member, please disclose this as soon as possible to your provider so that accommodations can be made.

Heart and Solutions may use or disclose records or other information about you without your consent or authorization in the following circumstances.

Emergency: If you are involved in a serious or life-threatening emergency and we cannot ask your permission, we will share information if we believe it will be helpful to you or others.

Debt Collections: If you refuse to pay your bill, we reserve the right to utilize an attorney or collection agency to obtain payment.

Consultation with Our Attorney: We reserve the right to consult with our attorney at any time. Our attorney is held to standards of confidentiality and is legally required to maintain confidentiality.

Child and Dependent Adult Abuse Reporting: If we have reason to suspect that a child or a dependent adult is abused, exploited, or neglected, we are required by law to report the matter within 24 hours to the Iowa Department of Human Services.

Court Proceedings: If you are involved in a court proceeding and a request is made for information about your diagnosis and treatment and the records thereof, such information is privileged under state law, and we will not release information unless you provide written authorization or a judge issues a court order. If we receive a subpoena for records or testimony, we will notify you so that you can file a motion to quash (block) the subpoena. However, while awaiting the judge’s decision, we are required to place these records in a sealed envelope and provide them to the Clerk of Court. If you, as a minor or adult, become a party in a civil commitment hearing, we may be required to provide your records to the magistrate, your attorney or guardian ad litem, a CSB evaluator, and/or a law enforcement officer.

Threat to Health or Safety: If your provider is engaged in their professional duties and you communicate to them a specific and immediate threat to cause serious bodily injury or death, to an identified or identifiable person, and they believe you have the intent and ability to carry out that threat immediately or imminently, your provider is legally required to take steps to protect third parties. These precautions may include:

1. Warning the potential victim(s) or the parent or guardian of the potential victim(s) if under 18.
2. Notifying a law enforcement officer, and/or 
3. Seeking your hospitalization. 

We will also use and disclose medical information about you when necessary to prevent an immediate, serious threat to your own health and safety. Heart and Solutions team members reserve the right to end a session if they feel unsafe in any way. Additionally, by signing this document, you agree that if any member of your session does not conduct themselves in a respectful manner to any team member, confidentiality rights are waived and the police will be contacted. Should a client or any of their support members verbally abuse a member of the Heart and Solutions team or act physically or verbally aggressive toward anyone in a Heart and Solutions office or session, they will be asked to leave the premises. If they refuse to leave the premises, confidentiality is waived and the police will be contacted. Should a team member be physically injured by another person in session, in the office or while performing their work duties, we reserve the right to file appropriate legal and or civil charges.

Insurance for Licensed Therapists: You should also be aware that most insurance companies require you to authorize your provider to provide them with a clinical diagnosis. Sometimes providers have to provide additional clinical information such as treatment plans or summaries, or copies of the entire record. This information will become part of the insurance company’s files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, we have no control over what they do with it after they receive it. In some cases, they may share the information with a national medical information databank. We will provide you with a copy of any report we submit if you request it in writing. By signing this Agreement, you give Heart and Solutions, LLC permission to provide requested information to your carrier if you plan to utilize insurance coverage for payment.

Supervision: All Heart and Solutions Behavioral Health Intervention Service Providers have their Bachelor's degree in a Human Services related field or their Bachelor's degree in another field with at least two years of Human Service experience.  All Heart and Solutions therapists are Master's level clinicians who are licensed to practice in the state of Iowa.  

Master’s level student interns, Temporarily Licensed Mental Health Counselors, Temporarily Licensed Marriage and Family Counselors, and Licensed Master's Level Social Workers require ongoing supervision in order to reach full licensure status.  This supervision is provided by a qualified supervisor within the agency or a contracted third party supervisor.  To ensure quality client care and services, client diagnoses, assessments, and notes may be shared and discussed with this supervisor. The supervisor is ethically responsible to maintain client confidentiality in the same manner as any Heart and Solutions team member.

Master’s level interns are also supervised by a faculty member from the student’s university. Additionally, with client consent, student interns may share video or audio recordings of sessions with supervisors from Heart and Solutions and/or their University for learning purposes. You will be informed of recording prior and an additional release is included below for recording consent. All master’s level student intern session information and clinical progress notes are supervised by Dr. Colleen Grote, Ph.D., LMHC. This is both for your benefit as our client and to ensure ethical gatekeeping and increased knowledge for student interns. 

