Psychotherapy Services Meetings Professional Fees Billing & Insurance Reinbursement Contacting Therapists Professional Records Patient Rights Minors & Parents Complaints or Grievances Limits on Confidentiality

Welcome. This document 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 new federal law that provides new privacy protections and new 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. 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 also available on this website (click here), 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 at the end of the first session. Although these documents are long and sometimes complex, it is very important that you read them carefully. You may revoke this Agreement in writing at any time. That revocation will be binding on us unless we have taken action in reliance on it; if there are obligations imposed on us by your health insurer in order to process or substantiate claims made under your policy; or if you have not satisfied any financial obligations you have incurred. Please read it carefully and jot down any questions you might have so that we can discuss them when we meet. When you sign this document, it will represent an agreement between us.

PSYCHOTHERAPY SERVICES
Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist/therapist and patient, and the particular problems you bring forward. There are many different methods we may use to deal with the problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about 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 uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. But there are no guarantees of what you will experience.

Our first two sessions will involve an evaluation of your needs. By the end of the evaluation, your therapist will be able to offer you initial impressions of what your work will include and a treatment plan to follow, if you decide to continue with therapy. You should evaluate this information along with your own opinions of whether you feel comfortable working with your specific therapist. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about our procedures, we should discuss them whenever they arise. If your doubts persist, we will be happy to help you set up a meeting with another mental health professional for a second opinion, or provide you with a referral to another professional.

MEETINGS
We normally conduct an initial evaluation that will last from 2 to 4 sessions. During this time, you and your therapist can both decide if your therapist is the best person to provide the services you need in order to meet your treatment goals. You have the right to decline services at any time. If psychotherapy is begun, we will usually schedule one appointment per week at a time we agree on. Appointments last from 45-50 minutes with the balance of the hour being used for charting purposes, although some sessions may be longer or more frequent. Once an appointment is scheduled, you will be expected to pay for it unless you provide 24 hours advance notice of cancellation or unless we both agree that you were unable to attend due to circumstances beyond your control. If it is possible, we will try to find another time to reschedule the appointment. If you fail to call or cancel your appointment three times, it will be necessary to refer you to another clinic or agency. Please make a commitment to notify us of the need to cancel in order to avoid this unpleasant outcome. It is important to note that insurance companies do not provide reimbursement for missed sessions.

PROFESSIONAL FEES

Initial Assessment (1 hour)

Psychotherapy Sessions (45-50 min.)

Other Services

In addition to weekly appointments, we charge this amount for other professional services you may need, however we will break down the hourly cost if we work for periods of less than one hour. Other services include report writing, telephone conversations lasting longer than 10 minutes, attendance at meetings with other professionals you have authorized, preparation of records or treatment summaries, and the time spent performing any other service you may request of us. If you become involved in legal proceedings that require our participation, you will be expected to pay for our professional time even if we are called to testify by another party. Because of the difficulty of legal involvement, we charge one and one half time our normal psychotherapy rate per hour for preparation and attendance at any legal proceeding.

BILLING AND INSURANCE REIMBURSEMENT
If you choose, you may pay for our services directly, and we will provide you with a receipt you may submit to your insurance or keep for yourself. Most insurance companies will cover some mental health needs. Depending on whether we are a “preferred provider” or covered provider, that coverage may be 80% or more. You should educate yourself about what your benefits are. We can assist you in doing this and will complete all forms necessary as required by your insurance. 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, we will provide you with whatever information we can based on our 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, we will be willing to call the company on your behalf. Sometimes, in spite of our best efforts, a company may still refuse payment. You, not your insurance company, are responsible for full payment of our services. You will be expected to pay your co-payment for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage which requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. In circumstances of unusual financial hardship, we may be willing to negotiate a fee adjustment or an installment payment plan.

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. While a lot 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 us to provide services to you once your benefits end. If this is the case, we will do our best to find another provider who will help you continue your psychotherapy.)

You should also be aware that your contract with your health insurance company requires that we provide it with information relevant to the services that we provide to you. We are required to provide a clinical diagnosis. Sometimes we are required to provide additional clinical information such as treatment plans or summaries, dates of treatment, name of clinician and type of treatment provided, or copies of your entire Clinical Record. In such situations, we 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. Though all insurance companies claim to keep such information confidential, we have 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. We will provide you with a copy of any report we submit, if you request it. By signing this Agreement, you agree that we can provide requested information to your insurance carrier.

