Consent For Evaluation and Treatment

Consent For Evaluation and Treatment
Please choose your payer*
Requests for services will begin with a consultation/assessment usually taking one to three sessions, depending on the situation. Feedback will be provided with suggestions given as to the course of treatment in terms of type (i.e., individual or couples therapy), length, and general approach. Referrals to other professionals may be made.

CONFIDENTIALITY

Sessions with your provider and the information discussed in them are confidential and are protected by state law and the ethical principles of your provider’s profession. That is, the contents of a session, or even whether or not you attend, will not be revealed to outside sources unless you have provided written permission to do so, or as required by law.
There are several important circumstances under which confidentiality may not be legally and/or ethically guaranteed, and which may require your provider to initiate hospitalization for you, notify the police or other government agency, or notify your family members to help protect you. Such circumstances include:
(1) when your provider believes you intend to harm yourself or another person;
(2) when your provider believes a child or elderly person or dependent person has been or is in danger of being abused or neglected; (3) if a judge subpoenas your mental health records—a rare but possible circumstance if you are involved in or become involved in litigation; and
(4) if your provider consults with another mental health professional regarding your case, in which case none of your personal identifying information will be used.
Otherwise, your provider will not disclose anything about your treatment, diagnosis, history, or even that you are a client without your full knowledge and consent.

CONTACTING YOUR PROVIDER

All calls to your provider’s office number are answered by confidential voice mail. Your provider will check for messages frequently throughout the workday, and will make every effort to return your call within 48 hours, with the exception of weekends and holidays. Your provider can also be reached by email. Email is the preferred method of communication for non-urgent logistical questions, such as those pertaining to scheduling. Email is not a secure form of communication and confidentiality cannot be guaranteed.

WHAT TO DO IN A PSYCHIATRIC EMERGENCY

Sometimes people experience an emotional crisis that requires immediate attention. In such a case, you may call the office first to see if an emergency appointment can be arranged. Please note that we do NOT provide emergency services. Your provider may not be immediately available during the day, evenings, or on weekends. However, your provider will return your call as soon as possible, usually on the same business day. Often, an appointment can be made on short notice, but this cannot be guaranteed. If you feel you cannot wait, or if it is outside office hours, you should contact your family physician, or go to the Emergency Department of your nearest hospital and ask for the psychiatrist on call.

FEES

The therapy hour involves approximately fifty minutes of direct contact, with the remaining ten minutes being used for notes, reports, and treatment planning. There is usually no charge for: (i) treatment planning outside the session; (ii) brief telephone contacts (15 min. or less) with you, family members where appropriate, and other professionals; and (iii) other brief and incidental involvements of your provider’s time. However, when tasks and consultation require considerable time, fees may be charged. Administrative fees will be charged for requests for file notes (for time and duplication costs), reviewing files/notes and writing reports.
Payment for therapy is normally expected at each session (check, Visa, MasterCard, PayPal, or American Express). Receipts and superbills are available to you upon request.

Please read through the policies to your respective payer below.

PROVIDER INVOLVEMENT IN LEGAL PROCEEDINGS

In the event you should require your provider’s testimony or involvement in legal or court proceedings, client consent will be required. Your provider will be unable to disclose any information pertaining to other family members or parties in counseling without each person’s specific consent. Court appearances, either requested or subpoenaed, as well as depositions and settlement conferences are billed at an hourly rate of $400.00. These rates will be charged at a minimum of four hours which includes time spent on preparation, travel, waiting, and testimony. The initial minimum four-hour charge of $1600 is due at the time of the subpoena. These charges are not allowable charges for insurance and are the sole responsibility of the client. Because it is often difficult to accurately determine the time needed to appear in court, there is a need for the therapist to clear his or her appointment schedule for the entire day. Such scheduling makes it necessary to charge in this manner.

Recording your therapy sessions is prohibited. Should you record your therapy session, whether in person or telehealth session, you will be charged $2000 per hour.

RECORD KEEPING

Your provider’s profession requires that treatment records be maintained after discontinuation of treatment. You may submit a request in writing to receive a copy of your records. Your provider will honor your request, unless your provider considers your records to be potentially dangerous, in which case we will forward them to another mental health provider of your choice.

