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Terms and Policy

Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW THIS NOTICE CAREFULLY.

Your health record contains personal information about you and your health. This information about you that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services is referred to as Protected Health Information (“PHI”). This Notice of Privacy Practices describes how we may use and disclose your PHI in accordance with applicable law and the NASW Code of Ethics. It also describes your rights regarding how you may gain access to and control your PHI.

We are required by law to maintain the privacy of PHI and to provide you with notice of our legal duties and privacy practices with respect to PHI. We are required to abide by the terms of this Notice of Privacy Practices. We reserve the right to change the terms of our Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that we maintain at that time. We will provide you with a copy of the revised Notice of Privacy Practices by posting a copy on our website, sending a copy to you in the mail upon request or providing one to you at your next appointment.

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU

For Treatment. Your PHI may be used and disclosed by those who are involved in your care for the purpose of providing, coordinating, or managing your health care treatment and related services. This includes consultation with clinical supervisors or other treatment team members. We may disclose PHI to any other consultant only with your authorization. We may also contact you to remind you of your appointments or to provide information to you about treatment alternatives or other health-related benefits and services that may be of interest to you.

For Payment. We may use and disclose PHI so that we can receive payment for the treatment services provided to you. This will only be done with your authorization. Examples of payment-related activities are: making a determination of eligibility or coverage for insurance benefits, processing claims with your insurance company, reviewing services provided to you to determine medical necessity, or undertaking utilization review activities. If it becomes necessary to use collection processes due to lack of payment for services, we will only disclose the minimum amount of PHI necessary for purposes of collection.

For Health Care Operations. We may use or disclose, as needed, your PHI in order to support our business activities including, but not limited to, quality assessment activities, employee review activities, licensing, and conducting or arranging for other business activities. For example, we may share your PHI with third parties that perform various business activities (e.g., billing or typing services) provided we have a written contract with the business that requires it to safeguard the privacy of your PHI. For training or teaching purposes PHI will be disclosed only with your authorization.

Required by Law. Under the law, we must disclose your PHI to you upon your request. In addition, we must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining our compliance with the requirements of the Privacy Rule.

Without Authorization. Following is a list of the categories of uses and disclosures permitted by HIPAA without an authorization. Applicable law and ethical standards permit us to disclose information about you without your authorization only in a limited number of situations.

As a social worker licensed in this state and as a member of the National Association of Social Workers, it is our practice to adhere to more stringent privacy requirements for disclosures without an authorization. The following language addresses these categories to the extent consistent with the NASW Code of Ethics and HIPAA.

Child Abuse or Neglect. We may disclose your PHI to a state or local agency that is authorized by law to receive reports of child abuse or neglect.

Judicial and Administrative Proceedings. We may disclose your PHI pursuant to a subpoena, court order, administrative order or similar process.

Deceased Patients. We may disclose PHI regarding deceased patients as mandated by state law. A release of information regarding deceased patients may be limited to an executor or administrator of a deceased person’s estate.

Medical Emergencies. We may use or disclose your protected health information in a medical emergency situation to medical personnel only in order to prevent serious harm. Our staff will try to provide you a copy of this notice as soon as reasonably practicable after the resolution of the emergency.

Family Involvement in Care. We may disclose information to close family members or friends directly involved in your treatment based on your consent or as necessary to prevent serious harm.

Health Oversight. If required, we may disclose PHI to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies and organizations that provide financial assistance to the program (such as third-party payors based on your prior consent) and peer review organizations performing utilization and quality control.
Law Enforcement. We may disclose PHI to a law enforcement official as required by law, in compliance with a subpoena, court order, administrative order or similar document, for the purpose of identifying a suspect, material witness or missing person, in connection with the victim of a crime, in connection with a deceased person, in connection with the reporting of a crime in an emergency, or in connection with a crime on the premises.
Specialized Government Functions. We may review requests from U.S. military command authorities if you have served as a member of the armed forces, authorized officials for national security and intelligence reasons and to the Department of State for medical suitability determinations, and disclose your PHI based on your written consent, mandatory disclosure laws and the need to prevent serious harm.

Public Health. If required, we may use or disclose your PHI for mandatory public health activities to a public health authority authorized by law to collect or receive such information for the purpose of preventing or controlling disease, injury, or disability, or if directed by a public health authority, to a government agency that is collaborating with that public health authority.

Public Safety. We may disclose your PHI if necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. If information is disclosed to prevent or lessen a serious threat it will be disclosed to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat.

