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Client Services Agreement
Welcome to my therapy practice. This document (the Agreement) contains important information about my 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 client 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.
I have always placed high importance on protecting the privacy of my clients, so there is little that I’ve had to change to come into compliance with the new laws. However, one change is that HIPAA requires that I provide you with a Notice of Privacy Practices for use and disclosure of PHI for treatment, payment and health care operations. The Notice, which is attached at the end of this Agreement, explains HIPAA and its application to your personal health information in greater detail. The law requires that I obtain your signature acknowledging that I have provided you with this information.
Although these documents are long and sometimes complex, it is very important that you read them carefully before our next session. We can discuss any questions you have about the procedures at that time. When you sign the acknowledgment of receipt and agreement form, it will represent an agreement between us. You may revoke this Agreement in writing at any time. That revocation will be binding on me unless I have taken action in reliance on it; if there are obligations imposed on me 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 note that I usually send each ongoing client (excluding short term and Employee Assistance clients) a copy of “Musings” from time to time. Musings, written by me, is a short article about life issues relavant to psychotherapy, counseling, and marriage counseling clients. Please let me know if you do not want to receive this publication. You may also read Musings and all back issues on my web page at www.home.earthlink.net/~jameshbird/.
Psycotherapy and Counseling Services
Psychotherapy and counseling are not easily described in general statements. They vary depending on the personalities of the therapist and client, and the particular problems you are experiencing. There are many different methods I may use to deal with the problems that you hope to address. Psychotherapy and counseling are not like a medical doctor visit. Instead, they call 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 in between sessions.
Psychotherapy and counseling 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, therapy has also been shown to have many benefits. Psychotherapy and counseling often lead to better relationships, solutions to specific problems, and significant reductions in feelings of distress. When therapy works, it will help you to be the chairperson of your own life. But there are no guarantees of what you will experience.
Our first few sessions will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some initial impressions of what our work might involve if you decide to continue with therapy. You should evaluate this information along with your own opinions of whether you feel comfortable working with me. 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 my procedures or anything else that happens in our sessions, please discuss them with me whenever they arise. It is especially important for you to raise any negative feelings you may develop about me or my work with you. If we are unable to work through these negative feelings to your satisfaction, I’ll be glad to provide you with names of therapists who could see you for a second opinion or to whom you could transfer or you could seek a referral on your own.
I normally conduct an evaluation that will last from 1 to 3 sessions. During this time, we can both decide if I am a good person to provide the services you need in order to meet your therapy goals. I usually schedule one 50-minute therapy session per week at a time we agree on, although some sessions may be longer or more or less frequent. I charge for cancellations of less than 24 hours and for no-shows. If you call to reschedule your appointment less than 24 hours before your scheduled time, I will waive the hourly charge only if we can agree on a new appointment time within three of my working days. If you elect to use insurance, it is important to note that insurance companies do not provide reimbursement for canceled sessions, so you will be expected to pay the entire fee, not just the coinsurance amount you might normally pay.
My professional hourly fee is based on a 50 minute in-person appointment. In addition, I charge my hourly fee for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Examples of other services might include report writing, telephone conversations lasting longer than 10 minutes (after 10 minutes, I charge on a prorated basis beginning at the start of the call), preparation of records or treatment summaries, and the time spent performing any other service you may request of me. 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. Because of the difficulty of legal involvement, I charge $150 per hour for preparation and $300 per hour for travel and attendance at any legal proceeding.
Due to my schedule, I am often not immediately available by telephone. My phone number (404-262-1819) is answered by a confidential answering machine that I monitor frequently throughout the business day and once or twice daily during weekends and holidays. Please speak clearly and give numbers slowly and twice, since I may not have any way to look up your number. If you have an urgent need, please make this very clear in your message. However, since I do not carry a beeper, there may be a delay in my receiving your call request. If you are unable to reach me and feel that you can’t wait for me to return your call, please contact your family physician or the nearest emergency room or mental health crisis center. If I will be unavailable for an extended time, I will provide you, via my outgoing message, with the name of a therapist colleague to contact, if necessary.
Limits on Confidentialty
The law protects the privacy of all communications between us. In most situations, I will only release information about your treatment to others if you sign a written Authorization Form for each release. My release form meets certain legal requirements imposed by 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:
- I may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my client. The other professionals are also legally bound to keep the information confidential. If you don’t object, I will not tell you about these consultations unless I feel that it is important to our work together. I will note any consultations in your Client Record (which is called “PHI” in my Notice of Privacy Practices).
- Disclosures required by health insurers are discussed elsewhere in this Agreement.
- If a client threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her or to contact family members or others who can help provide protection. There are some situations where I am 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 my professional services, I will not provide any information without your written authorization, unless I am ordered to do so by a court. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information.