You may be asked to sign a more general Authorization form allowing us to release this information. It is your option to refuse to release that information. However, you will then be responsible for paying out-of-pocket.

Once we have all the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if the benefits run out before you feel ready to end our sessions. It is important to remember that you always have the right to pay for our services yourself to avoid the problems described above (unless prohibited by contract).

If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, we have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court. If, after several attempts to collect any balance, your account is sent to a collection service we will be adding an interest charge to the account at a rate allowable by law. In most collection situations, the only information we release regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due.

CONTACTING THERAPISTS
We are often not immediately available by telephone. While we are usually in the office during the day, we probably will not answer the phone when we are with a patient. When we are unavailable, our telephones are answered by our secretary who will take your message, or by voice mail. We will make every effort to return your call on the same day you make it, with the exception of weekends and holidays. If you are difficult to reach, please inform us of some times when you will be available. If a problem can wait until our daytime hours, we would appreciate it if you would wait until then to contact us. In the case of emergencies after hours or on weekends, you can contact our clinic through our pager number 920-537-2011. A mental health professional will call you back and respond to the emergency. In any case, you can also contact your family physician or the nearest emergency room and ask for the psychiatrist on call. If we will be unavailable for an extended time, we will provide you with the name of a colleague to contact, if necessary. You may use e-mail to contact us regarding questions or thoughts you have between scheduled sessions. It can be a convenient way to communicate. However, there are limitations as well. Please remember:

PROFESSIONAL RECORDS
The laws and standards of our profession require that we keep Professional Health Information about you in your Clinical Record. 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 and/or upsetting to untrained readers. For this reason, we recommend that you initially review them in our presence, or have them forwarded to another mental health professional so you can discuss the contents. [We are sometimes willing to conduct this review meeting without charge.] In most situations, we are allowed to charge a copying fee of $.50 per page (and for certain other expenses). We may withhold your records until the fee is paid.

PATIENT RIGHTS
HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include requesting that we amend your record; requesting restrictions on what information from your Clinical Records 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, the Notice form, and our privacy policies and procedures. We are happy to discuss any of these rights with you.

MINORS & 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 unless we decide that such access is likely to injure the child, or we agree otherwise. HOWEVER, when seeking services for substance use issues, parents DO NOT have the right to examine records if the minor is 12 years of age or older. When appropriate the teenager will be asked to sign a release of information to their parents. Also, in the area pertaining to substance use, minors and their parents or guardian are required to sign all documents. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is our policy to request an agreement from parents that they consent to give up their access to their child’s records. If they agree, during treatment, we will provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. We will also provide parents with a summary of their child’s treatment when it is complete. Any other communication will require the child’s authorization, unless we feel that the child is in danger or is a danger to someone else, in which case, we will notify the parents of our concern. Before giving parents any information, we will discuss the matter with the child, if possible, and do our best to handle any objections he or she may have.

COMPLAINTS OR GRIEVANCES
You have the right to voice any complaint you have regarding your treatment here, your therapist, the secretary, billing or any other matter. Some complaints are best discussed with your therapist. If, however, you wish to speak to a different person, our Client’s Rights Specialist is Gregg Brewer. You may submit a complaint orally or in writing. This can be done either formally or informally. The distinction between the submissions will be explained to you and the choice will be up to you. Every attempt will be made to resolve your complaint quickly.

LIMITS ON CONFIDENTIALITY
The law protects the privacy of all communications between a patient and a psychologist/
therapist. 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 state law and HIPAA. There are other situations that require only that you provide written, advance consent. Your signature on this Agreement provides consent for those activities, as follows:

There are some situations in which we are 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. These situations are unusual in our practice.

If such a situation arises, we will make every effort to fully discuss it with you before taking any action and we will limit our disclosure to what is necessary.

While this written summary of exceptions to confidentiality should prove helpful in informing 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 we are not attorneys. In situations where specific advice is required, formal legal advice may be needed.

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