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Psychotherapist-Client Services Agreement
Updated July 15, 2018
This document 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 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 I provide you with a Notice of Privacy Practices (the Notice) for use and disclosure of PHI for treatment, payment and health care operations. The Notice, which is attached to 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 at the end of this session. 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 attached client agreement form, it will also represent an agreement between us.
Counseling is a unique process in which you will explore personal thoughts, feelings, beliefs, values and behaviors in order to improve problematic life situations and enhance personal potential. It is assumed that you have the resources to live more effectively, but you may have difficulty accessing these resources as a result of internal conflict, stress or outside influences.Although it is common to feel some relief after initial sessions, be prepared for periods of discouragement, emotional stress or worsening of symptoms during the counseling process as these are normal phenomena. Please let me know if you are experiencing any distress so we can focus on reducing it to reducing it to manageable levels. Although there are no guarantees, research shows that counseling often leads to symptom relief, better relationships, solutions to specific problems and more life fulfillment in general.
Sessions (held by appointment only) are 45 minutes in duration on a weekly basis although this may vary with your counseling goals, needs and progress. Attending sessions on a regular basis is critical for achieving counseling goals. During our first session, we will discuss number and frequency of sessions, and renegotiate as necessary. If you are more than 10 minutes late for a session and have not left a message on my voicemail (708) 448-1306, the session will be rescheduled, and you will be billed $30 for that session.
When using insurance, sessions will be billed to you at the rate specified by your insurance company.
You will be charged $30 for missed sessions or those cancelled without 24-hour notice.
Given the potential security problems with email, I am requesting that you contact me at the phone number I provided you, and leave a message on my confidential voicemail. For routine matters, please call during the following hours: Mon – Thurs (10am – 10 pm) Fri and Sat (10am – 3pm). During an emergency (you fear that you may harm or kill yourself or someone else, your physical safety is in jeopardy, a significant life crisis has occurred your symptoms are significantly impairing your normal functioning, please leave a message on my voicemail. If I do not return your call promptly, please call the crisis line (708) 258-3333 which is also provided on my voicemail message, call 911 or go to your nearest emergency room.
In general, any communications you make to me in the context of our counseling relationship (sessions, phone calls, written materials, drawings, etc.) are confidential. This means I am legally and ethically bound to keep your information confidential. However, there are exceptions to confidentiality which are listed below.
- When an identified individual’s safety is believed to be in danger (e.g., threats of suicide, homicide, child abuse, elder abuse, threat of assault).
- When you sign an authorization for release or exchange of information.
- My billing service, with which I have a formal business associate contract.
- Any staff members that I may hire for administrative purposes.
- All staff involved in processing insurance claims.
- Consultations with other health or mental-health professionals. Every effort is made to avoid revealing any identifying information.
- Case presentations for teaching purposes. Virtually no identifying information is provided.
- Information requested by a court order, government agency, or insurance company.
- In the event that a complaint or lawsuit is filed against me, I may disclose relevant information to defend myself.
The laws and standards of my profession require that I keep Protected 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, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents.
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 I 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 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 happy to discuss any of these rights with you.
Minors and Parents
Parents of children between 12 and 18 cannot examine their child’s records unless the child consents and unless I find that there are no compelling reasons for denying the access. Parents are entitled to information concerning their child’s current physical and mental condition, diagnosis, treatment needs, services provided, and services needed. Since parental involvement is often crucial to successful treatment, in most cases, I require that patients between 14 and 18 years of age and their parents enter into an agreement that allows parents access to certain additional treatment information including progress or issues of concern. 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.
Termination of Counseling Services
Please let me know when you are ready to terminate counseling. It is very helpful to have a final session to review progress, assess current status and discuss possible referrals. If for some reason, I am unable to continue providing counseling services to you, I will provide counseling referrals, and assist in transitioning counseling services to the best of my ability.
ILLINOIS NOTICE FORM
Effective September 23, 2013
Notice of Psychotherapists’ Policies and Practices to Protect the Privacy of Your Health Information
THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL 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 with your written authorization. I may also disclose PHI for payment purposes with your general consent. 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 psychologist.
