Intake Form

Please read the following carefully and check box at bottom of this form before submitting:          Office Practices and HIPAA, Informed Consent, and Client Rights & Therapist Duties Ed Geraty LCSW-C, LICSW, LCSW. Please read all of this information fully so that there will not be any misunderstandings about my practice. This document contains important information about my practice, and the Health Insurance Portability and Accountability Act (HIPAA), that provides privacy protections and patient rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations. My practice is not an emergency practice. If you are experiencing thoughts to harm yourself or someone else, signing the Intake form implies that you agree to go to the nearest hospital emergency room or call 911.You have 24 hours to cancel an appointment. If an appointment is not cancelled prior to 24 hours, or if you do not keep your scheduled appointment, you are billed a 75$ no show-no cancellation fee ($45 for group) . This fee is billed directly to you, not to your insurance company. Be aware that any paperwork that you request to be completed for you and emailed or mailed to another organization or agency is billed to you at 25$ a page to complete.   Any copayments, coinsurance, deductibles, and amounts for services not covered by insurance will be charged to you.  If for any reason your insurance does not reimburse my practice, you are responsible for the entire fee.  If, during your treatment, your symptoms become severe and I recommend a higher level of care (Medication consultation with a medical provider, hospitalization, partial hospitalization , or intensive outpatient treatment, and you do not follow through with those recommendations, I will not be able to continue to see you as a client. HIPAA requires that I 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 explains HIPAA and its application to your PHI in greater detail.  Your typed name or signature on the Intake form acknowledges that I have provided you with this.  If you have any questions, it is your right and obligation to ask so I can have a further discussion prior to signing the Intake form.  You may revoke this Agreement in writing at any time.  That revocation will be binding unless I have taken action in reliance on it. LIMITS ON CONFIDENTIALITY  The law protects the privacy of all communication between a patient and a therapist.  For clarity of note taking and authenticity, this practice may use speech to text technology to audio-record the therapy session conversation.  In most situations, I 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 some situations where I am permitted or required to disclose information without either your consent or authorization. If such a situation arises, I will limit my disclosure to what is necessary.  Reasons I may have to release your information without authorization 1.      If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the psychologist-patient privilege law.  I cannot provide any information without your (or your legal representative's) written authorization, or a court order, or if I receive a subpoena of which you have been properly notified and you have failed to inform me that you oppose the subpoena.  If you are involved in or contemplating litigation, you should consult with an attorney to determine whether a court would be likely to order me to disclose information. 2. If a government agency is requesting the information for health oversight activities, within its appropriate legal authority, I may be required to provide it for them .3.      If a patient files a complaint, I may disclose relevant information regarding that patient in order to defend myself.   4. If a patient files a worker's compensation claim, and I am providing necessary treatment related to that claim, I must, upon appropriate request, submit treatment reports to the appropriate parties, including the patient's employer, the insurance carrier or an authorized qualified rehabilitation provider 5.      I may disclose the minimum necessary health information to my business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services.  My business associates sign agreements to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract. There are some situations in which I am legally obligated to take actions, which I believe are necessary to attempt to protect others from harm, and I may have to reveal some information about a patient's treatment: 1.If I know, or have reason to suspect, that a child under 18 has been abused, abandoned, or neglected by a parent, legal custodian, caregiver, or any other person responsible for the child's welfare, the law requires that I file a report with the Maryland Abuse Hotline.  Once such a report is filed, I may be required to provide additional information. 2. If I know or have reasonable cause to suspect that a vulnerable adult has been abused, neglected, or exploited, the law requires that I file a report with the Maryland Abuse Hotline.  Once such a report is filed, I may be required to provide additional information .3.  If I believe that there is a clear and immediate probability of physical harm to the patient, to other individuals, or to society, I may be required to disclose information to take protective action, including communicating the information to the potential victim, and/or appropriate family member, and/or the police or to seek hospitalization of the patient .CLIENT RIGHTS AND THERAPIST DUTIES  Use and Disclosure of Protected Health Information:●       For Treatment – I use and disclose your health information internally in the course of your treatment.  If I wish to provide information outside of our practice for your treatment by another health care provider, I will have you sign an authorization for release of information.  Furthermore, an authorization is required for most uses and disclosures of psychotherapy notes.●       For Payment – I may use and disclose your health information to obtain payment for services provided to you as delineated in the Therapy Agreement.●       For Operations – I may use and disclose your health information as part of our internal operations.  For example, this could mean a review of records to assure quality.  I may also use your information to tell you about services, educational activities, and programs that I feel might be of interest to you.Patient's Rights:●       Right to Treatment – You have the right to ethical treatment without discrimination regarding race, ethnicity, gender identity, sexual orientation, religion, disability status, age, or any other protected category. ●       Right to Confidentiality – You have the right to have your health care information protected.  If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer.  I will agree to such unless a law requires us to share that information.●       Right to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of protected health information about you.  However, I am not required to agree to a restriction you request.●       Right to Receive Confidential Communications by Alternative Means and at Alternative Locations – You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations.●       Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI.  Records must be requested in writing and release of information must be completed.  Furthermore, there is a copying fee charge of $2.00 per page.  Please make your request well in advance and allow 2 weeks to receive the copies.  If I refuse your request for access to your records, you have a right of review, which I will discuss with you upon request.●       Right to Amend – If you believe the information in your records is incorrect and/or missing important information, you can ask us to make certain changes, also known as amending, to your health information.  You have to make this request in writing.  You must tell us the reasons you want to make these changes, and I will decide if it is and if I refuse to do so, I will tell you why within 60 days. ●       Right to a Copy of This Notice – If you received the paperwork electronically, you have a copy in your email.  If you completed this paperwork in the office at your first session a copy will be provided to you per your request or at any time.●       Right to an Accounting – You generally have the right to receive an accounting of disclosures of PHI regarding you.  On your request, I will discuss with you the details of the accounting process.●       Right to Choose – You have the right to decide not to receive services with me.  If you wish, I will provide you with names of other qualified professionals. ●       Right to Terminate – You have the right to terminate therapeutic services with me at any time without any legal or financial obligations other than those already accrued.  I ask that you discuss your decision with me in session before terminating or at least contact me by phone letting me know you are terminating services.●       Right to Release Information with Written Consent – With your written consent, any part of your record can be released to any person or agency you designate.  Together, we will discuss whether or not I think releasing the information in question to that person or agency might be harmful to you.Therapist’s Duties:●       I am required by law to maintain the privacy of PHI and to provide you with a notice of my legal duties and privacy practices with respect to PHI.  I reserve the right to change the privacy policies and practices described in this notice.  Unless I notify you of such changes, however, I am required to abide by the terms currently in effect.  If I revise my policies and procedures, I will provide you with a revised notice during our session. In addition, by checking the box below, I am stating I am aware of my insurance policy provisions related to payment for mental health services. ● COMPLAINTS  If you are concerned that I have violated your privacy rights, or you disagree with a decision I made about access to your records, you may contact me, the State of Maryland Department of Health, or the Secretary of the U.S. Department of Health and Human Services. Good Faith Estimate: Uninsured clients or clients who pay out of pocket, will be charged $110 per 50 minute session. If you are an Insured client, you may have a copay and deductible based on your insurance policy. Hence, you will be responsible for any out of pocket expenses, which can be between $10 and $110. Please verify your copay and deductible amount with your insurance before first visit.     CHECKING THE BOX BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS AND ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPAA NOTICE FORM DESCRIBED ABOVE.

A  reminder to text me at 410-804-1934 and let me know you have submitted this Intake form. Ed Geraty LCSW-C By submitting this form you are indicating that you have read and agree to the above.