PRACTICE POLICIES

The relationship between client and therapist is incredibly unique given that it is both deeply personal as well as professional. The following policies are in place to create a structure of continuity and accountability within which you and your provider can more freely focus on your clinical work together. If you have any questions or concerns about a practice policy, please feel free to address them with your provider so that they can discuss its purpose and its impact on your therapeutic relationship if needed.

APPOINTMENTS AND CANCELLATIONS

If you need to cancel or reschedule your session, we ask that you do so at least 24 hours in advance. A $50 fee will be charged if cancellation is less than 24 hours before the session. A fee is charged because late cancellations prohibit another client from accessing services. Many practices charge their full fee for service for a late cancel; Wild Hope Therapy, LLC chooses to charge a lower flat fee to avoid prohibitive costs to my clients, while still encouraging accountability between the client and provider. A no-show for an existing client will also result in a $50 fee. Three late cancels/no-shows in a row for an existing client may result in termination of services. Six late cancels/no-shows in a three month period may also result in termination. In the case of termination, we will refer you to another clinician or service provider that might better meet your needs. The late fee will be waived on the occasion of the first late cancel or in the case of extreme weather or health emergency.

For new clients, we will reschedule two times after either a late cancel or a no-show. After three late-cancels and/or no-shows, we will refer you to another clinician or service provider that might better meet your needs.

At times, we may need to cancel our appointments due to illness, family emergencies, or other circumstances outside of my control. In this case, we will give you as much notice as possible. Depending on your communication preferences stated in your client profile, will reach out to you via phone and email to ensure to the best of our ability that you are informed of the cancellation. We will also work to reschedule any appointment we cancel to the best of our ability.

PAYMENT AND INSURANCE

Payment is expected at time of service. It is your responsibility to be aware of your co-pay or deductible before your session. We accept credit card or check for payments. We do not accept cash at this time. A $35.00 service charge will be charged for any checks returned for any reason for special handling.

Please note that all clients are automatically enrolled in Autopay. Copays, coinsurance, deductible, sliding scale fees or self-pay fees will be charged within 24 hours of your session. You may OPT OUT of autopay through your client portal when you fill out your paperwork, or by notifying us at hello@wildhopetherapy.com

We accept many major insurance policies. It is your responsibility to identify your insurance plan and whether your provider is in-network with your particular plan; however, as insurance can be confusing we will assist you in any way we can to navigate your coverage. Please communicate any insurance concerns to us before our first session. If your insurance does not provide coverage, you will be responsible for the full fee of service.

We can provide a super bill to you in the case that you choose to submit your own claim for reimbursement if your provider is out-of-network with your insurance plan. In this case, the full fee for service would be due at time of service.

You may obtain a good faith estimate of my charges upon request prior to scheduling with me.

The No Surprises Act is a federal law which provides you with the right to a good faith estimate of the cost of services at my practice. However, Ohio licensing board rules require me to provide you with the actual cost of my charges in a written informed consent form to which you must agree prior to my providing services. That will be available to you prior to you being seen for services and prior to any billing. In most cases it is impossible to estimate how many sessions you will need, and that will not be determined until your concerns are evaluated and will also vary based on the progress that you make, which depends in part on your efforts with the process. You will be free to discontinue services at any time or the services may otherwise be terminated in accordance with the informed consent form language.

Although the No Surprises Law says that you may initiate a dispute process if the actual charges are substantially in excess of the Good Faith Estimated charges, i.e. if you are charged $400 more than the estimated cost for a session or for the total estimate provided, that is unlikely to happen and would be a violation of licensing board rules, since you will be agreeing up front to actual charges per session prior to being seen. Dispute information is available upon request, however. Any changes to my fees will require a change in the informed consent form fees, which you must agree to prior to having them go into effect, otherwise the fees will remain in effect for 12 months.

If you think you may have trouble paying your bills on time, please discuss this with your provider. We will also raise the matter with you so we can arrive at a solution together. If your unpaid balance reaches $300.00, we will notify you. If it then remains unpaid, we may terminate therapy with you if we cannot agree on a payment plan. Fees that continue unpaid after this may be turned over to small-claims court or a collection service and you agree to allow us to do that. If we choose to do that, we will report only enough information to collect fees due to the practice.

A late payment fee of $25.00 will be charged each month that a balance remains unpaid, since the practice will incur costs to rebill and other accounting costs. A returned check fee of $35.00 will be charged if your check bounces. Once a check is returned, I will no longer accept checks for future payments.