Research. PHI may only be disclosed after a special approval process.

Verbal Permission. We may also use or disclose your information to family members that are directly involved in your treatment with your verbal permission.

With Authorization. Uses and disclosures not specifically permitted by applicable law will be made only with your written authorization, which may be revoked.

YOUR RIGHTS REGARDING YOUR PHI

You have the following rights regarding PHI we maintain about you. To exercise any of these rights, please submit your request in writing to our Privacy Officer, Rana Dimmig, at 46 South Chestnut Street, Boyertown, PA 19512:

• Right of Access to Inspect and Copy. You have the right, which may be restricted only in exceptional circumstances, to inspect and copy PHI that is maintained in a “designated record set”. A designated record set contains mental health/medical and billing records and any other records that are used to make decisions about your care. Your right to inspect and copy PHI will be restricted only in those situations where there is compelling evidence that access would cause serious harm to you. We may charge a reasonable, cost-based fee for copies. If your records are maintained electronically, you may also request an electronic copy of your PHI.

• Right to Amend. If you feel that the PHI we have about you is incorrect or incomplete, you may ask us to amend the information although we are not required to agree to the amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us. We may prepare a rebuttal to your statement and will provide you with a copy. Please contact the Privacy Officer if you have any questions.

• Right to an Accounting of Disclosures. You have the right to request an accounting of certain of the disclosures that we make of your PHI. We may charge you a reasonable fee if you request more than one accounting in any 12-month period.
• Right to Request Restrictions. You have the right to request a restriction or limitation on the use or disclosure of your PHI for treatment, payment, or health care operations. We are not required to agree to your request unless the request is to restrict disclosure of PHI to a health plan for purposes of carrying out payment or health care operations, and the PHI pertains to a health care item or service that you paid for out of pocket. In that case, we are required to honor your request for a restriction.

• Right to Request Confidential Communication. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location.
• Breach Notification. If there is a breach of unsecured protected health information concerning you, we may be required to notify you of this breach, including what happened and what you can do to protect yourself.
• Right to a Copy of this Notice. You have the right to a copy of this notice.

COMPLAINTS

If you believe we have violated your privacy rights, you have the right to file a complaint in writing with our Privacy Officer, Rana Dimmig, at 46 South Chestnut Street, Boyertown, PA 19512, or with the Secretary of Health and Human Services at 200 Independence Avenue, S.W. Washington, D.C. 20201 or by calling (202) 619-0257. We will not retaliate against you for filing a complaint.

The effective date of this Notice is March 2010.
( Type Full Name )
Consent to Services
Welcome to my 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 (HIPPA), a federal law that provides privacy protections and 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, and my practice is in general accordance with HIPAA policies. 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 this document, it will also 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 or if you have not satisfied any financial obligations you have incurred.

PSYCHOLOGICAL SERVICES
Therapy is a relationship between people that works in part because of the clearly defined rights and responsibilities held by each person. This frame helps to create the safety to take risks and the support to become empowered to create change. As a client in psychotherapy, you have certain rights and responsibilities that are important for you to know about. There are also legal limitations to those rights that you should be aware of. I, as your therapist, have corresponding responsibilities to you. These respective rights are described in the following section. Psychotherapy has both benefits and risks. Risks sometimes include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness. Psychotherapy often requires discussing unpleasant aspects of your life. However, psychotherapy has been shown to have benefits for individuals who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress, and resolutions to specific problems. But, there are no guarantees about what will happen. Psychotherapy requires a very active effort on your part. In order to be most successful, you will have to work on things that we discuss outside of sessions.

The first few sessions will involve a comprehensive evaluation of your needs. By the end of the evaluation, I will be able to offer you some initial impressions of what our work may include. At that point, we will discuss your treatment goals and create a personalized, initial treatment plan, if you decide to continue. You should evaluate this information as well as your own assessment about when 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, we should discuss them whenever they arise.

SUPERVISED VISITATION
Supervised visitation is a process aimed at helping children be and feel safe with their parents. It is our goal to create a neutral setting where each party can be treated with equal respect for the best interest of their children. As a client of our practice, you have certain rights and responsibilities that are important for you to know about. There are also legal limitations to those rights that you should be aware of. We, as your monitors, have corresponding responsibilities to you. These respective rights are described in the following section.

