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The Center for Dialectical and Cognitive Behavioral Therapies, LLC
New Haven, Connecticut
PSYCHOTHERAPIST- PATIENT SERVICES AGREEMENT
Welcome to our practice. This document (the Agreement) contains important information about our professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a new federal law that provides new privacy protections and new 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 we 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 contained in this Agreement and posted in he waiting room area,, explains HIPAA and its application to your personal health information in greater detail. The law requires that we obtain your signature acknowledging that we have provided you with this information. Although these documents are long and sometimes complex, it is very important that you read them carefully before our next session. We can discuss any questions you have about the procedures at that time. When you sign 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 us unless we have taken action in reliance on it; if there are obligations imposed on us by your health insurer in order to process or substantiate claims made under your policy; or if you have not satisfied any financial obligations you have incurred.
Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychotherapist and patient, and the particular problems you are experiencing. There are many different methods we may use to deal with the problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home.
Psychotherapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. On the other hand, psychotherapy has also been shown to have many benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. But there are no guarantees of what you will experience.
Our first few sessions will involve an evaluation of your needs. By the end of the evaluation, we will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with therapy. You should evaluate this information along with your own opinions of whether you feel comfortable working with us. 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 our procedures, we should discuss them whenever they arise. If your doubts persist, we will be happy to help you set up a meeting with another mental health professional for a second opinion.
We normally conduct an evaluation that will last from 1 to 4 sessions. During this time, we can both decide if we are the best group to provide the services you need in order to meet your treatment goals. If psychotherapy is begun, we will usually schedule one 45-minute session (one appointment hour of 45 minutes duration) per week at a time we agree on, although some sessions may be longer or more frequent. Once an appointment hour is scheduled, you will be expected to pay a $75 fee if you do not attend unless you provide 48 hours advance notice of cancellation. It is important to note that insurance companies do not provide reimbursement for cancelled sessions. If it is possible, we will try to find another time to reschedule the appointment. Group therapy sessions will be scheduled to last between 45 and 90 minutes. Usually, if there are 6 or more group members, the sessions will be scheduled for 60-90 minutes.
The fee for the initial session is $175. Otherwise, our hourly fee is $150. In addition to weekly appointments, we charge this amount for other professional services you may need. Other services include report writing, telephone conversations lasting longer than 10 minutes, consulting with other professionals at your request, preparation of records or treatment summaries, and the time spent performing any other service you may request of us. If you become involved in legal proceedings that require our participation, you will be expected to pay for all of our professional time, including preparation and transportation costs, even if we are called to testify by another party. Because of the difficulty of legal involvement, we charge $250-$400 per hour for preparation and attendance at any legal proceeding. Our group psychotherapy and skills group fee is $55. If paid in advance, the fee is $50. PLEASE ALSO READ THE "BILLING AND PAYMENTS" SECTION OF THIS AGREEMENT.
Due to our work schedule, we are often not immediately available by telephone. While we are usually in our office between 8 AM and 6 PM, we probably will not answer the phone when we are with a patient. When we are unavailable, our telephone is answered by a machine that notifies us that a message has been left. We will make every effort to return your call on the same day you make it, with the exception of weekends and holidays. If you are difficult to reach, please inform us of some times when you will be available. If you are unable to reach us and feel that you can’t wait for us to return your call, contact your family physician or the nearest emergency room and ask for the psychologist or psychiatrist on call. If we will be unavailable for an extended time, we will provide you with the name of a colleague to contact, if necessary. We can also be contacted by email through cdcbt.com. If you do not want us to reply by email because someone else might read the reply, you must indicate this in the email. Although email we receive will be protected from outside readers and treated as “Psychotherapy Notes” (that is, not part of the Patient Health Information record as defined by HIPAA), we cannot insure that email received by you will be secure or that the transmission process will be secure. We encourage you to omit personally identifiable information in emails and if your email address makes you individually identifiable, that you are aware we cannot ensure its privacy either in transmission or at your end of the transmission. If we do not destroy them immediately after reading them, we will typically keep such items as Diary Cards, logs or homework assignments outside of your patient record as defined by HIPAA or consider them part of Therapy Notes which have a greater, but not unlimited degree of protection from scrutiny by outside agency (carefully read the HIPPA policy we provided if you are concerned about this).