COMMUNICATION BETWEEN SESSIONS

PLEASE NOTE THAT EMAIL, ELECTRONIC MESSAGING, VOICEMAIL, OR OTHER COMMUNICATION OUTSIDE OF A FACE-TO-FACE SESSION IS NOT A SUBSTITUTE FOR THERAPY. YOUR PROVIDER IS UNABLE TO PROVIDE A PROPER ASSESSMENT VIA THESE FORMS OF COMMUNICATION AND CANNOT PROMISE THEY WILL BE AVAILABLE FOR THERAPEUTIC INTERVENTIONS BETWEEN SESSIONS. IF YOU EVER FEEL YOUR ARE HAVING A MENTAL HEALTH EMERGENCY, PLEASES GO TO YOUR NEAREST EMERGENCY ROOM OR CALL 911.

The best way to reach the practice between sessions for cancellations, rescheduling, or other administrative concerns is through email (hello@wildhopetherapy.com). Please direct billing and insurance concerns to billing@wildhopetherapy.com. Email is checked several times a day and we will respond to your message as soon as possible. Please note that the practice uses Google Mail for email correspondence, and cannot guarantee confidentiality through email or any form of electronic communication.

SECURE MESSAGING

You may send your provider a secure message through your Simple Practice client portal. This messaging system is HIPAA compliant and a better way to send information between sessions that you would like to ensure is confidential. As noted above, communication between sessions is not a substitute for therapy and your provider is not able to provide assessment or interventions between face-to-face sessions, or via electronic or telecommunications.

If you provide clinical information between sessions, your provider will follow up at the next face-to-face session. If your message is more than a standard paragraph in length, your provider cannot guarantee they will be able to read it in its entirety. If your provider notices a pattern of sending messages of this nature often, they may discuss increasing sessions during the week, implementing journaling, or other strategies during a face-to-face session. Each provider has discretion over how they communicate via email or other means.

TELEPHONE ACCESSIBILITY

You may also contact the practice or your provider by phone between sessions at 614.328.9714. Providers will not answer the phone if they are in a session with another client, after 6 PM Monday through Friday, on weekends, or other holiday or vacation time. If your call is not answered, please leave a message on our voice mail. This voicemail is confidential and will only be listened to by staff of Wild Hope Therapy, LLC. Note that if someone is not immediately available to take your call, we will attempt to return your call within 24 hours. At this time, we provide primarily telehealth services. In-person services are provided at the discretion of the individual provider. All insurance plans have different coverage for telehealth services and it is your responsibility to ensure your coverage before a phone session occurs.

If a true emergency situation arises, please call 911 or go to your local emergency room.

SOCIAL MEDIA AND TELECOMMUNICATION

Due to the importance of your confidentiality and the importance of minimizing dual relationships, providers do not accept friend or contact requests from current or former clients on any social media site (Facebook, LinkedIn, Instagram, etc.). Adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of the therapeutic relationship. Wild Hope Therapy, LLC maintains public social media accounts that you may follow. The practice and providers will not follow current or former clients from this account for the same reasons listed above.

TELEHEALTH AND TELEMEDICINE

We offer telehealth exclusively at this time. In-person sessions should be discussed directly with your provider. It is your responsibility to ensure insurance coverage of telehealth or telemedicine services.

INTERACTIONS OUTSIDE OF THERAPY

From time to time, a provider will run into clients outside of therapy. If this happens, your provider will not acknowledge you due to your right to confidentiality. You may say hello to them if you would like but are not in any way expected or required to do so. Your provider will acknowledge that we ran into each other at the following face-to-face session.

TERMINATION

Ending a therapeutic relationship can be complex and difficult. Therefore, it is important to have a termination process in order to process the end of the relationship, review achievements, and ensure continuity of care if needed. The appropriate length of the termination depends on the length and intensity of the treatment.

Termination happens for many reasons: you decide you have met your goals; you move or change insurance carriers; you and your provider identify a goal which requires a clinician with different training, etc. Your provider may terminate treatment if they determine that the psychotherapy is not being effectively used or if you are in default on payment. They will not terminate the therapeutic relationship without first discussing and exploring the reasons and purpose of terminating with you directly. If therapy is terminated for any reason or you request another therapist, the practice will provide you with a list of qualified psychotherapists. You may also choose someone on your own or from another referral source. If you choose not to continue with another provider, your provider can assist in creating a plan for implementing coping skills after you have concluded therapy. We will support you in any way we can with this transition.

