ABC Counseling, LLC

HIPAA Notice of Privacy Practices

Patient Consent Form

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. Effective 3/22/2020

I am totally committed to maintaining clients’ confidentiality. I will only release healthcare information about you in accordance with federal and state laws and ethics of the counseling profession. This notice describes my policies related to the use and disclosure of your healthcare information.

Use and disclosure of protected health information is for the purpose of providing services. Providing treatment services, collecting payment and conducting healthcare operations are necessary activities for quality care. State and federal laws allow us to use and disclose your health information for these purposes. The practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

Treatment: I may need to use or disclose health information about you to provide, manage, or coordinate your care or related services. This could include consultants and potential referral sources. For instance, this may include a doctor you were referred to in order to help the doctor properly diagnose and treat you.   You will be asked to sign a release as part of your treatment if this becomes necessary for your ongoing care.

Payment: I may use your PHI as needed to verify insurance coverage and/or benefits with your insurance carrier, to process your claims as well as information needed for billing and collection purposes. We may bill the person in your family who pays for your insurance.

Healthcare Operations: I may need to use information about you to review my treatment procedures and business activity. Information may be used for certification, compliance, and licensing activities. Other examples of this use would be contacting you in regards to scheduling appointments.

Other uses or disclosures of your information which do not require your consent: There are some instances where I may be required to use and disclose information without your consent. For example (but not limited to): Information you and/or your child(ren) report about physical or sexual abuse; then by Florida State Law I am required to report this to the Department of Children and Family Services; Information provided by you that informs us that you are in danger of harming yourself or others; Information to remind you about or to reschedule appointments or treatment alternatives; Information shared with law enforcement if a crime is committed on our premises or against our staff or as required by law such as a subpoena or court order; I may use or disclose your health information to a person involved in your care, such as a family member, when you are incapacitated or in an emergency, or when permitted by law.

What are your rights?

The following are your rights with respect to your mental health information:

1. You have the right to ask to restrict uses or disclosures of your mental health information for treatment, payment, or health care operation. You have the right to also ask to restrict disclosures to family members or to others who are involved in your health care or payment for your health care. Please note that while I will try to honor your request and will permit requests consistent with my policies, I am not required to agree to any restriction.

2. You have the right to ask to receive confidential communications of information in a different manner or at a different place (for example: by sending it to a P.O. Box rather than your home address).

3. You have the right to see and obtain a copy of your mental health information that may be used to make decisions about you such as claims and case management records. You also may receive a summary of this health information. You must make a written request to inspect and copy your health information. In certain limited circumstances, I may deny your request to inspect and copy your mental health information if I believe that disclosure of certain information contained in your mental health records may be harmful to your condition or impede further treatment of your condition. This decision will be binding.

4. You have the right to amend information I maintain about you if you believe the mental health information about you is wrong or incomplete. If I deny your request, you may have a statement of your disagreement added to your mental health information.

5. You may have the right to receive an accounting of disclosures of your information made by me.

6. You have the right to a paper copy of this Notice. You may ask for a copy of this Notice at any time. Even if you have agreed to receive this Notice electronically, you are still entitled to a paper copy of this Notice.

7. If you believe that your rights have been violated, you may notify the Secretary of the U.S. Department of Health and Human Services if you have any complaint to make. I will not take any action against you for filing a complaint.

I reserve the right to change the terms of this notice and will inform you in writing of any changes. You then have the right to object or withdraw as provided in this notice.

Client Informed Consent

I look forward to working with you and would like to take this opportunity to outline some of what you may expect if you decide to work with me. The therapeutic relationship is a unique relationship, and therapy works, in part, because of clearly defined rights and responsibilities that apply to each of us. There are also legal issues that I will explain as well.

My Responsibilities to You as Your Therapist

Confidentiality

With the exception of certain specific legalities, which will be explained, you have the absolute right to the confidentiality of your therapy.  I cannot and will not tell anyone else what you have told me or even that you are in therapy, without your written permission.  Under the provisions of the Health Care Information Act of 1992, and underscored by the 2003 HIPAA initiative, I may legally speak to another health care provider or a member of your family about you, without your prior consent in certain circumstances, but I will not do so unless the situation is considered urgent, and no other option is available.  You may direct me to share information with whomever you choose, and you can change your mind and revoke that permission at any time.  You may also request to have someone you wish to attend a therapy session with you.

      The following statements describe the legal exceptions to your right of confidentiality.  You may be assured that I will make every effort to inform you of any time when I believe it necessary to exercise one of these options.

