Welcome to our practice. This document (the Agreement) 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) 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 use and disclosure of PHI for treatment, payment, and health care operations.
The Notice, which is attached to this Agreement, explains HIPAA and its application to your personal health information in greater detail. The law requires that we obtain your signature acknowledging we provided you with this information at the end of this session. Although these documents are long and sometimes complex, it is very important that you read them carefully before your session. You and Dr. Hoff can discuss any questions you have about the procedures at that time. When you sign this document, it will also represent an agreement between you, ATAGF, and Dr. Hoff.
YOUR PROFESSIONAL
Your professional, Kristin Hoff, PsyD, LP, CMPC, is a Licensed Psychologist and Certified Mental Performance Consultant ® (CMPC). She has a Psy.D. in Clinical Psychology and completed the requirements for licensure as a psychologist in the state of North Dakota (#627), Minnesota (LP6836), and Wisconsin (#3059-57). Individuals who are Certified Mental Performance Consultants have completed the requirements put forth by the Association for Applied Sport Psychology for this certification. This includes coursework in sport and performance psychology as well as providing sport psychology services under mentorship from another qualified sport psychology professional. She is required to complete continuing education credits in psychology and sport psychology to maintain her licenses and certification.
PSYCHOLOGICAL SERVICES
You are likely coming to see Dr. Hoff for mental health therapy (therapy), which can include managing psychological symptoms negatively impacting sport performance, or a psychological evaluation for diagnostic clarification and treatment planning purposes. Therapy and psychological evaluations are not easily described in general statements. It varies depending on the personalities of the professional and patient and the problems you are experiencing. There are many different methods we may use to deal with the problems you hope to address, although Dr. Hoff typically uses evidence-based interventions in cognitive behavioral therapy (CBT) and acceptance and commitment therapy (ACT). Therapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. For your meetings with Dr. Hoff to be most successful, you will have to work on things you and Dr. Hoff talk about during your sessions, at home, and within the performance environment (practice, competition, academics).
The length of a course of therapy varies based upon goals you establish with Dr. Hoff, your symptoms, their severity, frequency of sessions, your motivation to participate in therapy or the evaluation, and your ability to implement learned skills outside of session. The length of a psychological evaluation will depend upon the referral question being answered, your symptoms, and your attendance at scheduled sessions.
Therapy and psychological evaluations can have benefits and risks. Since therapy and psychological evaluations often involve discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. On the other hand, they have also been shown to have many benefits. Therapy and psychological evaluations often lead to better relationships, solutions to specific problems, and significant reductions in feelings of distress. Yet, there are no guarantees of what you will experience.
The first few sessions with Dr. Hoff will involve an evaluation of your needs. Part of this evaluation may involve completing psychological inventories or testing with Dr. Hoff or with a psychology technician (who is supervised by a licensed psychologist). By the end of the evaluation, Dr. Hoff will be able to offer you some first impressions of what your work together will include. There may also be a treatment plan to follow which may include referrals to other professionals for services (such as psychotherapy and/or other treatment recommendations). You should evaluate this information along with your own opinions of whether you feel comfortable working with these professionals. Therapy and psychological evaluations involve a large commitment of time, money, and energy, so you should be very careful about the professional(s) you select. If you have questions about our procedures at ATAGF, you should discuss them with Dr. Hoff whenever they arise. If your doubts persist, Dr. Hoff will be happy to help you set up a meeting with another mental health professional for a second opinion.
MULTIPLE RELATIONSIPS IN SPORT PSYCHOLOGY
Dr. Hoff must follow applicable laws and rules as well as the ethics codes within clinical and sport psychology, and she takes this responsibility seriously. Because sport psychology is a specialty area, there are few professionals in the region that provide these services. This means Dr. Hoff may be working with individuals that you know, such as teammates or other athletes at your or another institution. Dr. Hoff will take reasonable steps to minimize any conflict of interest prior to working with you. Should a conflict of interest arise during your work with her, she will address this with you in a manner that maintains confidentiality and minimizes harm for all impacted parties. If you have any questions about multiple relationships in sport psychology, please ask Dr. Hoff who is happy to discuss this with you.
SOCIAL MEDIA
Dr. Hoff does not communicate with, or contact, any of her clients through social media platforms like Twitter, Facebook, LinkedIn, and TikTok. In addition, if she discovers that she has accidentally established an online relationship with you, she will cancel that relationship. This is because these types of casual social contacts can create significant security risks for you.