LIMITS ON CONFIDENTIALITY
The law protects the privacy of all communications between a patient and a psychotherapist. In most situations, we can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance consent. Your signature on this Agreement provides consent for those activities, as follows:
• We may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, we make every effort to avoid revealing the identity of our patient unless the other professional is also known to you and is providing professional services to you. The other professionals are also legally bound to keep the information confidential. We will usually inform you about consultations in which your identity will be revealed, but If you don’t object, we may also seek consultations without revealing your identity and without informing you when we feel that it is important to our work together. We will note all consultations in your Clinical Record (which is called “PHI” in our Notice of Policies and Practices to Protect the Privacy of Your Health Information). If another professional is involved in your treatment for the problem we are also addressing (such as physicians prescribing medications relevant to the psychological problem we are addressing), we will ask for your permission to exchange information necessary to coordinate our treatments
• You should be aware that we practice with other mental health professionals and that we employ administrative staff. In most cases, we need to share protected information with these individuals for both clinical and administrative purposes, such as scheduling, billing and quality assurance. All of the mental health professionals are bound by the same rules of confidentiality. All staff members have been given training about protecting your privacy and have agreed not to release any information outside of the practice without the permission of a professional staff member.
• We also have contracts with accounting and billing firms. As required by HIPAA, we have a formal business associate contract with these businesses, in which they promise to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, we can provide you with the names of these organizations and/or a blank copy of this contract.
• Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement.
There are some situations where we are permitted or required to disclose information without either your consent or Authorization:
• If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the psychologist-patient privilege law. We cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in, or contemplating, litigation, you should consult with your attorney to determine whether a court would be likely to order us to disclose information. Additional fees will be charged to you as outlined below if forensic (legal or court) issues become involved.
• If a government agency is requesting the information for health oversight activities, we may be required to provide it.
• If a patient files a complaint or lawsuit against us, we may disclose relevant information regarding that patient in order to defend ourselves. You will be charged at the forensic rate for any time spent regarding that charge unless a judge orders otherwise.
• If a patient files a worker’s compensation claim, we must, upon appropriate request, furnish all treatment reports to the patient’s employer and to the patient or his/her attorney.
There are some situations in which we are legally obligated to take actions, which we believe are necessary to attempt to protect others from harm and we may have to reveal some information about a patient’s treatment. These situations are unusual in our practice.
• If we have reason to suspect or believe that a child under 18 years of age (1) has been abused or neglected, (2) has had non-accidental physical injury, or injury which is at variance with the history given of such injury, inflicted upon such child, or (3) is placed at imminent risk of serious harm, then we must report this suspicion or belief to the appropriate authority, usually the Commissioner of Children and Families. Once such a report is filed, we may be required to provide additional information.
• If we have reason to believe or suspect that an elderly or disabled or incompetent individual has been abused, we may have to report this to the appropriate authority. Once such a report is filed, we may be required to provide additional information.
• If we believe that a patient presents an imminent risk of personal injury to another identifiable individual, we may be required to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the patient. We may also have to take protective action if another’s property is endangered.
If a patient presents an imminent risk of personal injury to him/herself, we may be obligated to seek hospitalization for him/her, or to contact family members or others who can help provide protection.
If such a situation arises, we will make every effort to fully discuss it with you before taking any action and we will limit our disclosure to what is necessary.
If you participate in a group, we request that you and other group members respect the privacy of all group members and agree not to release names or any identifying information about each other outside of the group. CDCBT LLC and its individual professionals cannot, however, take responsibility for breaches in this agreement by other group members.
While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. The laws governing confidentiality can be quite complex, and we are not attorneys. In situations where specific advice is required, formal legal advice may be needed.