Should you fail to schedule an appointment for six consecutive months, unless other arrangements have been made in advance, for legal and ethical reasons, the practice must consider the professional relationship discontinued.

INFORMED CONSENT FOR THERAPY

I am an Ohio licensed mental health therapist and am engaged in private practice providing mental health services to the public.

General Information The therapeutic relationship is unique in that it is a highly personal and at the same time, a contractual agreement. Given this, it is important for us to reach a clear understanding about how our relationship will work, and what each of us can expect. This consent will provide a clear framework for our work together. Feel free to discuss any of this with me. Please read and indicate that you have reviewed this information and agree to it by filling in the checkbox at the end of this document.

The Therapeutic Process You have taken a very positive step by deciding to seek therapy. The outcome of your treatment depends largely on your willingness to engage in this process, which may, at times, result in considerable discomfort. Remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety, etc. There are no miracle cures. I cannot promise that your behavior or circumstance will change. I can promise to support you and do my very best to understand you and repeating patterns, as well as to help you clarify what it is that you want for yourself.

Appointments

Appointments are made by calling (614) 328-9714, emailing hello@wildhopetherapy.com, or using your client portal. Please call or email to cancel or reschedule at least 24 hours in advance, or you will be charged $50.00 for the missed appointment unless I determine an emergency was involved. Third party payers will not cover or reimburse for missed appointments. Appointments are 50-55 minutes in length, but session length may vary for clinical reasons. The number of appointments depends on many factors and we will discuss this as part of your treatment planning. Since there is no way a therapist can see another client when they have a late arrival, no reductions are provided when a client arrives late for an appointment. Some insurance companies will only pay for the actual time during which services are rendered. In that case you, the client, will be billed for the portion of the appointment time when no services could be rendered. In some cases governmental insurance or employee assistance programs do not allow billing for missed or partially missed appointments and if that is the case you will be billed in accordance with those programs’ rules.

Relationship

My relationship with clients is a professional and therapeutic relationship. In order to preserve this relationship, it is imperative that I not have any other type of relationship with you. Personal and/or business relationships undermine the effectiveness of the therapeutic relationship. I will not accept friend or follow requests on social media including Facebook, LinkedIn, Instagram or on any other social media site. I do have a professional Instagram account for my practice that you may follow, but I will not follow any current or former clients from this account.

If we see each other accidentally outside of the therapy office, I will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to me, and I do not wish to jeopardize your privacy. However, if you acknowledge me first, I will be more than happy to speak briefly with you, but feel it appropriate not to engage in any lengthy discussions in public or outside of the therapy office. You always have the right to terminate services with me at any time and for any reason.

Goals, Purposes and Techniques

There may be alternative ways to effectively treat the problems you are experiencing. It is important for you to discuss any questions you may have regarding the treatment I recommend and to have input into setting the goals of your therapy. As therapy progresses these goals may change. You and I will jointly determine how to effect the changes you are seeking to make for yourself. You always have the opportunity to seek either another opinion or a different therapist. I will let you know if I feel that we are not a good fit or if you might obtain better help elsewhere. I will always retain the right to terminate my therapy with you in the event that I feel you would be better served elsewhere, if I feel you are not complying with treatment requests, or if payments due to me remain unpaid. In the event that I terminate services with you I will offer you referrals.

Confidentiality

Laws protect the privacy of all communications between a client and a therapist. In most situations I can only release information about your treatment to others if you sign a written authorization. There are some situations where I am permitted or required to disclose information either with or without your consent or authorization. For example:

• If you are involved in a court proceeding and a request is made for information concerning your treatment, I cannot provide such information without your written authorization or a court order. If you are involved in or contemplating litigation, you should consult your attorney to determine whether a court would be likely to order me as your therapist to disclose information;

• If a government agency is requesting the information, I may be required to provide it;

• If you file a complaint or lawsuit against me, I may disclose relevant information about you in order to defend myself;

• If you file a worker’s compensation claim, I may be required, upon appropriate request, to provide a copy of your records, or a report of your treatment.