If you have an online presence, there is a possibility that you may encounter Dr. Hoff by accident. If that occurs, please discuss it with Dr. Hoff during your next meeting. Dr. Hoff believes that any communications with clients online have a high potential to compromise the professional relationship. In addition, please do not try to contact Dr. Hoff via social media as she will not respond and will terminate any online contact, no matter how accidental.
MEETINGS
Dr. Hoff normally conducts an evaluation during the first session that typically consists of answering questions. During this time, you and Dr. Hoff can both decide if she is the best professional to provide the services you need to meet your treatment goals. If psychotherapy or sport performance sessions begin, Dr. Hoff will usually schedule one, 45-minute session (one appointment hour of 45 minutes duration) per week at a time you agree on, although some sessions may be shorter / longer or more / less frequent. If you complete any psychological testing, this is likely to be conducted in several different sessions. Dr. Hoff will be able to discuss the plan for testing with you after the initial session.
Once an appointment hour is scheduled, you are asked to provide 24 hours [1 day] advance notice of cancellation if you are unable to make it to your appointment. Although ATAGF provides reminder calls, SMS (text) messages, or emails for appointment times as a courtesy, it is your responsibility to know when you are scheduled to meet with Dr. Hoff. Given reminder calls/SMS (text)/email messages can be made less than 24 hours in advance, if you cancel when you get your reminder, it is likely your cancellation will be considered a late cancellation/no-show. After two late cancellations and/or no-shows, Dr. Hoff reserves the right to remove you from a regular spot in her schedule and speak with you prior to scheduling additional appointments to determine your commitment to therapy, sport performance enhancement, evaluation, or combination of these. She maintains a strict attendance policy; if you are unable to regularly attend your sessions with her, she may discuss referring you to another professional for ongoing work.
PROFESSIONAL FEES
The fees involved for services at ATAGF depend upon the service involved. Please contact ATAGF administrative staff or speak with Dr. Hoff for more information about fees for the services provided to you. In addition to regularly scheduled appointments, Dr. Hoff may charge for other professional services you may need, although she will break down the hourly cost if she works for periods of less than one hour. Other services may include but are not limited to telephone conversations lasting longer than 5 minutes, consulting with other professionals with your permission, preparation of records or treatment summaries, and the time spent performing any other service you may request of her. If you become involved in legal proceedings that require Dr. Hoff’s participation, you will be expected to pay for all her professional time, including preparation and transportation costs, even if she is called to testify by another party. Because of the difficulty of legal involvement, she charges more than the hourly rate for preparation and attendance at any legal proceeding. You are encouraged to discuss this fee with Dr. Hoff prior to any legal involvement.
CONTACTING DR. HOFF
Due to the work schedule of Dr. Hoff, she is often not immediately available by telephone. She is usually working Monday through Friday, although her hours in the office vary each day; please discuss office hours directly with Dr. Hoff or her administrative staff. She probably will not be available when she is with a patient. The ATAGF telephone is answered by an administrative assistant 8am to 8pm Monday through Thursday and from 8am to 5pm on Friday. These administrative assistants know where to reach Dr. Hoff and may inform you when she is available to speak with you. Dr. Hoff will make every effort to return your call on the same day you make it, except for evenings, weekends (Friday through Sunday), and holidays. If you are difficult to reach, please inform ATAGF administrative assistants of times when you will be available.
If you are unable to reach Dr. Hoff and feel that you cannot wait for her to return your call, it is advised you utilize these emergency services:
National Crisis Lines:
- Call or Text 988 (Suicide and Crisis Lifeline); chat at 988lifeline.org/chat
- Text HELLO to 741741
- National Disaster or Distress Hotline: Call or text 1-800-985-5990 (if you are experiencing emotional distress related to any natural or human-caused disaster. The helpline is free, multilingual, confidential, and available 24 hours a day, seven days a week)
- Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) Disaster Distress Helpline: 1-800-985-5990 or text TalkWithUs to 66746
- LGBTQ+ Hotline: (866) 488-7386
- Rape Abuse & Incest National Network (RAINN) (800) 656-4673 or live chat: https://www.rainn.org/
- National Domestic Violence Hotline at 800-799-SAFE or text LOVEIS to 22522 for 24/7 help. If you can’t call visit TheHotline.org to learn how to create a safety plan or get immediate help through the 24/7 “Chat Now” feature.
State Specific Resources:
If Dr. Hoff will be unavailable for an extended period, she will provide you with the name of a colleague to contact, if necessary. PLEASE NOTE: ATAGF providers, including Dr. Hoff, do not carry a pager and are not available 24 hours a day. If you believe you may need such crisis services, ATAGF and Dr. Hoff are not the best practice for you.