THE THERAPY PROCESS

Your provider will conduct an initial comprehensive evaluation, and use an approach that your provider believes will be most effective in attaining the goals that you both have established. It is crucial for you to actively participate in this process by attending regular sessions, preparing for them, and practicing any between session exercises. Your input is essential in establishing treatment goals, issues, risks and benefits of change, the time commitment involved, costs, and other pertinent aspects of your situation. Periodically, you and your provider will evaluate your progress and, if necessary, redesign the treatment plan, goals, and/or methods.
As with any successful intervention, there are both benefits and risks associated with psychotherapy. Risks may include experiencing uncomfortable levels of feelings such as sadness, guilt, shame, anxiety, anger, frustration or conflicts with other people. Some changes may lead to feeling worse in the short run. However, long term benefits may include improvement in mood and distress, better relationships, and solutions to personal problems.
Evaluations and therapy are completely voluntarily. You may discontinue treatment at any time. However, it is important to discuss terminating treatment with your provider and to make subsequent plans for referral or discontinuation of treatment.

CONSENT OF NON-SECURE FORMS OF ELECTRONIC COMMUNICATION

Electronic communication, including but not limited to phone, email and text, between you and your therapist may not be secure. Email and text communication does not provide a completely secure means of communication. While your therapist will take reasonable efforts to protect your confidentiality, there is some risk that any protected health information contained in email or text may be disclosed to or intercepted by unauthorized third parties.

The following protected health information may be sent to you by unsecure means: information related to the scheduling of meetings and other appointments, information related to billing and payment. Use of more secure communications, such as phone or fax, are always an alternative that are available to you if you elect to not give consent to the above forms of communication. You also have the right to terminate this agreement at any time.

THE CONSENT WILL TERMINATE:

1. If client (you) revokes consent. Should you choose to revoke consent, please communicate to your clinician.
2. On termination of services.

You have the right to terminate this agreement at any time.

By signing this form, you acknowledge that you have been informed of the risks, including but not limited to my confidentiality in treatment, of transmitting my protected health information by unsecured means. You also understand that you may terminate this authorization at any time.

You understand that your clinician makes available to you the following means of communication (Gmail, TherapyNotes) that are designed to be secure and to maintain confidentiality.

TELEHEALTH (REMOTE SERVICES)

“Telehealth” involves consultation, treatment, transfer of medical data, emails, telephone conversations, and education using interactive video, audio, or voice communications.
1. Unless we explicitly agree otherwise, our telehealth exchange is confidential. The same regulations governing face-to-face interactions remain in effect for telehealth.

2. Regardless of your location, our telehealth occurs in the state of California, and is governed by the laws of that state. In a manner of speaking, you use this modality to visit our office in California.
3. You understand that telehealth is neither a universal substitute, nor the same as, face-to-face psychotherapy treatment. You accept the distinctions made using telehealth vs. face-to-face psychotherapy. In particular, you accept that telehealth does not provide emergency services. Your signature indicates that you understand that you may choose to engage in telehealth at your own discretion.

4. You are responsible for information security on your computer. If you decide to keep copies of our emails or communication on your computer, it is up to you to keep that information secure.
5. The risks involved with telehealth include the potential release of private information due to the complexities and abnormalities involved with the Internet. Viruses, Trojans, and other involuntary intrusions have the ability to grab and released information you may desire to keep private. Furthermore, there is the risk of being overhead by anyone near you if you do not place yourself in a private area and open to other’s intrusion.

NOTICE OF PRIVACY PRACTICES

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.

OUR COMMITMENT TO YOUR PRIVACY

Our practice is dedicated to maintaining the privacy of your personal health information as part of providing professional care. We also are required by law to keep your information private. These laws are complicated, but we must give you this important information. This document is a shorter version of the full, legally required NPP. However, we can’t cover all possible situations so please inquire if you have any questions.
We will use the health information that we get from you or from others mainly to provide you with treatment, to arrange payment for our services, and for some other business activities which are called, in the law, health care operations. If we or you want to use or disclose (send, share, release) your information for any other purposes, we will discuss this with you and ask you to sign an Authorization form to allow this.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION

