PATIENT SERVICES AGREEMENT, DISTANCE THERAPY DISCLOSURES, AND HIPAA DISCLOSURES

This document (the “Agreement”) contains important information about my professional services and business policies. It also provides details regarding the Health Insurance Portability and Accountability Act (HIPAA), a federal law that ensures privacy protections and patient rights concerning the use and disclosure of your Protected Health Information (PHI) for treatment, payment, and health care operations. HIPAA mandates that we provide you with a Notice of Privacy Practices (“the Notice”) for the use and disclosure of PHI for these purposes. 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 that we have provided you with this information. It is crucial that you read this document carefully. We can discuss any questions you have about these procedures at any time. Your signature on this document will represent an agreement between us. You may revoke this Agreement in writing at any time. Such revocation will be binding on us unless we have already taken action in reliance on it; there are obligations imposed on us by your health insurer to process or substantiate claims under your policy; or if you have not fulfilled any financial obligations incurred.

PSYCHOLOGICAL OR COUNSELING SERVICES

Psychotherapy varies depending on the personalities of the psychologist and the patient, as well as the specific issues you are experiencing. There are various methods I may use to address the problems you wish to tackle. Psychotherapy is not like a medical doctor visit; it requires a very active effort on your part. For therapy to be most successful, you will need to work on the things we discuss both during our sessions and at home. Psychotherapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects of your life, you may experience temporary uncomfortable feelings such as sadness, guilt, anger, frustration, loneliness, and helplessness. On the other hand, psychotherapy has been shown to have many benefits, including improved relationships, solutions to specific problems, and significant reductions in feelings of distress. However, there are no guarantees of what you will experience.

Our first session will involve an evaluation of your needs. By the end of the evaluation, I will provide a diagnosis and a treatment plan. You should evaluate this information along with your feelings about working with me. If you have questions about my procedures, we should discuss them whenever they arise. If doubts persist, I will be happy to help you arrange a meeting with another mental health professional for a second opinion.

DISTANCE THERAPY

Distance Therapy is conducted through synchronous audio or visual electronic communication. Your initial session and any subsequent sessions may be conducted via distance therapy. Distance therapy can be a viable option for people who face scheduling, location, health, or transportation issues. It may also appeal to those who prefer not to meet in an office setting. Some people feel more comfortable communicating openly via electronic methods than in person. Others find therapy more accessible this way, as they do not know when they may need support the most.

The type of distance therapy I typically practice is telephonic. Usually, I will call you (possibly from a private number) either upon your request or at a scheduled date and time for a session. Our session will consist of discussing relevant matters to make a diagnosis and treatment recommendation. You will need access to a telephone to use this distance therapy option.

Distance therapy may have some downsides, which you must consider:

• Lack of nonverbal communication: Even with video conferencing, the therapist may not notice signs such as dilated pupils, nervous foot-tapping, or twitching.
• Risk of private information being vulnerable if using a public access computer or a computer on a shared network.
• Delays due to equipment issues.
• Possibility of technological failure during the session.
• Delayed response to crisis situations.
• Difficulty addressing severe or complex mental health concerns.

To mitigate the risks of using electronic communication for distance therapy, I recommend that you:

• Avoid using a public access computer or a computer on a shared network for any of our communications.
• Do not use “auto-remember” names or passwords on any accounts used for our communications.
• If you plan to use a device owned by your employer, please consider your employer’s policy related to the use of work devices for personal communication before doing so.

PROFESSIONAL FEES

My session fee may vary and will be disclosed to you prior to your consultation. I charge by the hour for other professional services you may need. These services include report writing, telephone conversations lasting longer than 10 minutes, consulting with other professionals with your permission, preparation of records or treatment summaries, and any other services you request. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Due to the complexity of legal involvement, I charge $250 per hour for preparation, travel, and attendance at any legal proceeding.

CONTACTING ME

Due to varied work schedules and the improbability of my answering the phone while with a patient, I am often not immediately available by telephone. When unavailable, my telephone is answered by voice mail that is monitored frequently. I will make every effort to return your call on the same day you make it, except on weekends and holidays. If you are difficult to reach, please inform me of times when you will be available. If you are unable to reach me and feel that you cannot wait for a return call, contact your family physician or the nearest emergency room and ask for the psychologist or psychiatrist on call. If you are experiencing a life-threatening emergency, call 911.