LIMITS ON CONFIDENTIALITY
The law protects the privacy of all communications between a patient and a professional. In most situations, we 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 you provide written, advance consent. Your signature on this Agreement provides consent for those activities, as follows:
- Dr. Hoff may occasionally find it helpful to consult other medical and/or mental health professionals about a case or a legal representative regarding questions as it relates to providing care. During a consultation, she makes every effort to avoid revealing the identity of the patient. The other professionals are also legally bound to keep the information confidential. If you do not object, she will not tell you about these consultations unless she feels it is important to your work together. She will note consultations in your Clinical Record (which is called “PHI” in our Notice of Privacy Practices attached to this Agreement). Dr. Hoff does routinely consult with Dr. Haugen, who provides similar services. Drs. Hoff and Haugen will follow ethical standards regarding these consultations, and if Drs. Hoff and Haugen believe it is best for Dr. Hoff to consult with another sport psychologist, she will do so. If you are concerned about this consultation relationship between Dr. Hoff and Dr. Haugen, please discuss this with Dr. Hoff.
- You should be aware Dr. Hoff practices with other mental health professionals, and we employ administrative staff. In most cases, we need to share protected health information with these individuals for both clinical and administrative purposes, such as scheduling, billing, and quality assurance. All mental health professionals are bound by the same rules of confidentiality. All 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 the professional staff member involved in your care.
- ATAGF also has contracts with various entities that enable us to perform treatment, billing, and practice management operations. As required by HIPAA, we have formal business associate contracts with these businesses, in which they promise to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, Dr. Hoff can provide you with the names of these organizations and/or a blank copy of this contract.
- Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement.
- If a patient threatens to seriously harm himself/herself/themself or someone else, Dr. Hoff or ATAGF staff may take actions to prevent this, including seeking hospitalization for him/her/them, notifying law enforcement, or contacting family members or others who can help provide protection.
There are some situations where ATAGF and/or Dr. Hoff is permitted or required to disclose information without either your consent or authorization:
- If you are involved in a court proceeding and a request is made for information concerning your evaluation, diagnosis, and treatment, such information is protected by the provider-patient privilege law. ATAGF professionals cannot provide any information without your written authorization or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order your professional to disclose information.
- If a government agency is requesting the information for health oversight activities, Dr. Hoff may be required to provide it for them.
- If a patient files a complaint or lawsuit against an employee of ATAGF, the ATAGF employee may disclose relevant information regarding that patient to defend him or herself.
- If a patient files a worker’s compensation claim, ATAGF must, upon appropriate request, provide appropriate information including a copy of the patient’s record or other information concerning mental health care services, to the North Dakota Worker's Compensation Bureau.
There are some situations in which an ATAGF provider is legally obligated to take actions, which we believe are necessary to attempt to protect others from harm and we may have to reveal some information about a patient’s treatment.
- If we have reason to suspect that a child is abused or neglected, the law requires that we file a report with the Department of Human Services. Once such a report is filed, we may be required to provide additional information.
- If we have knowledge of or reasonable cause to suspect that an adult with developmental disabilities or mental illness is abused, neglected, or exploited, the law requires that we report such information to the Protection and Advocacy Project. Once such a report is filed, we may be required to provide additional information.
- If a patient threatens serious physical harm to an identifiable victim, we may take actions to protect the victim. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the patient.
If such a situation arises, Dr. Hoff will make every effort to fully discuss it with you before taking any action and will limit my disclosure to what is necessary.
Although this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important you and Dr. Hoff discuss any questions or concerns you may have now or in the future. The laws governing confidentiality can be complex, and Dr. Hoff is not an attorney. In situations where specific advice is required, formal legal advice may be needed.
PROFESSIONAL RECORDS
The laws and standards of Dr. Hoff’s profession require that she keep Protected Health Information about you in your Clinical Record. You may examine and/or receive a copy of your Clinical Record (or a summary or explanation of the information contained in your Clinical Record if agreed by you in advance) if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, Dr. Hoff recommends that you initially review them in her presence or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, ATAGF can charge a copying fee of $20 per page for the first 25 pages, 75 cents per page for any pages beyond twenty-five and includes administrative, document retrieval, and postage charges. There may be instances in which Dr. Hoff does not believe reviewing your record is in your best interest, and this will be discussed with you should this occur.