• If I have good reason to believe that you will harm another person, I must attempt to inform that person and warn them of your intentions. I must also contact an appropriate law enforcement authority and ask them to offer protection to your intended victim.
• If I have good reason to believe that you or someone else is abusing or neglecting a child, a vulnerable adult, or an elderly person, I must inform the Department of Children and Family Services.
• If I have good reason to believe that you are in imminent danger of harming yourself, I may legally break confidentiality and call for assistance from a family member or a person with the authority to act on your behalf. I will attempt to explore all other options with you before I take this step.
• If you are filing a complaint or are a plaintiff in a lawsuit where you bring up the question of your mental health, you will have already automatically waived your right to the confidentiality of these records in the context of the complaint or lawsuit. Despite that, I will not release information without your signed consent or a court order. We can also discuss obtaining a protective order to help maintain confidentiality of your records.  Please let me know if you are or are aware that you may be in a situation like this in the future, so we can be diligent in planning on protecting your privacy to the best of our ability.

Couples and Family Counseling

If you are seeing me as a part of a couple or family, there are additional issues to be aware of.  At times it may be deemed necessary to see subsets or individuals in the couple or family separately.  The reason for which to do so will be explained.  In these cases, I maintain a policy of not keeping secrets of what is said or discussed in the individual sessions.  This means that I will not actively hold a secret unless I believe it is necessary to do so for reasons such as safety.  At the same time, others involved in the couple or family counseling will not be given all details of the individual sessions but may be given certain pertinent information.

Insurance does not cover marital therapy, but it typically does cover family therapy.  Family therapy is defined as therapy with 2 or more family members present, which does include a marital couple.  One person must be listed as the identified patient and they would be the one the counseling would be billed under.  The other stipulation for insurance to cover the counseling is that the identified patient must qualify for a mental health diagnosis is billable through insurance.  If neither partner qualifies for one of these mental health diagnoses, then insurance will NOT cover the counseling and the clients would be required to pay for counseling out of pocket.

Record Keeping

I keep brief records of our sessions noting that you have been seen, our topic(s) of discussion, some of my observations of you, and your progress.  This is done for me to keep track of your progress and be able to have record of what we have worked on.  You have a right to review, and request a copy of, information contained in your file at any time, allowing reasonable and adequate time for it to be copied and compiled.  You have a right to request that I correct any information in your file that you believe represents an error.  You have a right to give me a written request that I make a copy of your file, or a summary of your treatment to be given to any other health care provider.  I cannot copy any documents, reports, or any other information supplied by other providers, however, as this is a HIPAA violation.  Your records are maintained as securely as possible, and it is important to note that all financial and business-related records are maintained in a database, as well hard copy files.  Your records will be kept for a period of seven years and then will be destroyed.

Diagnosis

If a third party, such as an insurance or managed care company, is paying part of your bill for therapy, I am required to provide a diagnosis to that third party to receive payment.  Diagnoses are the technical terms that describe the nature of what brings you to treatment.  If I do use a diagnosis, I will discuss it with you.  All the diagnoses come from a book titled: Diagnostic & Statistical Manual-V. I have a copy of this book and will be glad to share whatever information from it that may be helpful in the understanding of your diagnoses.

Other Rights

You have a right to ask questions about anything that happens in therapy.  I am always willing to discuss treatment options, choices, and decisions.  Feel free to ask me to try something that you think may be helpful.  You can ask me about my training for working with the concerns that you bring, and you can request that I refer you to someone else if you decide I’m not the right therapist for you.  You are free to leave therapy at any time.

Managed Care and Insurance Coverage

It is important that you understand some things related to the handling of insurance billing.  As a provider of mental health services, I contract with several different insurance and managed care organizations, as an accommodation to you.  Each of these contracts establishes a negotiated fee, which is substantially less than the full fee-for-service, in some cases nearly 50% of the fee.  Your assistance in dealing with collection of this reduced fee is essential to my business.  It will be very helpful if you take care of co-pays and/or other obligations at the time of your session.  When we run into difficulty collecting reimbursement for services (which is frequently the case) you will be asked for assistance in helping to accomplish payment for services that have been rendered in good faith.

If your therapy is being paid for in full or in part, by a managed care or insurance company, there are usually limitations to your rights of confidentiality.  Managed care and/or insurance companies frequently impose their own rules and expectations according to whatever contract or plan in which you are enrolled.  These limitations may include such things as: securing referral information from specific sources (e.g., a medical doctor), specific and limited access to therapy, for example, a limited number of sessions, or a limited dollar amount available for coverage.  They may have specific time frames within which you must complete your therapy or require you to use medication if their reviewing professional deems it appropriate.  They may also decide that you must see a therapist other than me, within their network, if I am not on their list of providers.  Such firms also usually require some sort of detailed reports of your progress in therapy, and in some instances, copies of your case file, on a regular basis.  I do not have control over any aspect of their rules. However, I am willing to do what is within reason to help you maximize the benefits available to you by completing necessary forms, submitting required reports, etc. as needed.