– 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.
- “Use” applies only to activities within my [office, clinic, practice group, etc.] such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
- “Disclosure” applies to activities outside of my [office, clinic, practice group, etc.], such as releasing, transferring, or providing access to information about you to other parties.
- “Authorization” is your written permission to disclose confidential mental health information. All authorizations to disclose must be on a specific legally required form.
II. Other 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. 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. I will also need to obtain an authorization before releasing your Psychotherapy Notes. “Psychotherapy Notes” are notes I have made about our conversation during a private, group, joint, or family counseling session, which I have kept separate from the rest of your record. These notes are given a greater degree of protection than PHI.
You may revoke all such authorizations (of PHI or Psychotherapy Notes) at any time, provided each 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.
I will also obtain an authorization from you before using or disclosing:
- PHI in a way that is not described in this Notice.
- PHI for marketing purposes.
III. Uses and Disclosures without 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 a child known to me in my professional capacity may be an abused child or a neglected child, I must report this belief to the appropriate authorities.
- Adult and Domestic Abuse – If I have reason to believe that an individual (who is protected by state law) has been abused, neglected, or financially exploited, I must report this belief to the appropriate authorities.
- Health Oversight Activities – I may disclose protected health information regarding you to a health oversight agency for oversight activities authorized by law, including licensure or disciplinary actions.
- Judicial and Administrative Proceedings If you are involved in a court proceeding and a request is made for information by any party about your evaluation, diagnosis and treatment and the records thereof, such information is privileged under state law, and I must not release such information without a court order. I can release the information directly to you on your request. Information about all other psychological services is also privileged and cannot be released without your authorization 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 must be informed in advance if this is the case.
- Serious Threat to Health or Safety – If you communicate to me a specific threat of imminent harm against another individual or if I believe that there is clear, imminent risk of physical or mental injury being inflicted against another individual, I may make disclosures that I believe are necessary to protect that individual from harm. If I believe that you present an imminent, serious risk of physical or mental injury or death to yourself, I may make disclosures I consider necessary to protect you from harm.
- 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.
- When the use and disclosure without your consent or authorization is allowed under other sections of Section 164.512 of the
- Privacy Rule and the state’s confidentiality law. This includes certain narrowly-defined disclosures to law enforcement
- agencies, to a health oversight agency (such as HHS or a state department of health), to a coroner or medical
- examiner, for public health purposes relating to disease or FDA-regulated products, or for specialized government
- functions such as fitness for military duties, eligibility for VA benefits, and national security and intelligence.
There may be additional disclosures of PHI that I am required or permitted by law to make without your consent or authorization, however the disclosures listed above are the most common.
IV. Patient’s Rights and Psychologist’s Duties
- 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 send your bills to another address.)
- 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 and Psychotherapy Notes. On your request, I will discuss with you the details of the request for access process. You also have a right to an electronic form of these records.
- 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.
- Right to Restrict Disclosures When You Have Paid for Your Care Out-of-Pocket. You have the right to restrict certain disclosures of PHI to a health plan when you pay out-of-pocket in full for my services.
- Right to Be Notified if There is a Breach of Your Unsecured PHI. You have a right to be notified if: (a) there is a breach use or disclosure of your PHI in violation of the HIPAA Privacy Rule) involving your PHI; (b) that PHI has not been encrypted. to government standards; and (c) my risk assessment fails to determine that there is a low probability that your PHI has been compromised.
- Right to Opt out of Fundraising Communications. You have a right to decide that you would not like to be included in fundraising communications that I may send out.
- I am required by law to maintain the privacy of PHI and to provide you with a notice of my legal duties and privacy practices with respect to PHI.
- I reserve the right to change the privacy policies and practices described in this notice. Unless I notify you of such changes, however, I am required to abide by the terms currently in effect.
- If I revise my policies and procedures, I will provide you with copy of the revised policy and verbally explain the policy changes.
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 Dr. Jessica Loftus at (708) 448-1306
You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. The person listed above can provide you with the appropriate address upon request.
This notice will go into effect on September 23, 2013.