There are some situations in which I am legally obligated to take actions that I believe are necessary to attempt to protect others from harm, and in such cases I might have to reveal some information about your treatment. If such a situation arises, I will make every effort to fully discuss it with you before taking any action, if I deem that to be appropriate under the circumstances, and will limit disclosure to what is necessary. For instance:

• If I have reason to believe that a child, a developmentally or physically disabled or elderly adult is being neglected or abused, the law may require me to report that information to the appropriate state or local agency;

• If I believe you present a clear and substantial danger of harm to yourself and/or others, I may be obligated to take certain protective actions. This may include contacting family members, seeking hospitalization for you, notifying any potential victim(s), and/or notifying the police.

You agree that I may release information about your claim(s) to the Ohio Department of Insurance in connection with any insurance company’s failure to properly pay a claim in a timely manner as well as to the Ohio Department of Commerce, which requires certain reporting of unclaimed funds. In those instances, only the minimal, required, information will be supplied.

You agree that from time to time I may have the need to consult with my practice attorney regarding legal issues involving your care (this is an infrequent occurrence, but does happen from time to time). My practice attorney is bound by confidentiality rules also. In addition, I will reveal only the information that I need to reveal to receive appropriate legal advice in connection with those contacts.

You should be aware that I may practice with other health professionals and that I may employ administrative staff. In most cases, I need to share protected information with these individuals for both clinical and administrative purposes, such as typing, scheduling, billing, and quality assurance and you agree that I may do that. If I do that, I will only release the information necessary in order for me to provide help to you, the client. All of the health professions will be bound by the same rules of confidentiality. All staff members will have been given training about protecting your privacy and will have agreed not to release any information outside of the practice without the permission of a professional staff member.

Also, I may have a contract with a collection agency. I will have a formal business contract with this business, in which it promises to maintain the confidentiality of this data except where release of certain information is allowed or is required by law.

In addition, I may have a contract with a billing service. I will have a formal HIPAA business associate contract with this business, in which it promises to maintain the confidentiality of this data except where release of certain information is allowed or is required by law.

This summary is designed to provide an overview of confidentiality and its limits. It is important that you read the Notice of Privacy Practices form that has been provided to you for more detailed explanations, and that you discuss with me any questions or concerns that you have.

Legal Situations

If you or the client (if the client is a ward of a guardian) become involved in legal proceedings that require my participation you will be expected to pay for all of my professional time, even if I am called to testify by another party. I will ask that a retainer be paid of half of the expected fees at least one week prior to providing these services, and the second half of expected fees and any additional fees that may have been accrued be paid within one week after services are delivered. Any unused amounts will be refunded. My professional time for legal proceedings may include preparation (document review or letter preparation), phone consultation with other professionals or you, record copying fees, and travel time to and from proceedings, testifying, and time that I wait in court prior to or after I may be called to testify). Due to the time-consuming and often difficult nature of legal involvement, I charge $225.00 per hour for these services. You will also be responsible for any legal fees that I may incur in connection with the legal proceeding, which may include responding to subpoenas.

Please be advised that as a treating therapist I cannot ethically provide any recommendations on guardianship, custody, visitation, parenting capacity or abilities or what is in the best interest of the child(ren) if you or your child(ren) are involved in custody/divorce/guardianship proceedings.

Professional Records

The laws and standards of my profession require that I keep Protected Health Information about you in your client file. Your client file may include information about your reasons for seeking therapy, a description of the ways in which your problems affect your life, your diagnosis, the goals for treatment, your progress toward those goals, your medical and social history, your treatment history, results of clinical tests (including raw test data), any past treatment records that I receive from other providers, reports of any professional consultations, any payment records, and copies of any reports that have been sent to anyone. You may examine and/or receive a copy of all of your records that I have prepared in connection with your treatment if you request them in writing, unless I determine for clearly stated treatment reasons that disclosure of the records to you is likely to have an adverse effect on you, and in that event under Ohio law I may exercise the option of turning the records over to another mental health therapist designated by you, unless otherwise required by federal law. Because these are professional records they can be misinterpreted and/or upsetting to untrained readers, I therefore recommend that you initially review them with me or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge fees set under Ohio and federal laws for copying and sending records. These fees may change every year, so I will let you know what the charge is at the time that a records request is made. If you desire to have the information sent to you electronically, if I maintain the information in an electronic format, I will provide the information in that format if you agree to accept the potential risks involved in sending the information that way.

As your therapist, I may also keep a set of psychotherapy notes which are for my own use and which are designed to assist me in providing you with the best treatment. These notes are kept separate from the rest of your records. In order for psychotherapy notes to be released to third parties, you must sign a separate authorization in addition to one for the rest of your records. I will discuss with you whether or not I am maintaining psychotherapy notes on you.