Supervised visitation has both benefits and risks. Risks sometimes include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness. Supervised visitation often requires discussing unpleasant aspects of your life, as well as putting trust in a stranger to help you during a difficult transition. However, supervised visitation has been shown to have benefits for individuals who undertake it. Supervised visitation can lead to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress, and resolutions to specific problems. But, there are no guarantees about what will happen. Supervised visitation requires a very active effort on your part.

The first sessions will involve a comprehensive evaluation of your needs. We will discuss your custody goals and create a personalized, initial plan for visitation, if you decide to continue. You should evaluate this information as well as your own assessment about when you feel comfortable working with us. Supervised visitation involves a large commitment of time, money, and energy, so you should be very careful about the provider you select. If you have questions about our procedures, we should discuss them whenever they arise.

Your monitor will be present at all times during your visit. All contact will take place in the sight and hearing of the monitor at all times. It is our policy to stagger arrival and departure times to protect all parties. Please adhere to the arrival and departure times your monitor assigns you. Custodial and visiting parents will adhere to their monitor’s guidance at exchange and during scheduled visitation. Non-compliance with guidelines or challenging the authority of the monitor may lead to termination of services at the discretion of the monitor. Visitation will be canceled if a parent is suspected of being under the influence of alcohol or non-prescription drugs. Parents and child/children must speak English unless otherwise specified during visitation and must speak loud enough for monitor to hear. Family members or friends authorized by the court to participate in visitation may attend visitation with prior knowledge and approval of your monitor must comply with guidelines. We strive to insure that visits last the agreed upon amount of time. However, if your child becomes distressed, the visit may be terminated early. This does not mean that future visits will not occur. But allowing the distress to continue decreases the likelihood of future successful visits.

Rules of Conduct - The following is prohibited during visitation:
1. Inappropriate demands for physical contact, foul language, shouting, threats of violence or abuse, attempts to move child/children out of sight or hearing of monitor.
2. Passing of correspondence or messages to the other parent (such as regarding legal matters) through child/children or monitor.
3. Using the visitation for the service of court documents.
4. Sharing of detailed court information or court documents with the child/children and/or making of promises about future living arrangements, time sharing or visitation modifications. Visit discussions should focus on the present to avoid pressure and/or disappointment.
5. Speaking negatively about the other parent, his or her family or designee in front of the child/children and/or questions about the other parent’s whereabouts or activities.
6. Taking photographs of the child/children without prior written consent from custodial parent.
7. Permanent alterations of child/children during visitation without prior written consent of custodial parent. Alteration includes but is not limited to haircuts, tattoos, body or ear piercing.
8. Smoking in the presence of the child/children or monitor.
9. Weapons or any articles that could be used a weapon at site of visitation.
10. Contact or confrontation between parents during exchange or visitation.

APPOINTMENTS
I normally conduct an evaluation that will last from one to three sessions. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If psychotherapy is begun, I will usually schedule one 60 minute session at a time and frequency we agree on.

CANCELLATION
Psychological services are most effective when meeting times are regular and consistent. The time scheduled for you appointment is assigned to you and you alone. If you need to cancel or reschedule a session, it is required that you provide more than 24 hours notice. If you miss a session without cancelling, or cancel with less than 24 hours notice, you must pay my standard fee for the missed session. It is important to note that insurance companies do not provide reimbursement for cancelled sessions. In addition, you are responsible for coming to your session on time scheduled. If you are late, your appointment will still need to end on time.

FEES, BILLING, AND PAYMENT
Psychotherapy sessions billed at the standard fee of $100 per hour, unless otherwise agreed upon. Session fees are payable at times of service unless alternative arrangements have been arranged prior to the time of session. Fees will be reevaluated periodically. Legal fees are not billable to insurance companies and will be charged to the patient directly (eg. court reports, court appearances). A fee of $1000 per day is due one week prior for court testimony. Testimony is provided only with subpoena or order of court. Reports and communication may be billed at $25 per 15 minutes, at the discretion of the therapist.

Supervised visitation is billed at the standard fee of $45 per hour, unless otherwise agreed upon, with the exception of therapeutic supervision which is billed at the psychotherapy rate listed above. Session fees are payable at the time of services unless alternative arrangements have been arranged prior to the time of session. Fees will be reevaluated periodically. Legal fees are not billable to insurance companies and will be charged to the patient directly (eg. court reports, court appearances). A fee of $450 per day is due one week prior for court testimony. Testimony is provided only with subpoena or order of court. Reports and communication may be billed at $10 per 15 minutes, at the discretion of your supervisor.