1. You can ask us to communicate with you about your health and related issues in a particular way or at a certain place which is more private for you. For example, you can ask us to call you at home, and not at work to schedule or cancel an appointment. We will make every effort to respect your wishes.
2. You have the right to look at the health information we have about you such as your medical and billing records.* You can even get a copy of these records but we may charge you.
4. If you believe the information in your records is incorrect or missing important information, you can ask us to make some kinds of changes (called amending) to your health information. You must submit a written request and provide a justification for the desired change.
5. You have the right to a copy of this notice. We will inform you of any updates or changes to this policy.
6. You have the right to file a complaint if you believe your privacy rights have been violated. You can file a complaint with our Privacy Officer and with the Secretary of the Department of Health and Human Services. All complaints must be in writing. Filing a complaint will not change the health care we provide to you in any way.
If you have any questions regarding this notice or our health information privacy policies, please contact us at info@sfstress.com.

Please read through the policies to your respective payer below.

Fairmont Policies
Fees

The fees for your sessions will be paid for by your employer as long as you are an eligible employee in good standing with the company, subject to any limits under your benefit plan, and as long as further sessions are considered clinically appropriate. Please note that certain professional services outside of the presenting problems, such as chart preparation requests, disability paperwork, and participation in legal proceedings, may be outside the services paid for by your employer and may incur additional fees. Any additional fees will be discussed and agreed upon when they are requested. Fees for services may be subject to change in the future and we will notify you of any changes.

Cancellation Policy

Please remember that insurance will not reimburse you for fees incurred for missed appointments. This is your responsibility. If you arrive late for an appointment, it will be counted as a full session. If another client is not waiting and your provider is able to take the time, the hour may be extended so that you receive the full length of your therapy session.

Modern Health Policies
Fees

The fees for your sessions will be paid for by your employer as long as you are an eligible employee in good standing with the company, subject to any limits under your benefit plan, and as long as further sessions are considered clinically appropriate. Please note that certain professional services outside of the presenting problems, such as chart preparation requests, disability paperwork, and participation in legal proceedings, may be outside the services paid for by your employer and may incur additional fees. Any additional fees will be discussed and agreed upon when they are requested. Fees for services may be subject to change in the future and we will notify you of any changes.

Cancellation Policy

Please remember that insurance will not reimburse you for fees incurred for missed appointments. This is your responsibility. If you arrive late for an appointment, it will be counted as a full session. If another client is not waiting and your provider is able to take the time, the hour may be extended so that you receive the full length of your therapy session.

Carelon Policies
If you are insured, you agree that San Francisco Stress and Anxiety Center will bill the insurance company and will accept payment from your insurance company at their rates for the services. You agree that any insurance carrier with whom you have a policy shall direct to San Francisco Stress and Anxiety Center any benefits and payments related to services rendered to you by San Francisco Stress and Anxiety Center providers. You authorize and consent that San Francisco Stress and Anxiety Center may provide your insurance company with any and all necessary information, including therapist notes, requested in connection with its review and consideration of the claim for payment of benefits. You are responsible for payment of all charges not covered by insurance, and any and all co-pays, coinsurance, deductibles, and any other payments are due

Fees

We will let you know your co-pay/co-insurance prior to your intake appointment. We recommend you research your policy prior to the first appointment in order to ensure understanding of fees.

Cancellation Policy

If you need to cancel or reschedule a session, please reach out to your clinician as soon as possible. We do ask that sessions are canceled or rescheduled 24 hours before your scheduled session.

If you have a Carelon Health Commercial plan, you will be responsible to pay the full fee of your therapy session should it be canceled within 24 hours or missed.

LGTC Policies for Aetna, HealthNet (MHN) and Kaiser
San Francisco Stress and Anxiety Center is in partnership with Los Gatos Therapy Center.

If you are insured, you agree that San Francisco Stress and Anxiety Center will bill the insurance company and will accept payment from your insurance company at their rates for the services. You agree that any insurance carrier with whom you have a policy shall direct to LGTC/SF Stress any benefits and payments related to services rendered to you by San Francisco Stress and Anxiety Center providers. You authorize and consent that San Francisco Stress and Anxiety Center may provide your insurance company with any and all necessary information, including therapist notes, requested in connection with its review and consideration of the claim for payment of benefits. You are responsible for payment of all charges not covered by insurance, and any and all co-pays, coinsurance, deductibles, and any other payments are due

Fees

We will let you know your co-pay/co-insurance prior to your intake appointment. We recommend you research your policy prior to the first appointment in order to ensure understanding of fees.