My Training and Experience

            I am registered with Psychologytoday.com.  Please review my biography there.  I look forward to getting to know more about you, and you will learn a little bit about me through the counseling process.

Your Responsibilities as a Consumer of Therapeutic Services

Timeliness of Sessions

You are responsible for coming to your sessions on time, and at the time we have scheduled. If you are late, we will still end at the scheduled time. If you miss a session without canceling, or you cancel with less than 24 hours’ notice, you will be billed a $75.00 administrative fee. If you miss an appointment and do not contact us, we reserve the right to cancel ALL future sessions.  We want to provide quality care to our clients and need to know in a timely manner if you will not be able to attend. 

The reverse of this policy also applies and if your appointment is canceled without notice, you will be credited with the appropriate cancellation fee.

You may cancel an appointment by leaving a voice mail message.  The message should include the date, time, your name and a brief indication of when you would like to reschedule.  The only exception to this policy is if traveling to the appointment would endanger your safety in any way, such as in the case of hurricane or tornado warnings.

Payment

You are responsible for seeing that your sessions are paid in full by yourself or your insurance or managed care company.  Fees charged in this office typically cover a 45-55-minute session and are $150 per session, and $175 for the intake/evaluation session. 

Any overdue bills will be charged 1.5% interest. If you eventually refuse to pay your debt, I reserve the right to give your name and amount owed, along with whatever other information may be required for recovery, to a collection agency.

New pay scale is effective 8/20/2018.  If you are with an insurance company or an EAP, any cost will be in compliance with insurance companies contracted with this therapist.

Insurance Information

If you have insurance, you are responsible for providing the necessary information required to bill the company, including any forms, policy effective date, identification information, date of birth, and complete address.  You must pay your deductible, if it applies, and any co-payment at the time of service.  You must arrange for any pre-authorization necessary.  Your insurance or managed care company will be billed by the office, as a courtesy to you.  If, for some reason, a reimbursement check is mailed directly to you, and you have not paid for the service it covers, you are responsible for paying that amount by the time of your next appointment; it is important to include a copy of any “Explanation of Benefits” information you receive, along with your payment.  If you have paid for a service that becomes reimbursed by a third party, that amount will be credited to your account, or refunded directly to you.

Safety

You are responsible for coming to sessions free of alcohol or mind-altering drugs.  If I have reason to believe that you show up for a session under the influence of alcohol or mind-altering drugs, I will not proceed with our session and it will be treated as a cancelled appointment with less than 24-hour notice.  In this instance, I will also be forced to make sure you have an alternative ride home from the office, which may result in a phone call to a friend or family member or a taxi. In addition, weapons of any kind are not allowed on the property.

Informed Consent

You are responsible for giving informed consent to participate in treatment.  I will explain the therapy process to you, but it is your responsibility to ask me about any parts that you are concerned about or do not understand.  You may and should ask questions throughout the therapy process regarding goals, expectations, procedures, benefits, and possible risks involved in counseling.  It is your responsibility to be active throughout therapy as it is an interactive process requiring self-disclosure, self-exploration, and responsible action.

Complaints

If you are unhappy with any aspect of your therapy, I hope you will talk with me about it, so I can respond to your concerns. I am willing to take criticism seriously and treat it with care and respect.  If you believe that I have behaved illegally or unethically, you can make a formal complaint with the State of Florida, Department of Health, Division of Medical Quality Assurance.  If you have a billing complaint, please bring it to my attention so that it can be resolved.  If the complaint, however, has anything to do with the way your insurance or managed care company is handling your case, I will be of whatever assistance may be possible, if you understand that I am powerless to affect the outcome of their decisions.

Other things to be aware of, including telehealth options

Office Hours

My hours of availability may vary from week to week.  I will do my best to work with you in order to find a session time that is convenient for the both of us.  I can be reached via telephone during regular business hours.  Contacting Me via Phone at 321-446-2113 for schedule changes, billing, and other non-emergency related business.  If your call is not answered, please leave a message with your name, number, and the reason you are calling and please let me know if it is urgent.  I reserve the right to charge for phone calls over 15 minutes in length that are counseling in nature.

Email Communication

Communicating via email is an easy and convenient way to report important information.  It is very important to be aware that emails can be relatively easy to access by unauthorized people and hence, can compromise the privacy and confidentiality of the information within the emails.  At this time my emails are not encrypted.  If you communicate confidential or highly private information via email, I will assume that you have made an informed decision, will view it as your agreement to take the risk that such communication may be intercepted, and will honor your desire to communicate on such matters via email.  Please, be aware that emails are part of the medical records.  Also, do not use email for emergencies, due to the fact that I may not receive the message immediately, they are not a reliable way for me to provide support for you in an emergency.  Additionally, computer or network problems, emails may not be deliverable, and I may not check my emails daily.  Also, please be a considerate user of this service.  Email is not therapy and should not be used for lengthy or in-depth discussions which should be reserved for sessions.  It is important to note that we cannot engage in therapy via email.  The purpose of communication in this format would be to relay appropriate support and encouragement during a difficult time, and/or share information relevant to some particular issue or situation.  As with phone calls, I reserve the right to charge for lengthy emails that require an extended period of time to read and respond to. 