Fees, Payments, and Billing

Payment for services is an important part of any professional relationship. This is even more true in therapy; one treatment goal is to make relationships and the accountability and boundaries they involve clear. I am responsible for providing services, and you are responsible for payment of these services.

My current regular fees are as follows. You will be given advance notice if my fees should change. Regular therapy services are $175.00 for the first diagnostic session, $150 for a 55 minute session, $125 for a 45 minute session, and $100 for a 30 minute session. Please pay for each session before or at its end. I have found that this arrangement helps us stay focused on our goals during the session. It also allows me to keep my fees as low as possible because it cuts down on my bookkeeping costs. I accept checks, cash, Visa, MasterCard, American Express, Discover, FSA and HSA account payments. Other payment or fee arrangements must be worked out before the end of our first meeting.

Please note that all clients are automatically enrolled in Autopay. Copays, coinsurance, deductibles, sliding scale fees or self pay fees will be charged within 24 hours of your session. You may OPT OUT of autopay through your client portal when you fill out your paperwork, or by notifying us at hello@wildhopetherapy.com

I ask that you provide 24 hours notice if you must cancel your appointment. If you do not cancel within 24 hours of your appointment, or you do not attend your appointment, a $50 fee will be charged to your account. If you late cancel/no show to your scheduled appointments 3 times in a row, I may terminate our services and provide you referrals. If a client late cancels 6 times within a 3 month period, I may also terminate services and will provide you with referrals. Utilizing this policy is up to clinician discretion and will always be discussed with the client.

Good Faith Estimate and No Surprises Act: You may obtain a good faith estimate of my charges upon request prior to scheduling with me.

Telephone consultations: I believe that telephone consultations may be suitable or even needed at times in our therapy. If so, I will charge you my regular fee, prorated for the time needed. If I need to have long telephone conferences with other professionals as part of your treatment, you will be billed for these at the same rate as for regular therapy services. If you are concerned about this, please be sure to discuss it with me in advance so we can set a policy that is comfortable for both of us. Of course, there is no charge for calls about appointments or similar business issues. Insurance companies will typically not provide reimbursement for telephone consultations.

Extended sessions: Occasionally it may be better to go on with a session, rather than stop or postpone work on a particular issue. When this extension is more than 10 minutes I will tell you, because sessions that are extended beyond 10 minutes will be charged on a prorated basis. Insurance may not pay for the extended portion of a session.

Reports: I will not charge you for my time spent making routine reports to your insurance company.

If you think you may have trouble paying your bills on time, please discuss this with me. I will also raise the matter with you so we can arrive at a solution together. If your unpaid balance reaches $300.00, I will notify you. If it then remains unpaid, I may terminate therapy with you if we cannot agree on a payment plan. Fees that continue unpaid after this may be turned over to small-claims court or a collection service and you agree to allow me to do that. If I choose to do that, I will report only enough information to collect fees due to me.

A late payment fee of $25.00 will be charged each month that a balance remains unpaid, since I will incur costs to rebill and other accounting costs. A returned check fee of $35.00 will be charged if your check bounces. Once a check is returned, I will no longer accept checks for future payments.

Because I am a licensed mental health therapist, many health insurance plans will help you pay for therapy and other services I offer. Because health insurance is written by many different companies, I cannot tell you what your plan covers. Please read your plan’s booklet under coverage for “Outpatient Psychotherapy” or under “Treatment of Mental and Nervous Conditions.” Or call your employer’s benefits office to find out what you need to know.

If your health insurance will pay part of my fee, I will help you with your insurance claim forms. However, please keep some things in mind: I had no role in deciding what your insurance covers. Your employer or you (if you have individual coverage) decided which, if any, services will be covered and how much you have to pay. You are responsible for checking your insurance coverage, deductibles, payment rates, copayments, and so forth. Your insurance contract is between you and your insurance company; it is not between me and the insurance company unless I have signed a separate agreement with that particular company. You are responsible for paying the fees we agree upon. If you ask me to bill a separated spouse, a relative, or an insurance company and I do not receive payment on time, I will then expect this payment from you, and you agree to pay amounts due. In addition, the plan may have rules, limits, and procedures that we should discuss and I may not be on one of their panels. Please bring your health insurance plan’s description of services to one of our early meetings, so that we can talk about it and decide what to do.