- If a government agency is requesting the information for health oversight activities, I may be required to provide it for the agency.
- If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client in order to defend myself.
- If a client files a worker’s compensation claim, and I am providing treatment related to the claim, I must, upon appropriate request, furnish copies of all therapy reports and bills.
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 client’s treatment. These situations are very unusual in my practice.
- If I have reason to believe that a child has been abused, the law requires that I file a report with the appropriate governmental agency, usually the Department of Human Resources. Once such a report is filed, I may be required to provide additional information.
- If I have reasonable cause to believe that a disabled adult or elder person has had a physical injury or injuries inflicted upon such disabled adult or elder person, other than by accidental means, or has been neglected or exploited, I must report to an agency designated by the Department of Human Resources. Once such a report is filed, I may be required to provide additional information.
- If I determine that a client presents a serious danger of violence to another, I may be required to take protective actions. These actions may include notifying the potential victim, and/or contacting the police, and/or seeking hospitalization for the client. If such a situation arises, I will make every effort to fully discuss it 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 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 I am not an attorney. In situations where specific advice is required, formal legal advice may be needed.
The laws and standards of my profession require that I keep Protected Health Information about you in your Client Record. You may examine and/or receive a copy of your Clinical Record, if you request it in writing, with the following unusual exceptions. The exceptions would involve danger to yourself or others. An example would include reference to another person when I believe that your accessing your Clinical Record is reasonably likely to cause substantial harm to that other person. Another example would be when information has been supplied to me confidentially by others. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review your therapy records in my presence, or have them forwarded to another mental health professional so you can discuss the contents. If I need to refuse your request for access to your records, you have a right of review (except for information provided to me confidentially by others), which I will discuss with you upon request.
In addition, I may also keep a set of Psychotherapy Notes on your case. These Notes are for my own use and are designed to assist me in providing you with the best psychotherapy and counseling. While the contents of Psychotherapy Notes vary from client to client, they generally consist of notes to myself about our work that would not be very meaningful to others. They may also contain particularly sensitive information that you or others reveal to me that is not required to be included in your Client Record. These Psychotherapy Notes are kept separate from your Client Record. My Psychotherapy Notes regarding you are not available to you and cannot be sent to anyone else, with the possible exception of a court order. I’ve never been asked to release copies of my Psychotherapy Notes, and in virtually all cases, would refuse to do so unless mandated by law, so this information remains highly protected and confidential. Insurance companies cannot require you to authorize me to release my Psychotherapy Notes as a condition of coverage nor penalize you in any way for your refusal to provide it.
HIPAA provides you with several new or expanded rights with regard to your Client Record and disclosures of protected health information. These rights include requesting that I 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 my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and my privacy policies and procedures. I am willing to discuss any of these rights with you.
Minors & Parents
Clients under 18 years of age who are not emancipated and their parents should be aware that the law allows parents to examine their child’s treatment records unless I believe that doing so would endanger the child or we agree otherwise. Because privacy in therapy is often crucial to successful progress, particularly with teenagers, it is my 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, I will provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. 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 my concern. Before giving parents any information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have.
Billing & Payments
You will be expected to pay for each therapy session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. In cases of unusual financial hardship, I may be willing to negotiate a payment installment plan.
Considerations Regarding Third Party Payment (Insurance Reimbursement)
Some of my Clients elect to use their insurance to help pay for our time together. If you decide to involve your insurance company in your therapy, I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. It is very important that you find out exactly what mental health services your insurance policy covers. But, before deciding to use your insurance coverage, please read the following four paragraphs very carefully so you will know how filing for insurance may affect you.
Filing for third party reimbursement requires that your therapy, or “treatment,” be certified as “medically necessary.” This requires me to provide the insurance company with a diagnosis to justify your treatment. It is my understanding that you will have this diagnosis attached to your insurance records for a number of years to come. It is also my understanding that this diagnosis, and possibly other personal information about you and your therapy, will be kept in shared insurance computers for some period of time. The diagnosis may lead to your being uninsurable for underwritten insurance (e.g., disability, life, health, etc.) for a number of years.
If your insurance is a managed care policy, as most insurance policies are today, I may be required to send the insurance company much personal information about you in addition to the mental health diagnosis. I may also be required to write frequent reviews releasing more personal information with each review. I cannot guarantee that this information will be treated confidentially once it is released and out of my hands. Also, managed care policies usually limit the frequency of psychotherapy and counseling appointments and the total number of sessions they consider necessary to treat your diagnosis.
As noted earlier, insurance companies will not pay for missed therapy appointments, whether no-shows or late cancellations. You are responsible for paying for the reserved time.