We do require a form of payment on file for all insurance plans under Kaiser, Aetna, and Healthnet (formerly MHN). We will first bill to your insurance plan, but if the claims continue to be denied or they are not fully covering your sessions, you are still responsible for the full balance of your sessions to continue working with your therapist. We will charge the payment on file for the balance due.

Deductibles, Copays, and Co-Insurance:

Depending on your plan, you may be responsible for a copay each session. We charge this copay when we submit your sessions to insurance each time. For deductibles needing to be met or co-insurance, we rely on your Estimation of Benefits (EOB) from your insurance that we get when they answer your claims we submit. Until we find out directly from your insurance that they will cover your sessions, you are responsible for any contracted rates that are due because of a co-insurance or deductible that was shown when we ran your benefits. In the event you overpay and your insurance will in fact cover the sessions, we will immediately refund your payments and start charging the correct amounts.

Cancellation Policy

If you need to cancel or reschedule a session, please reach out to your clinician as soon as possible. We do ask that sessions are canceled or rescheduled 24 hours before your scheduled session.

Cancellation coverage policies may vary by plan, please check with your insurance provider regarding coverage or reimbursement for late-cancels or missed sessions.

Private Pay Policies
BILLING/INSURANCE REIMBURSEMENT

You may be able to receive reimbursement from your insurance company for seeing an “out of network provider.” It is your responsibility to determine whether or not your insurance company will reimburse you and to what extent you will be reimbursed. If you wish to seek reimbursement from your health insurance company, your provider will complete any reasonable forms to enable you to do so. If required to provide clinical information, your provider will make every effort to release only the information about you that is necessary for the purposes requested. By signing this agreement, you agree that your provider can provide required information to your insurance carrier in order to help you receive reimbursement. However, ultimately you are responsible for all incurred fees. If you have an outstanding balance for more than 2 months, we reserve the right to use legal matters including hiring a collection agency and/or using small claims court to receive payment. Should this occur, certain information pertaining to your treatment will be released.

CANCELLATION POLICY
PAYMENT IS EXPECTED FOR ANY MISSED SESSION, UNLESS RESCHEDULED OR CANCELLED 24 HOURS IN ADVANCE.

Please remember that insurance will not reimburse you for fees incurred for missed appointments. This is your responsibility. If you arrive late for an appointment, you will be charged the full session fee. If another client is not waiting and your provider is able to take the time, the hour may be extended so that you receive the full 50 minutes.

By signing this form, you acknowledge that you have read and agree to the cancellation policy.

Lyra Policies
Fees

The fees for your sessions will be paid for by your employer as long as you are an eligible employee in good standing with the company, subject to any limits under your benefit plan, and as long as further sessions are considered clinically appropriate. Please note that certain professional services outside of the presenting problems, such as chart preparation requests, disability paperwork, and participation in legal proceedings, may be outside the services paid for by your employer and may incur additional fees. Any additional fees will be discussed and agreed upon when they are requested. Fees for services may be subject to change in the future and we will notify you of any changes.

Progress and Outcomes

To monitor your progress and inform your treatment, your provider will collect regular outcomes data from you. You'll be asked to share your personal email address with your provider so that they may work with Lyra Health to collect feedback on our sessions. Lyra will send you an email on your provider's behalf that will contain information about Lyra’s services, including your sessions, and periodically ask several questions about progress towards your goals. You are not required to provide this data in order to continue your sessions with your provider.

Cancellation Policy

Please remember that Lyra will not reimburse you for fees incurred for missed appointments. This is your responsibility. Lyra's policy states you may cancel up to 24 hours in advance. If you arrive late for an appointment, you will be charged the full session fee for the contracted rate of that provider with the payment you have on file, if your Lyra benefits do not cover a missed/late cancel session. If another client is not waiting and your provider is able to take the time, the hour may be extended so that you receive the full length of your therapy session. Every therapist who works with Lyra benefits has a different contracted rate, ranging from $125-235. If you have questions about your specific rate for your therapist that you would be responsible, please reach out to billing@sfstress.com

Consent For Evaluation and Treatment

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