I will provide information about you to your insurance company with your consent, and by signing below you agree that I may do that. If I have a contract with your insurance company then billing will be sent in accordance with the contract I have with that company. If I am not contracted with that insurance company, then I will supply you with an invoice for my services with the standard diagnostic and procedure codes for billing purposes, the times we met, my charges, and your payments. You can use this to apply for reimbursement. By signing this form, you agree to assign any reimbursement you receive from your insurance company to me.

If you choose to not have me send information to your insurance company, you must select this option before each session and then pay for the session in full. I will then not report any information to your insurance company about that session. Although insurance companies say that they maintain confidentiality, oftentimes they report information to a national data bank that may later affect your ability to obtain other types of insurance.

Emergencies and After-Hours Care

I may be reached by phone at (614) 328-9714. I will make every effort to return messages within 24 hours; however, I may not always be able to do that. Current clients will be notified during sessions of upcoming travel or vacation. If you have an emergency you should go directly to a hospital emergency department or call 911. The National Suicide Prevention Lifeline number is 1-800-273-8255. Emergencies are urgent situations and require immediate action; this includes if you feel that you may be a harm to yourself or others.

Incapacity or Death of Therapist

In the event that I am incapacitated or die, it will be necessary for another therapist to take possession of your file and records. By signing this form, you consent to allow another licensed mental health professional whom I designate to take possession of your file and records, provide you with copies upon request, or to deliver them to a therapist of your choice.

Disclosing Information to Family Members, Relatives, or Close Friends

By signing this document, you agree to allow me, if you are incapacitated, in an emergency situation, or are not available, to contact a family member, a relative, a close friend or any other person you identify, and disclose your personal health information that directly relates to that person’s involvement in your healthcare. This information will be disclosed as necessary only if I determine that it is your best interest based on my professional judgment.

Email, Texting, and Electronic Communications

I prefer that we agree together how to use electronic communication such as e-mail, texting, or other electronic communications. If you decide you want to utilize any form of electronic communication, you acknowledge that there are confidentiality risks inherent in such communications if they are unencrypted and you agree to accept those risks.

By signing this document, you agree that you understand the risks involved in unencrypted electronic communications and agree to accept such risks in communications from either me to you or you to me that involve scheduling and/or therapy, if we decide together it is appropriate to do so.

If you do not want me to contact you at a certain email, address or phone number, please let me know at our first meeting.

Acknowledgment of Informed Consent to Treatment

I voluntarily agree to receive mental health assessment, care, treatment, or services and authorize you to provide such care, treatment or services as are considered necessary and advisable. I further authorize the submission of information to an insurance company or third party payer, to obtain reimbursement unless I direct otherwise.

I understand and agree that I will participate in the planning of my care, treatment, or services and that I may stop such care, treatment or services that I receive through you at any time. I also understand that there are no guarantees that treatment will be successful.

By signing this Acknowledgement of Informed Consent to Treatment, I, the undersigned client, acknowledge that I have both read and understood all the terms and information contained herein and I agree to be bound by the provisions in this agreement. Ample opportunity has been offered to me to ask questions and seek clarification of anything unclear to me. If an adult with a court appointed guardian is the client I am signing on behalf of the ward as the authorized guardian. (Information will be shared with the ward as appropriate.)

I also acknowledge that I have received a copy of the Notice of Privacy Practices for the mental health therapist listed at the top of this form.

Notice of Policies and Practices to Protect the Privacy of Your Health Information

THIS NOTICE DESCRIBES HOW MENTAL HEALTH AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

I. 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 in most instances without your consent under HIPAA, but I will obtain consent in another form for disclosing PHI for other reasons**,** including disclosing PHI outside of my practice, except as otherwise outlined in this Policy. In all instances I will only disclose the minimum necessary information in order to accomplish the intended purpose. To help clarify these terms, here are some definitions:

• “PHI” 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 therapist.

- 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, which would include an audit.

- 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.

• “Use” applies only to activities within my practice, such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.

• “Disclosure” applies to activities outside of my practice, such as releasing, transferring, or providing access to information about you to other parties.

II. Uses and Disclosures Requiring Authorization

I may use or disclose PHI for purposes outside of treatment, payment, and 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 and health care operations, I will obtain an authorization from you before releasing this information, including uses and disclosures of PHI for marketing purposes, and disclosures that constitute a sale of PHI. Examples of disclosures requiring an authorization include disclosures to your partner, your spouse, your children, except in some limited instances where they are involved in your health care, in which case I will obtain your consent first. Any disclosure involving psychotherapy notes, if I maintain them, will require your signed authorization, unless I am otherwise allowed or required by law to release them. You may revoke an authorization for future disclosures, but this will not be effective for past disclosures which you have authorized.