LIMITS ON CONFIDENTIALITY

The law protects the privacy of all communications between a patient and a mental health 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 some situations where only your written, advance consent is required. Your signature on this Agreement provides consent for these activities, as follows:

• I may occasionally find it helpful to consult with other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the patient’s identity. The other professionals are also legally bound to keep the information confidential. If you do not object, we will not inform you about these consultations unless we feel it is important to our work together. I will note all consultations in your Clinical Record.
• I have a privacy contract with our accountants and billing agents, such as US Service Animals and US Support Animals. As required by HIPAA, I have a formal business associate contract with them, which ensures the confidentiality of data except as specifically allowed in the contract or as required by law.
• Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement.
• If a patient seriously threatens to harm themselves, I may be obligated to seek hospitalization or contact family members or others who can help provide protection. The law generally allows a professional to disclose confidential information only to medical or law enforcement personnel if there is a probability of imminent physical injury by the patient to themselves or others, or if there is a probability of immediate mental or emotional injury to the patient.

There are some situations where I am permitted or required to disclose information without your consent or Authorization:

• 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. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order us to disclose information.
• If a government agency is requesting information for health oversight activities, I may be required to provide it.
• If a patient files a complaint or lawsuit against us, I may disclose relevant information regarding that patient to defend myself.
• If a patient files a worker’s compensation claim, I must, upon appropriate request, provide records relating to treatment or hospitalization for which compensation is being sought.

There are some situations in which I am legally obligated to take actions to attempt to protect others from harm, and I may have to reveal some information about a patient’s treatment:

• If I have cause to believe that a child under 18 has been or may be abused or neglected (including physical injury, substantial threat of harm, mental or emotional injury, or any kind of sexual contact or conduct), or that a child is a victim of a sexual offense, or that an elderly or disabled person is in a state of abuse, neglect, or exploitation, the law requires that I report it to the appropriate governmental agency. Once such a report is filed, I may be required to provide additional information.
• If I determine that there is a probability that the patient will inflict imminent physical injury on another, or that the patient will inflict imminent physical, mental, or emotional harm upon themselves or others, I may be required to take protective action by disclosing information to medical or law enforcement personnel or by securing hospitalization of the patient.

If such a situation arises, I will make every effort to discuss it fully with you before taking any action, and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should help inform you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. The laws governing confidentiality can be quite complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed.

PROFESSIONAL RECORDS

You should be aware that, pursuant to HIPAA, I may keep Protected Health Information (PHI) about you in two sets of professional records. One set constitutes your Clinical Record, which includes information about your reasons for seeking therapy, how your problem impacts your life, your diagnosis, the goals set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records I receive from other providers, reports of any professional consultations, your billing records, and any reports sent to anyone, including reports to your insurance carrier. Except in unusual circumstances involving danger to yourself or others, you may examine and/or receive a copy of your Clinical Record if you request it in writing. Because these are professional records, they can be misinterpreted or upsetting to untrained readers. For this reason, I recommend that you review them in my presence or have them forwarded to another mental health professional to discuss the contents. If we refuse your request for access to your Clinical Record, you have a right of review, which we will discuss with you upon your request.

I may also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they may include the contents of our conversations, my analysis of those conversations, and how they impact your therapy. They may also contain particularly sensitive information that is not required to be included in your Clinical Record. These Psychotherapy Notes are kept separate from your Clinical Record. While insurance companies can request and receive a copy of your Clinical Record, they cannot receive a copy of your Psychotherapy Notes without your signed, written Authorization. Insurance companies cannot require your Authorization as a condition of coverage nor penalize you for your refusal. You may examine and/or receive a copy of your Psychotherapy Notes unless I determine that release would be harmful to your physical, mental, or emotional health.

PATIENT RIGHTS

HIPAA provides you with several rights regarding your Clinical Record and disclosures of protected health information. These rights include requesting that your doctor amend 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 our policies and procedures recorded in your records; and the right to a paper copy of this Agreement and the attached Notice form.

MINORS AND PARENTS

Patients under 18 years of age who are not emancipated and their parents should be aware that the law may allow parents to examine their child’s treatment records. However, if the treatment is for suicide prevention, chemical addiction or dependency, or sexual, physical, or emotional abuse, the law may provide that parents may not access their child’s records. Any other communication will require the child’s Authorization unless I feel that the child is in danger or is a danger to someone else, in which case I will notify the parents of the concern. Before giving parents any information, I will discuss the matter with the child, if possible, and do my best to handle any objections they may have.

BILLING AND PAYMENTS

You are expected to pay for each session unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed upon when requested. If your account has not been paid for more than 60 days and no payment arrangements have been made, we have the option of using legal means to secure payment. This may involve hiring a collection agency or going through small claims court, which will require us to disclose otherwise confidential information. In most collection situations, the only information we release regarding a patient’s treatment is 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.

DISCLOSURE OF YOUR DIAGNOSTIC MEDICAL INFORMATION

Your privacy is of the utmost importance to me. I will not release or verify any confidential medical or diagnostic information unless I receive: 1) a fully compliant HIPAA release form indicating the exact information you wish me to release, signed by you and the receiving person or entity; 2) a copy of your identification; and 3) an acknowledgment that you and the receiving party understand that the requested information is not required to live with an emotional support animal and that you may not be denied housing because you have an emotional support animal.