PATIENT RIGHTS
HIPAA provides you with several new or expanded rights regarding your Clinical Record and disclosures of protected health information. These rights include requesting that ATAGF amends 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 ATAGF policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and ATAGF privacy policies and procedures. Dr. Hoff or an ATAGF administrative assistant is happy to discuss any rights with you.
MINORS & PARENTS
Patients under 18 years of age who are not emancipated, and their guardians, should be aware the law may allow guardians to examine their child’s treatment records unless Dr. Hoff decides that such access is likely to injure the child or the legal guardian and the child’s professional agree otherwise. Because privacy in mental health treatment and sport performance consulting is often crucial to successful progress, particularly with teenagers, it is sometimes ATAGF’s policy to request an agreement from guardians that they consent to give up their access to the child’s records. If they agree, during treatment, Dr. Hoff will provide them only with general information about the progress of the child’s treatment, and his/her/their attendance at scheduled sessions. Dr. Hoff may also provide guardians with a summary of their child’s treatment when it is complete. Any other communication will require the child’s Authorization, unless Dr. Hoff feels the child is in danger or is a danger to someone else, in which case, Dr. Hoff will notify the guardians of her concern. Before giving guardians any information, Dr. Hoff will discuss the matter with the child, if possible, and do her best to handle any objections the child may have.
RECORDING
Your sessions with Dr. Hoff may not be recorded in any way by any party unless agreed to in writing by mutual consent (between you/your guardian and Dr. Hoff). The end date of this mutual consent will be included in the written agreement. A copy of this written agreement will be maintained in your medical record. Additionally, you may not screenshot any portion of telehealth sessions without mutual consent.
APPOINTMENT REMINDERS
ATAGF utilizes electronic SMS messaging (texting) for appointment reminders which may include phone calls with voicemail or emails. It is your responsibility to ensure that contact information (phone number, email) is updated with ATAGF staff and that failure to do so may result in someone other than yourself receiving the appointment reminder. You may also choose to opt out of text messaging and/or email reminders or to receive them in an alternative format, such as a phone call with voicemail. To do so, please submit the request to ATAGF staff in writing and appointment reminders will be handled accordingly.
BILLING AND PAYMENTS
You will be expected to pay for each session at the time it is held, unless you have insurance coverage that requires another arrangement, or you and Dr. Hoff agree otherwise. Credit card payments and similar arrangements are more confidential than checks (with names on them), as we deposit these checks into our banking account. Payment schedules for other professional services will be agreed to when they are requested. In circumstances of unusual financial hardship, Dr. Hoff may be willing to negotiate a fee adjustment (if allowed by managed care contracts) or payment plan.
If you would like someone other than yourself to pay your bill at ATAGF (such as parent of someone over the age of 18 or your institution’s athletic department), we need additional information from you. We ask you provide contact information for the individual or entity responsible for the account and provide your written authorization for us to speak with them about matters pertaining to your bill. This authorization does not mean they have access to your medical record unless you explicitly authorize this access on the release of information. Additional information is included in the form Payment of Outstanding Balances attached to this Agreement.
If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, ATAGF has the option of using legal means to secure the payment. This may involve hiring a collection agency (i.e., United Accounts) or going through small claims court which will require Dr. Hoff to disclose otherwise confidential information. In most collection situations, the only information ATAGF releases regarding a patient’s treatment is his/her/their name, the nature of services provided, and the amount due. If such legal action is necessary, its costs will be included in the claim.
If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon or if the arrangements have not been followed, Dr. Hoff may speak with you about a referral to another agency or professional who is able to provide more cost-effective services to you.
INSURANCE REIMBURSEMENT
For you and Dr. Hoff to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. ATAGF administrative assistants and Dr. Hoff will fill out forms and provide you with whatever assistance they can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of Dr. Hoff’s fees. It is very important that you find out exactly what mental health services your insurance policy covers.
You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, ATAGF administrative staff will provide you with whatever information they can based on their experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, ATAGF administrative staff will be willing to call the company on your behalf.
Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. Although much can be accomplished in short-term therapy, some patients feel that they need more services after insurance benefits end. Some managed care plans will not allow professionals to provide services to you once your benefits end. If this is the case, Dr. Hoff will do her best to find another professional who will help you continue your psychotherapy.
You should also be aware that your contract with your health insurance company requires that ATAGF provides it with information relevant to the services that your provider provides to you. Dr. Hoff is required to provide a clinical diagnosis when using insurance. Sometimes Dr. Hoff is required to provide additional clinical information such as treatment plans, summaries, or copies of your entire clinical record. In such situations, Dr. Hoff 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, ATAGF has no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. Dr. Hoff will provide you with a copy of any report she submits, if you request it in writing. By signing this Agreement, you agree that ATAGF can provide requested information to your carrier.