III. Uses and Disclosures Requiring Neither Consent nor Authorization

I may use or disclose PHI without your consent or authorization as allowed by law, including under the following circumstances:

• Serious Threat to Health or Safety: If I believe that you pose a clear and substantial risk of imminent serious harm, or a clear and present danger, to yourself or another person I may disclose your relevant confidential information to public authorities, the potential victim, other professionals, and/or your family in order to protect against such harm. If you communicate to me an explicit threat of inflicting imminent and serious physical harm or causing the death of one or more clearly identifiable victims, and I believe you have the intent and ability to carry out the threat, then I may take one or more of the following actions in a timely manner: 1) take steps to hospitalize you on an emergency basis, 2) establish and undertake a treatment plan calculated to eliminate the possibility that you will carry out the threat, and initiate arrangements for a second opinion risk assessment with another mental health professional, 3) communicate to a law enforcement agency and, if

feasible, to the potential victim(s), or victim's parent or guardian if a minor, all of the following information: a) the nature of the threat, b) your identity, and c) the identity of the potential victim(s). I will inform you about these notices and obtain your written consent, if I deem it appropriate under the circumstances.

• Worker’s Compensation: If you file a worker’s compensation claim, I may be required to give your mental health information to relevant parties and officials.

• Felony Reporting: I am allowed to report any felony that you report to me that has been or is being committed.

• For Health Oversight Activities: I may use and disclose PHI if a government agency is requesting the information for health oversight activities. Some examples could be audits, investigations, or licensure and disciplinary activities conducted by agencies required by law to take specified actions to monitor health care providers, or reporting information to control disease, injury or disability.

• For Specific Governmental Functions:** I may disclose PHI of military personnel and veterans in certain situations, to correctional facilities in certain situations, and for national security reasons, such as for protection of the President.

• For Lawsuits and Other Legal Proceedings:** If you are involved in a court proceeding and a request is made forinformation concerning your evaluation, diagnosis or treatment, such information is protected by law. I cannot provide any information without your (or your personal or legal representative’s) written authorization, or acourt order, or at times an administrative subpoena, unless the information was prepared for a third party. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a courtwould be likely to order me to disclose information. If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself.

• Abuse, Neglect, and Domestic Violence:** If I know or have reason to suspect that a child under 18 years of age or a developmentally disabled, or physically impaired child under 21 years of age has suffered or faces a threat of suffering any physical or mental wound, injury, disability, or condition of a nature that reasonably indicates abuse or neglect of the child or developmentally disabled individual under 21, the law requires that I file a report with the appropriate government agency, usually the County Children Services Agency. Once such a report is filed, I may be required to provide additional information. If I have reasonable cause to believe that a developmentally disabled adult, or an elderly adult in an independent living setting or in a nursing home is being abused, neglected, or exploited, the law requires that I report such belief to the appropriate governmental agency. Once such a report is filed, I may be required to provide additional information. If I know or have reasonable cause to believe that a patient or client has been the victim of domestic violence, I must note that knowledge or belief and the basis for it in the patient’s or client’s records.

• To Coroners and Medical Examiners:** I may disclose PHI to coroners and medical examiners to assist in the identification of a deceased person and to determine a cause of death.

• For Law Enforcement: I may release health information if asked to do so by a law enforcement official in response to a court order, subpoena, warrant, summons or similar process, subject to all applicable legal requirements.

• Required by Law. I will disclose health information about you when required to do so by federal, state or local law.

• Public Health Risks. I may disclose health information about you for public health reasons in order to prevent or control disease, injury or disability; or report births, deaths, non-accidental physical injuries, reactions to medications or problems with products.

• Information Not Personally Identifiable. I may use or disclose health information about you in a way that does not personally identify you or reveal who you are.

Other uses and disclosures will require your signed authorization, unless the use or disclosure is allowed or required by law.