Parents and Minors: While privacy in counseling services is crucial to successful progress, parental involvement can also be essential. It is Heart and Solutions’ policy not to provide treatment to a child under age 13 unless s/he agrees that we can share any clinically necessary information with a parent. For children 14 and older, we request an agreement between the client and the parents allowing us to share general information about treatment progress and attendance, as well as a treatment summary upon completion of the counseling services. All other communication will require the child’s agreement, unless we believe there is a safety concern (see also above section on Confidentiality for exceptions), in which case we will make every effort to notify the child of our intention to disclose information ahead of time. In this situation, we will make every effort to handle any objections that are raised, but will be required to break confidentiality even if objections persist. We will not release any information to parents or guardians if it will jeopardize the physical or mental well being or safety of the client. We reserve the right to deny access to records and clinical information to parents and guardians of minors if sharing the information is not in the best interest of the client.

Release of Information to Primary Care Doctor and School: If you have signed a release for us to share information with your primary care doctor and/or school, a letter will be faxed or mailed to these providers in an effort to collaborate and provide a more holistic approach to your treatment.

Communication Methods: Heart and Solutions team members may utilize cellular phone services such as, but not limited to: Verizon, AT&T, TMobile and US Cellular. Heart and Solutions team members may utilize an internet or wifi based service such as Google Voice for phone calls and text messages. Heart and Solutions team members additionally utilize Google Suites for Gmail communication. Heart and Solutions is not responsible for the confidentiality of text messages, voice calls, emails, or voicemails sent to the intended recipient utilizing the contact information provided.

Professional Records: Heart and Solutions providers are required to keep appropriate records of the services that we provide. Your records are maintained utilizing an electronic system called Valant. In signing this agreement, you consent to your service records being housed in Valant. We keep records noting that you were here, your reasons for seeking counseling services, the goals and progress we set for treatment, your diagnosis, topics we discussed, your medical, social, and treatment history, records we receive from other providers, copies of records we send to others, and your billing records. Except in unusual circumstances that involve danger to yourself, you have the right to a copy of your file. Due to the fact that these are professional records, they may be misinterpreted and/or upsetting to untrained readers. For this reason, we recommend that you initially review them with your provider or have them forwarded to another mental health professional to discuss the contents. If we refuse your request for access to your records, you have a right to have the decision reviewed by another mental health professional, which we will discuss with you upon your request.

Heart and Solutions clients, and guardians of clients, have access to all non-restricted client records and documentation authored by Heart and Solutions, LLC. Restricted client records include but are not limited to any and all second hand information such as documents from other agencies and collaborative services involving third parties. Records will also be considered restricted if access to them will cause harm or risk of harm to the physical or mental well being of the client.

Collaborating agencies must request documentation in writing and provide appropriate releases of information. Heart and Solutions will release requested information only when a completed release is on file and the client has been notified and has given consent.

You have the right to considerate, safe, and respectful care without discrimination of race, ethnicity, color, gender, sexual orientation, age, religion, national origin, or source of payment. You have the right to ask questions about any aspects of the counseling process and about your provider’s specific training and experience. You have the right to expect that your provider will not have social or sexual relationships with clients or with former clients and will uphold the ethical codes of the American Counseling Association, the American Association for Marriage and Family Therapy, and the National Association of Social Workers.

Right to Request Restrictions: You have the right to request restrictions on certain uses and disclosures of your protected health information. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care. If you ask us to disclose information to another party, you may request that we limit the information we disclose.

Right to Receive Confidential Communication by Alternative Means and at Alternative Locations: You have the right to request and receive confidential communication of Protected Health Information by alternative means and at alternative locations (for example, you may not want a family member to know that you are in treatment). Upon your request, we will send your bills to another address. You may also request that we contact you only at work, or that we 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 a Copy of this Notice: You have the right to a paper copy of this notice. You may ask your provider to give you a copy of this notice at any time. Heart and Solutions, LLC reserves the right to change policies and/or to change this notice, and to make the changed notice effective for medical information already accrued as well as any information received in the future. The notice will contain the effective date. A new copy will be given to you or posted in the waiting room. We will also have copies of the current notice available via request.

Complaints and Grievances: If you believe your privacy rights have been violated or you have a concern with the quality of your treatment, you may file a complaint. To do this, please call us at 800-531-4236 or contact us by email at help@heartandsolutions.net. You may also send a written complaint to the U.S. Department of Health and Human Services.

Compliments and Suggestions: We welcome and appreciate your compliments and suggestions! Please contact us at 800-531-4236 or by email at help@heartandsolutions.net.