Once we have all information about your insurance coverage, you and Dr. Hoff will discuss what you can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your sessions. It is important to remember that you always have the right to pay for your sessions with Dr. Hoff yourself to avoid the problems described above unless prohibited by contract.
CONSENT FOR RELEASE OF PROTECTED HEALTH INFORMATION TO INSURANCE COMPANY
You authorize Assessment and Therapy Associates of Grand Forks, PLLC to disclose to your current insurance carrier past and present information that is necessary to prepare an insurance claim. The insurance company will use this information to process claims for benefits. You authorize all insurance payable on claims originating from Assessment and Therapy Associates of Grand Forks, PLLC to be paid directly to Assessment and Therapy Associates of Grand Forks, PLLC. You understand that no other use will be made of this information except for that otherwise authorized by law.
EMAIL INFORMED CONSENT
Email can be a useful method of correspondence for clients. Transmitting confidential information by email can create several risks, both general and specific that clients need to be aware of if they choose this method of correspondence.
General email risks include but are not limited to the following:
- Email can be immediately broadcasted worldwide and received by many intended and unintended recipients;
- Recipients can forward email messages to other recipients without the original sender’s permission or knowledge;
- Users can easily send an email to the incorrect address;
- Email is easier to falsify than handwritten or signed documents;
- Backup copies of email may exist even after the sender or recipient has deleted his or her copy; and
- Without the benefit of face-to-face interaction, emails can be misinterpreted in tone and meaning.
Specific email risks include but are not limited to the following:
- Email containing information pertaining to a client’s diagnosis and/or treatment must be included in the client’s medical record. Thus, all individuals who have access to the medical record will have access to the email messages;
- If you are sending your emails from your employer’s and/or educational institution’s computer and/or email account, they do have access to your emails;
- While it is against the law to discriminate, an employer who has access to your email could use the information to discriminate against the employee. Additionally, the employee could suffer social stigma from a workplace disclosure;
- Insurance companies who learn of your PHI information could deny you coverage; and
- Although therapists and ATAGF staff will endeavor to read and respond to email correspondence promptly, they cannot guarantee that any particular email message will be read and responded to within any particular time frame.
Conditions for use of email:
All email messages sent or received that concern your diagnosis or treatment or that are a part of your medical record will be treated as part of your PHI. Reasonable means will be used to protect the security and confidentiality of the email. Because of the risk outlined above, the security and confidentiality of email cannot be guaranteed.
Your consent to email correspondence includes your understanding of the following conditions:
- All emails to and from you concerning your protected health information (PHI) will be a part of your file and can be viewed by health care, insurance providers, and ATAGF office support staff.
- Your email messages may be forwarded within ATAGF as necessary for diagnosis, treatment, and reimbursement. However, they will not be forwarded outside the office without your consent or as required by law.
- Though all efforts will be made to respond promptly, this may not be the case. Because the response cannot be guaranteed do not use email in a medical or mental health emergency.
- You are responsible for following up with the therapist or support staff if you have not received a response.
- Medical information is sensitive and unauthorized disclosure can be damaging. You should not use email for communications concerning diagnosis or treatment of AIDS/HIV infection, other sexually transmittable diseases, mental health, developmental disability, or substance abuse issues. It is your right, however, to choose to communicate about this information if you desire.
- Since employers and educational institutions do not observe an employee’s or student’s right to privacy in their email system, you should not use your employer’s or educational institution’s email system to transmit or receive confidential emails.
- ATAGF will take reasonable steps to ensure that all information shared through emails is kept private and confidential. However, ATAGF is not liable for improper disclosure of confidential information that is not a result of our negligence or misconduct.
- If you consent to the use of email, you are responsible for informing your therapist of any type of information that you do not want sent to you by email.
- It is your responsibility to update your email address with ATAGF staff members and clinicians if it changes.
- You are responsible for protecting your password and access to your email account and any email you send or receive from ATAGF to ensure your confidentiality. Your ATAGF and its staff members cannot be held liable if there is a breach of confidentiality caused by a breach in your account security.
- Any email that you send that discusses your diagnosis or treatment constitutes informed consent to the information being transmitted. If you wish to discontinue emailing information, you must submit a written notification that you wish to discontinue or an email informing your therapist that you are withdrawing consent to email information.
- Signing this does not mean Dr. Hoff will use email for communication. Specific terms will be discussed with you directly, as she utilizes email on a case-by-case basis for specific reasons.