IV. Patient's Rights and Duties

Patient’s Rights:

• *Right to Request Restrictions and Disclosures–*You have the right to request restrictions on certain uses and disclosures of protected health information about you for treatment, payment or health care operations. However, I am not required to agree to a restriction you request, except under certain limited circumstances, and will notify you if that is the case. One right that I may not deny is your right to request that no information be sent to your health care plan if payment in full is made for the health care service. If you select this option then you must request it ahead of time and payment must be received in full each time a service is going to be provided. I will then not send any information to the health care plan for that session unless I am required by law to release this information.

• 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. If your request is reasonable, then I will honor it.

• 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, except under some limited circumstances. If I maintain the information in an electronic format you may obtain it in that format. This does not apply to information created for use in a civil, criminal or administrative action or proceeding. I may charge you reasonable amounts for copies, mailing or associated supplies under most circumstances. I may deny your request to inspect and/or copy your record or parts of your record in certain limited circumstances. If you are denied copies of or access to your PHI, you may ask that my denial be reviewed. Under certain stances where I feel, for clearly stated treatment reasons, the disclosure of your record might have an adverse effect on you, I will provide your records to another mental health therapist of your choice.

• 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, but will note that you made the request. Upon your request, I will discuss with you the details of the amendment process.

• Right to an Accounting – With certain exceptions, you generally have the right to receive an accounting of disclosures of PHI, not including disclosures for treatment, payment or health care operations for paper records on file for the past six years and for an accounting of disclosures made involving electronic records, including disclosures for treatment, payment or health care operations, for a period of three years. 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, to provide you with this notice of my legal duties and privacy practices with respect to PHI, and to abide by the terms of this notice.

• I reserve the right to change the privacy policies and practices described in this notice and to make those changes effective for all of the PHI I maintain.

• If I revise my policies and procedures, which I reserve the right to do, I will make available a copy of the revised notice to you on my website, if I maintain one, and one will always be available at my office. You can always request that a paper copy be sent to you by mail.

• In the event that I learn that there has been an impermissible use or disclosure of your unsecured PHI, unlessthere is a low risk that your unsecured PHI has been compromised, I will notify you of this breach.

V. Complaints

If you are concerned that I have violated your privacy rights, or you disagree with a decision I make about access to your records, you may file a complaint with me and I will consider how best to resolve your complaint. Contact me, the Privacy Officer, if you wish to file a complaint with me. In the event that you aren’t satisfied with my response to your complaint, or don’t want to first file a complaint with me, then you may send a written complaint to the Secretary of the U.S. Department of Health and Human Services in Washington, D.C., 200 Independence Avenue S.W., Washington, D.C. 20201, Ph: 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/compliants/.

There will be no retaliation against you for filing a complaint.

VI. Effective Date:

This notice is effective as of March 1, 2020.

VII. Privacy and Security Officer: I act as my own Privacy and Security Officer. My contact information is listed at the beginning of this form.

CONSENT FOR TELEHEALTH CONSULTATION

I understand that my health care provider wishes me to engage in a telehealth consultation.
My health care provider explained to me how the video conferencing technology that will be used to affect such a consultation will not be the same as a direct client/health care provider visit due to the fact that I will not be in the same room as my provider.
I understand that a telehealth consultation has potential benefits including easier access to care and the convenience of meeting from a location of my choosing.
I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my health care provider or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.
I have had a direct conversation with my provider, during which I had the opportunity to ask questions in regard to this procedure. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand.

CONSENT TO USE THE TELEHEALTH BY SIMPLEPRACTICE SERVICE

Telehealth by SimplePractice is the technology service we will use to conduct telehealth videoconferencing appointments. It is simple to use and there are no passwords required to log in. By signing this document, I acknowledge:

Telehealth by SimplePractice is NOT an Emergency Service and in the event of an emergency, I will use a phone to call 911.
Though my provider and I may be in direct, virtual contact through the Telehealth Service, neither SimplePractice nor the Telehealth Service provides any medical or healthcare services or advice including, but not limited to, emergency or urgent medical services.
The Telehealth by SimplePractice Service facilitates videoconferencing and is not responsible for the delivery of any healthcare, medical advice or care.
I do not assume that my provider has access to any or all of the technical information in the Telehealth by SimplePractice Service – or that such information is current, accurate or up-to-date. I will not rely on my health care provider to have any of this information in the Telehealth by SimplePractice Service.
To maintain confidentiality, I will not share my telehealth appointment link with anyone unauthorized to attend the appointment.

By signing this form, I certify:

That I have read or had this form read and/or had this form explained to me.
That I fully understand its contents including the risks and benefits of the procedure(s).
That I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.