TOM EDWARDS, LCSW

Financial Agreement

 

I agree to pay Tom Edwards, LCSW, according to the fee scale below:

FEES:

Diagnostic Interview/ Initial Consultation: $175

Individual Therapy 45-55 min: $150

Family Therapy 45-55 min: $150

Group Therapy 60 min: $50

Group Therapy 90 min: $75

Existing Patient Check In 30 min: $85

Extended Individual / Family Therapy 75-90 min: $175

Court-related services (including co-parenting) per hour: $200

Missed Appointment: $75

 

REGARDING FEES/ TREATMENT DURATION: It is understood that Tom Edwards, LCSW is not paneled with insurance providers. Fees charged by Tom Edwards, LCSW are considered reasonable and customary. They may, or may not, be equal to waht a particular insurance company reimburses. Tom Edwards, LCSW will provide documentation necessary, should a patient or parent wish to file for out of network benefits. The course and length of mental health treatment is directly related to the clinical needs ond wishes of each patient. Patients, parents, or guardians who would like a prediction of treatment course are welcome to discuss in the initial or subsequent session(s).

I certify that I am an authorized user of this card and that I will not dispute the payment, so long as the payment corresponds to the terms agreed to in this form. I understand that I may withdraw from this agreement or change options at any time with proper notification. All information is kept private and is available only to Tom Edwards and/or office staff trained re: HIPPA.

AUTHORIZATION FOR TREATMENT OF MINORS/DEPENDENTS

 

            In Tennessee, a person who is 16 years or older can legally give his/her consent receive health service ( TCA 33-6-101). Individuals under the age of 16 years are legal minors and must have a parent or legal guardian authorize professional services.

            I certify that I am the parent or legal guardian of the patient above, who is a minor or dependent under the laws of the state of Tennessee. I authorize Tom Edwards, LCSW, to provide psychological treatment to this patient. I further authorize that I have legal standing to involve this patient in treatment and am responsible for communicating any limitations to that as well as any elements of a parenting plan, if applicable, that would affect the involvement.

           Such treatment may include, but is not limited to, individual psychotherapy, group psychotherapy, family therapy, clinical inventories and questionnaires, and/or other specialized procedures, which are generally accepted in the field of clinical social work.

 

 

 

 

 

ADULT PATIENT AUTHORIZATION FOR TREATMENT

 

            Being of legal age to grant consent, I authorize Tom Edwards, LCSW to provide my psychological treatment. I understand that this treatment may include, but is not limited to, individual psychotherapy, group psychotherapy, family therapy, clinical inventories, and/or other specialized procedures, which are generally accepted in the field of clinical social work.

 

TREATMENT AGREEMENT

I/ We understand and agree to the following as it relates to the treatment of the above- named patient:

That entering into psychological treatment is a voluntary activity. Although parents may initiate therapy for their children, there is always the choice to participate.

That therapy is built on honest disclosure by all involved.

That children and adolescents, like adults, have the right to confidentiality. Tom Edwards, LCSW will not disclose the details of a patient's therapy without that patient's consent, unless the safety of that patient or others is thought to be at risk. Exceptions to this include suspected abuse or neglect that has not been reported. Of course, the patient is free to disclose as he or she sees fit.
That Tom Edwards, LCSW will, from time to time, discuss clinical issues via telephone and/or internet video conferencing applications. It is understood that these communications may not be secure.

That Tom Edwards, LCSW does not provide emergency psychiatric care. I/We
have the responsibility to deal with emergency situations by either calling 911, proceeding to an emergency room, or putting into place some other designated emergency plan. I/We understand that I/We will have access to an answering service to address after-hours situations. 

That should therapy not lead to the desired outcome, I/ We will have the responsibility to communicate that concern to Tom Edwards, LCSW. I/ We may be given information about other treatment options and are welcome to pursue them at any time.
 

SIGNATURES BELOW INDICATE REVIEW, AGREEMENT, AND CONSENT TO ALL ABOVE POLICIES.

 

Tom Edwards, LCSW

NOTICE OF PRIVACY PRACTICES (HIPPA) *PLEASE PRINT AND KEEP

 

This notice describes how medical information about you may be used and disclosed and how you can get access to this information.  Please review it carefully.

 

PROTECTED HEALTH INFORMATION

Information about your health is private.  And it should remain private.  Tom Edwards is required by federal and state law to protect the privacy of your health information.  We call it:

 

“PROTECTED HEALTH INFORMATION” (PHI)

Tom Edwards must follow legal regulations with respect to:

 

How we use your PHI

Disclosing your HI to others

Your Privacy Rights

Office contacts for more information or, if necessary, a complaint

 

USING OR DISCLOSING YOUR PHI

 

FOR PAYMENT

After providing treatment, we will ask your insurer to pay their fee as appropriate. Some of your PHI will be entered into my computers in order to track sessions and payments.  This may include a description of your health problem and the treatment I provided. If you choose to request out of network benefits from your insurance company, I will be required to release information as to session types and diagnoses.

 

SPECIAL USES

1)      Remind you of an appointment

2)      Tell you about other health benefits and services

 

YOUR WRITTEN AUTHORIZATION MAY BE REQUIRED

We may use or disclose your PHI for treatment, payment or health care operations or as required or as permitted by law.  We will ask you for authorization with specific instructions and limits on our use or disclosure of your PHI.  You may revoke this authorization at any time.

 

REQUIRED OR PERMITTED USES

1.      We may use your PHI in an emergency when you are not able to express yourself.

2.      When required by law, when ordered by a Court.

 

YOUR PRIVACY RIGHTS AND HOW TO EXERCISE THEM

·       Right to Request Limited use or Disclosure

·       Right to Confidential Communication

·       Right to Revoke Your Authorization

·       Right to Inspect and Copy

·       Right to Amend Your PHI

 

These above requests need to be made to this Office in writing.  We may refuse your request for limited use or disclosure or your request to inspect and copy your record, if we believe that doing so will cause you harm.  Similarly, we may refuse your request to amend your PHI and you have a right to disagree in writing.  This document will be filed with your medical record.

 

WHAT IF I HAVE A COMPLAINT?

If you believe that your privacy has been violated, you may file a complaint with us or with the Secretary of Health and Human Services in Washington, DC.  We will not retaliate or penalize you for filing a complaint with this office or the Secretary.

 

SOME OF OUR PRIVACY OBLIGATIONS AND HOW WE FULFILL THEM

Federal health information privacy rules require us to give you notice of our privacy practices.  This document is our notice.  We will abide by the privacy practices set forth in this notice.  However, we reserve the right to change this notice and our privacy practices when permitted or as required by law.