Additionally, if you are using text messaging to communicate, the same issues that are presented concerning email are also relevant with text messages.  If you chose to use text messaging, you assume all responsibility if any of the information is confidential. 

We are offering Telehealth for all clients.  We are using a HIPAA compliant site to minimize keep your information private.  Please read the disclosures below.

Social Networking

Due to ethical considerations, I am unable to link up with clients through my personal social networking profiles.  This is due to the therapeutic relationship being most successful when I keep my personal life separate from my work, as the therapeutic relationship only allows for minimal information about the therapist, and only what is relevant to the counseling process, to be revealed.  I do maintain a business page on Facebook in which I share links of blog posts that I write, as well as other articles and pictures that I come across.

Clients are able to “like” this page and follow me via Facebook, just understand that other people you are connected with will be able to see that you have done so.  Although not everyone that “likes” this page is a client, it is understandable to assume that others will assume you are a client if you “like” the page.  Therefore, you should only do so after taking this into consideration and making an informed decision.  With the new changes to how people can communicate with business pages, you are also now able to send me a private message through the Facebook page.  Additional charges in terms of messages that take a long time to read and respond to as well as confidentiality issues listed above in the section on Email Communication apply to this form of communication as well.

TELE-HEALTH INFORMED CONSENT AND AGREEMENT

What is “Tele-Health? “Tele-Health”, also referred to as telemedicine and tele-therapy, is the practice and delivery of medical, mental or behavioral health treatment by a licensed provider where client/patient care, treatment, and/or services are provided through the use of real-time electronic communications in which the provider is located at a physical site that differs from the client/patient or recipient of those services.

Risks to Confidentiality, the laws that protect confidentiality of medical and mental health information disclosed between a provider and client/patient also apply to tele-heath. As such, all information transmitted via electronic means will be treated as confidential, except in the event of credible of harm to self or others and reports of child and/or elder abuse.

Risk to confidentiality as a result of participating in tele-health include disruption or distortion of transmitted communications due to technical failures, information interceptions by unauthorized persons, environmental barriers such as loud noises and/or lighting issues that occur outside of the provider’s control, and technical difficulties due to operator error. Although risks exist, the provider agrees to make every effort to minimize risks, as well as have alternate plans for conducting sessions when technical barriers are present.

By signing this consent, you are hereby agreeing to the following terms and acknowledgements:

*I understand that tele-therapy/tele-health is the use of electronic information and communication technologies by a health care provider to deliver services to an individual when he/she is located at a different site than the provider; and I further give consent to participating in and receiving tele-health services from [Select Counselor at the Bottom of the Page] my ABC Counselor.

*I understand that there are risks associated with participating in tele-health/tele-therapy including, but not limited to, the possibility, despite reasonable efforts on the part of my provider, that: transmission of PHI could be disrupted or distorted by technical failures, the transmission could be intercepted by unauthorized persons and client’s environmental factors may limited the effectiveness of treatment due to noise, lighting or lack of privacy.

*I understand that the laws that protect privacy and the confidentiality of medical information also applies to tele-health. If a third-party (i.e. insurance company or EAP organization) assumes financial responsibility for mental and/or behavioral health services provided, the third-party payor will have access to confidential Personal Health Information (PHI) as outlined in the Practice Policies.

*I understand that it is my responsibility to ensure that tele-health is covered by my insurance policy or Employee Assistance Program authorization, and I am responsible for any co-payments, co-insurances and non-covered charges.  I also agree to have a credit/debit card on file in order to process payments electronically.

*I understand that if the provider deems it clinically appropriate for mental or behavioral health services to be rendered in-person, due to repeated technical failures, severity of symptoms or other risk factors, a referral will be made to a provider in my area or arrangements will be made for me to be seen by [Select Counselor at the Bottom of the Page] at ABC Counseling LLC in the Rockledge, Florida.

*I understand that I have the right to withhold or withdraw my consent to the use of tele-health/telemedicine in the course of my care at any time, without affecting my right to future care or treatment. I may revoke my consent verbally or in writing at any time by contacting my counselor at (321) 446-2113.  As long as this consent is in force, my counselor may provide health care services to me via tele-health/telemedicine without the need for me to sign another consent form

For additional information regarding tele-health/telemedicine, please see FL Admin Code 59G-1.057