My signature below indicates that I have read, understand, and agree to the terms of the Heart and Solutions Consent to Treatment including privacy practices, patient rights, and patient financial responsibility. By signing this document, I am providing consent to be treated by Heart and Solution for outpatient therapy and/or Behavioral Health Intervention Services. I understand that insurance billing is provided as a courtesy and that I am financially responsible to Heart and Solutions, LLC for all charges resulting from my treatment. It is my responsibility to notify Heart and Solutions, LLC of any changes in my health care coverage. While Heart and Solutions, LLC verifies my insurance eligibility, exact benefits cannot be determined until the insurance plan receives the claim. I agree to accept financial responsibility for all services received by me or by my dependents. I authorize direct payment from my health insurance plan to Heart and Solutions, LLC for all services provided to me or my dependent. This is a direct assignment of my rights and benefits under this policy. A photocopy of this assignment shall be considered as effective and valid as the original. We have discussed the privacy practices, and I understand that I may request a copy at any time in the future. I consent to accept these policies as a condition of receiving mental health services.

Appendix B: HIPAA Privacy Authorization and Release Form

This form provides a client’s informed authorization for use and disclosure of his/her protected health information, including personally identifiable information. This form is required by the Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164 (HIPAA) to be completed, signed, and dated by the client prior to the use and disclosure of the client’s protected health information, as described below.

Section I – Authorization

I,  understand that my counselor is a graduate student in the master’s degree in Clinical Mental Health Counseling program and that my counselor is providing my counseling session(s) as a required part of his/her practicum, internship, or externship course requirement for that program. I authorize Heart and Solutions and the internship student) to video record all or part of my counseling session(s) and to use and disclose the video recording, including my name and all of my protected health information contained in the video recording, to the counselor/student’s practicum, internship, or externship course instructor and students in that course. 

Section II – Extent of Authorization

I understand that the purpose of the video recording is for the above-named counselor/student to receive professional training and constructive feedback on his/her counseling skills to improve the quality of counseling services that I (and future clients of the counselor/student) receive. To be specific, once I complete and sign this form, I understand that the above-named counselor/student will upload the video recording of my counseling session(s) to password-protected platforms used by the university  for educational purposes. 

The video recording (and a written transcript of the video recording) will be disclosed to and used by the counselor/student’s practicum, internship, or externship course instructor and the students in that course for educational and professional training purposes, including a course presentation, a case conceptualization, and a verbatim paper. I understand that my personally identifiable information (e.g., my name) will be redacted from the written transcript and other written assignments, but not redacted from the video recording. I further understand that neither the video recording nor any written assignment will be used for any other purpose or disclosed to any persons outside of the counselor/student’s course, as described herein, without my additional written consent, except as permitted or required by law (see Section IV below).

Section III – Effective Period

This HIPAA Privacy Authorization and Release Form is valid and remains in effect until the end of the counselor/student’s practicum, internship, or externship course. I understand that the video recording and the written transcript will be deleted at that time. If there is a desire to keep either the video recording or the written transcript for a longer period of time, my additional written consent will be required before doing so. 

Section IV – Acknowledgements and Disclosures

I understand that the above-named Site Director or Approved Site Supervisor and counselor/student, as well as the course instructor and students will be required to maintain the same confidentiality as that required by members of the counseling profession. However, I acknowledge that there are certain exceptions to such confidentiality that require disclosure even without my authorization. Such exceptions that may require disclosure include: (1) my threat or act of serious harm to myself or another, (2) my disclosure of abuse of a minor, an elder, or an incapacitated adult, and/or (3) the issuance of a lawful subpoena, search warrant, or judicial court order that requires disclosure.

I understand that I have the right to revoke this authorization, in writing, at any time. I understand that my revocation will not be effective to the extent that any person or entity has already acted on my authorization. In other words, a revocation of my authorization cannot be retroactive and it will become effective only when my written revocation is received and processed. A copy of the written revocation must be sent to the Client’s Healthcare Provider and Heart and Solutions: 

Heart and Solutions, LLC 

PO Box 233 Grundy Center, IA 50638

 

I understand that my treatment, payment, enrollment, or eligibility for benefits will not be subject to or conditioned on whether I sign this authorization. I understand that my decision to sign this form, and therefore to release my protected health information, is completely voluntary. I understand that, although my information used and disclosed pursuant to this form will be kept confidential and only used as described above, such information may no longer be protected by state or federal law, including HIPAA. Moreover, even though the video recording and the written transcript of my counseling session(s) will be deleted, I understand that written assignments, feedback, reviews, and grades based on them may be education records of the counselor/student that are maintained by Liberty University beyond completion of the course described in Section III above. In such an event, my personally identifiable information will not be part of any such education records.

Section V – Agreement and Signature

By signing below, I (or, if the client is a minor or is incapacitated, I on behalf of the client) agree that I have carefully read and fully understand all of this HIPAA Privacy Authorization and Release Form, and I voluntarily agree to release my (or the client’s) protected health information, as described above.