By signing this Agreement, you agree that I can provide requested information to your carrier, should you decide to involve your insurance company in your therapy. Remember, you have the right to pay privately for your psychotherapy and counseling and leave this third party out of our confidential relationship.
Notice of Privacy Practices
HIPAA requires that I give you the following Notice of Privacy Practices which reads as a legal document. Most of the points were covered in “softer” ways in the Client Services Agreement, above, but please read both parts. After you read the entire document, I will ask you to sign a form showing that you agree to abide by the Client Services Agreement and the Notice of Privacy Practices.
Notice of Privacy Practices
Notice of Policies and Practices to Protect the Privacy of Your Health Information
This notice describes how clinical and medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
- Uses and Disclosures for Treatment, Payment, and Health Care Operations
- I may use or disclose your protected health information (PHI),
for treatment, payment, and health care operations purposes with
your consent. To help clarify these terms, here are some definitions:
- refers to information in your health record that could identify you.
- “Treatment, Payment and Health Care Operations”
- Treatment is when I provide, coordinate or manage your health care and other services related to your health care. An example of treatment would be when I consult with another health care provider, such as your family physician or another psychotherapist.
- Payment is when I obtain reimbursement for your healthcare. Examples of payment are when I disclose your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.
- Health Care Operations are activities that relate to the performance and operation of my practice. Examples of health care operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and care coordination.
- applies only to activities within my office such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
- applies to activities outside of my office, such as releasing, transferring, or providing access to information about you to other parties.
- I may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your consent. To help clarify these terms, here are some definitions:
- Uses and Disclosures Requiring Authorization
- I may use or disclose PHI for purposes outside of treatment, payment, or health care operations when your appropriate authorization is obtained. An “authorization” is written permission above and beyond the general consent that permits only specific disclosures. In those instances when I am asked for information for purposes outside of treatment, payment or health care operations, I will obtain an authorization from you before releasing this information. As a general rule, I do not release my personal Psychotherapy Notes. “Psychotherapy Notes” are notes I have made about our conversation during a private, group, couple’s, or family counseling session, which I have kept separate from the rest of your medical record. These notes are given a greater degree of protection than PHI.
- You may revoke the authorization for release of your PHI at any time, provided the revocation is in writing. You may not revoke an authorization to the extent that (1) I have relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, law provides the insurer the right to contest the claim under the policy.
- Uses and Disclosures with Neither Consent nor Authorization
- I may use or disclose PHI without your consent or authorization in the following circumstances:
- Child Abuse – If I have reasonable cause to believe that a child has been abused, I must report that belief to the appropriate authority.
- Adult and Domestic Abuse – If I have reasonable cause to believe that a disabled adult or elder person has had a physical injury or injuries inflicted upon such disabled adult or elder person, other than by accidental means, or has been neglected or exploited, I must report that belief to the appropriate authority.
- Health Oversight Activities – If I am the subject of an inquiry by my licensing board, I may be required to disclose protected health information regarding you in proceedings before the Board. I will attempt to inform you and explain what has to be revealed.
- Judicial and Administrative Proceedings – If you are involved in a court proceeding and a request is made about the professional services I provided you or the records thereof, such information is privileged under state law, and I will not release information without your written consent or a court order. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. You will be informed in advance if this is the case.
- Serious Threat to Health or Safety – If I determine, or pursuant to the standards of my profession should determine, that you present a serious danger of violence to yourself or another, I may disclose information in order to provide protection against such danger for you or the intended victim.
- Worker’s Compensation – I may disclose protected health information regarding you as authorized by and to the extent necessary to comply with laws relating to worker’s compensation or other similar programs, established by law, that provide benefits for work-related injuries or illness without regard to fault.
- Your Rights and My Duties
- Your Rights:
- Right to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of protected health information. 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. (For example, you may not want a family member to know that you are seeing me. On your request, I will not leave messages for you on your home answering machine, as long as I have an alternative way of contacting you.)
- Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI in my mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. I may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed. On your request, I will discuss with you the details of the request and denial process.
- Right to Amend – You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. I may deny your request. On your request, I will discuss with you the details of the amendment process.
- Right to an Accounting – You generally have the right to receive an accounting of disclosures of PHI. On your request, I will discuss with you the details of the accounting process.
- Right to a Paper Copy – You have the right to obtain a paper copy of the notice from me upon request, even if you have agreed to receive the notice electronically.
- My 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 discuss these changes with you during a session.
- Your Rights:
- 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, James H. Bird, LCSW, at 404-262-1819. You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. I can provide you with the appropriate address upon request.
- This notice will go into effect on May 19, 2003.
- I reserve the right to change the terms of this Notice and to make the new Notice provisions effective for all PHI that I maintain. If this should occur, I will provide you a written copy of the revised notice.