Should a balance accrue and no payment is received, I reserve the right to seek remuneration by any means legally possible including, but not limited to, the retention of a collection agency. Fees may be paid in cash, by credit card or check. There will be a $25 fee for any returned checks. Should three checks be returned, all future fees must be paid in cash, at my discretion.

PROFESSIONAL RECORDS
I am required to keep appropriate records of the psychological services that I provide. Although psychotherapy often includes discussions of sensitive and private information, normally very brief records are kept noting that you have been here, what was done in session, and a mention of the topics discussed. You have the right to a copy of your file at any time. You have the right to request that a copy of your file be made available to any other health care provider at your written request. Your records are maintained in a secure location.

CONFIDENTIALITY
If ordered by the court to participate in supervised visitation or therapy, this document serves as a release of information releasing your provider to report his/her observations, diagnosis, opinion, and suggestions/recommendation, in writing or by testimony to the court, as delineated in your court order. By signing this agreement, you indicate that you understand that all of your communications become part of the clinical record.

The confidentiality of all communications between a client and a therapist is generally protected by law and I, as your therapist, cannot and will not tell anyone else what you have discussed or even that you are in therapy without your written permission. In most situations, I can only release information about your treatment requirements imposed by HIPAA.

There are, however, several exceptions in which I am legally bound to take action even though that requires revealing some information about a patient’s treatment if at all possible. I will make every attempt to inform you when these will have to be put into effect. The legal exceptions to confidentiality include, but are not limited, to the following:
1. If there is good reason to believe you are threatening serious bodily harm to yourself or others. If I believe a client is threatening serious bodily harm to another, I may be required to take protective actions, which may include notifying the potential victim, notifying the police, or seeking appropriate hospitalization. If a client threatens harm to him/herself or another, I may be required to seek hospitalization for the client, or to contact family members or others who can provide protection.
2. If there is good reason to suspect, or evidence of, abuse and/or neglect towards children, the elderly or disabled persons. In such a situation, I am required by law to file a report with the appropriate state agency.
3. In response to a court order or where otherwise required by law. In cases that are court ordered, I may be called to testify as to what has occurred in court ordered counseling. Please be aware that all communication in court ordered cases are subject to my preparation of a report or testimony as defined in the court order. Some orders preclude testimony, wanting the counseling to be therapeutic. In others a periodic report to the court or attorneys is ordered. We will review your court order together so as to best understand your specific case and the impact court involvement will have on our therapeutic relationship with regards to confidentiality.
4. To the extent necessary, to make a claim on a delinquent account via a collection agency.
5. To the extent necessary, for emergency medical care to be rendered.
Finally, there are times when I find it beneficial to consult with colleagues as part of my practice for mutual professional consultation. Your name and unique identifying characteristics will not be disclosed. The consultant is also legally bound to keep the information confidential.

CONTACTING ME
I am often not immediately available by telephone. I do not answer the phone when I am with a client, and I am not always in the office during normal business hours. If you need to reach me between sessions, or in an emergency, you have the right to a timely response. You may leave a message on my confidential voicemail at any time and your call will be returned as soon as possible or by the next business day under normal circumstances. I do check my voicemail every night and on weekends. Please make sure to inform me of the nature of the emergency and a number where I may reach you and I will make every attempt to get in touch with you as soon as possible. You may also reach me by email.
It remains your responsibility to take care of yourself until such time as we can talk. If you feel unable to keep yourself safe, call 911 and go to your nearest emergency room. I will make every attempt to inform you in advance of any planned absences, and provide you with a name and phone number of the person covering the practice.

OTHER RIGHTS
If you are unhappy with what is happening in therapy, I hope you’ll talk with me so that I can respond to your concerns. Such concerns will be taken seriously and with care and respect. You may also request that I refer you to another therapist and are free to end therapy at any time.
You have the right to considerate, safe, and respectful care, without discrimination as to race, ethnicity, color, gender, sexual orientation, age, religion, national origin, or source of payment. You have the right to ask questions about any aspect of the therapy and about my specific training and experience. You have the right to expect that I will not have social or sexual relationships with clients or former clients.

CONSENT TO PSYCHOTHERAPY
Your signature below indicates that you have read this agreement and agree to its terms. It also serves as an acknowledgement that you have received the HIPAA Notice Form described above.
( Type Full Name )