Insurance Information

APPOINTMENTS/NO SHOWS/CANCELLATIONS

There is a great demand for mental health services, and many of our providers have waiting lists to be seen.  Each missed appointment represents a lost opportunity to see another client who could have benefited from the session.  We assess no show/late cancellation fees in hopes that clients will be more mindful of their appointment commitments and help ensure efficient services for everyone.

In the event you cannot keep your appointment, 2 business days notice is required. If you miss your appointment or do not cancel within 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 at 5PM CST to avoid a fee. If you cancel on Saturday or Sunday, you will be charged a late cancellation fee.  The fee is automatically assessed when an appointment is cancelled without sufficient notice. The fee will be removed if a doctor's note is provided.

If you have several standing appointments and you miss two appointmenst in a row without contacting the office, all future appointments will be cancelled without notice.  You are responsible for remembering your appointments.   

ZERO-TOLERANCE POLICY
Our organization is committed to providing a safe, secure, and respectful environment for our staff and clients. We have a zero-tolerance policy for any form of bullying, violence, aggression, or harassment directed toward our staff members either in person, telephone, email, or text message.  Such behavior will not be tolerated under any cirmcumstance.  Please be aware that any individual found engaging in bullying will be immediately dismissed from our practice, with no exceptions.  If a client's family member exhibits any of these behaviors, this will also result in the client's dismissal from our practice.

ARRIVAL TIME 
All clients should arrive prior to their appointment start time to confirm current information on file and pay any fees due.  Clients 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 client (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 client’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 clients 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. 

Bay Area Psychological Consultants does not file out-of-network insurnace carriers. Payment is required IN FULL at the time of service for all services provided to clients with out-of-network insurance carriers.  Client will be responsible for filing the claim to their out-of-network insurance carrier for reimbursement.  A superbill will be provided to client upon request for filing for reimbursement. 

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 may require Bay Area Psychological Consultants to disclose otherwise confidential information. In most collection situations, the only information released regarding a client’s treatment is his/her name, the nature of services provided, and the amount due.

FORMS/LETTERS
Fees starting at $25 will be assessed for the completion of certain forms or letters as these services are not covered by insurance.  Payment must be received in advance, and the forms/letters will be completed within a specified number of business days dependent upon the form requested.

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

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 Clients Regarding Privacy of Health Information.  If such a situation arises, providers will make an effort to discuss it with you. 

LEGAL PROCEEDINGS
Contents and documentation of any individual, joint, and/or family psychotherapy session by the client or their family member(s) will not be used in any divorce, separation, child custody, and/or any other legal proceedings. Clients understand and agree that Bay Area Psychological Consultant clinicians will not participate in any legal proceedings based on information obtained during or concerning psychotherapy.

OFFICE HOURS AND PHONE CALLS
Our office hours are 8:00 A.M. to 5:00 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 clinician'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.

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 Clients 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 clients 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 client or others in relationship with the client 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 clients’ 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 client files a complaint or lawsuit against, BAPC may disclose relevant information regarding that client 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 client’s employer, the insurance carrier or an authorized qualified rehabilitation provider.

 

Additional Disclosures

The law protects the privacy of all communications between a client 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, clinicians 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 Clients 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.