You should be aware that, pursuant to HIPAA, we keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that we receive from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in unusual circumstances that involve danger to yourself and others or where information has been supplied to us confidentially by others, 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, we require that you initially review them in our presence, or have them forwarded to another mental health professional so you can discuss the contents. In most situations, we are allowed to charge a copying fee of $.75 per page (and for certain other expenses). If we refuse your request for access to your records, you have a right of review, which we will discuss with you upon request.
In addition, we may also keep a set of Psychotherapy Notes. These Notes are for our own use and are designed to assist us in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the contents of our conversations, our analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to us that is not required to be included in your Clinical Record. They may also include information from others provided to us confidentially. These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. We cannot currently imagine a situation in which we would release Psychotherapy notes except as noted above.
HIPAA provides you with several new or expanded rights with regard to your Clinical Record and disclosures of protected health information. These rights include requesting that we amend your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about our policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and our privacy policies and procedures. We are happy to discuss any of these rights with you.
MINORS & PARENTS
Patients under 16 years of age who are not emancipated and their parents should be aware that the law may allow parents to examine their child’s treatment records unless we decide that such access is likely to injure the child. (There are some circumstances in which we can provide treatment for not more than 6 sessions to a child under 16 without parental consent or notification, but the requirements for such nonconsensual treatment are complicated and can be discussed on request.) Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is sometimes our policy to request an agreement from parents that they consent to give up their access to their child’s records. If they agree, during treatment, we will provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. We may also provide parents with a summary of their child’s treatment when it is complete if the parents request it. Any other communication will require the child’s consent, unless we feel that the child is in danger or is a danger to someone else, in which case, we will notify the parents of our concern. Before giving parents any information, we will discuss the matter with the child, if possible, and do our best to handle any objections he/she may have.
BILLING AND PAYMENTS
You will be expected to pay for each session at the time it is held, unless we agree otherwise. Payment schedules for other professional services will be agreed to when they are requested. (In circumstances of unusual financial hardship, we may be willing to negotiate a fee adjustment or payment installment plan). In addition to weekly appointments, we may charge for other professional services you request. Other services include report writing, telephone conversations lasting longer than 10 minutes, consulting with other professionals at your request, preparation of records or treatment summaries, and the time spent performing any other service you may request of us. If you become involved in legal proceedings that require our participation, you will be expected to pay for all of our professional time, including preparation and transportation costs, even if we are called to testify by another party. Because of the difficulty of legal involvement, we charge $250 - $400 per hour for preparation and attendance at any legal proceeding.
If your account has not been paid for more than 60 days and arrangements for payment has not been agreed upon, we have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require us to disclose otherwise confidential information. In most collection situations, the only information we release regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due. If such legal action is necessary, its costs will be included in the claim.
In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment - particularly if you have a POS ("point of service") or "Out of Network" benefit. WE ARE NOT ON THE PANELS OF MANAGED INSURANCE PLANS. We will fill out forms and provide you with whatever assistance we can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of our fees. It is very important that you find out exactly what mental health services your insurance policy covers.
You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, we will provide you with whatever information we can based on our experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, we will be willing to call the company on your behalf.
Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in short-term therapy, some patients feel that they need more services after insurance benefits end. If we cannot provide services under the limitations of your insurance coverage and you cannot afford out-of-pocket payment, we will try to refer you to a provider who accepts the limitations imposed by your insurance company. This may not always be possible.
You should also be aware that your contract with your health insurance company requires that we provide it with information relevant to the services that we provide to you if you wish them to pay for the services. We are required to provide a clinical diagnosis. Sometimes we are required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, we will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, we have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. We will provide you with a copy of any report we submit, if you request it. By signing this Agreement, you agree that we can provide requested information to your carrier.
Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your sessions. It is important to remember that you always have the right to pay for our services yourself to avoid the problems described above- You need to know that frequently you will be responsible for paying for treatment even if you have health-care insurance. It will be your responsibility to make any appeals for denials.
Your signature below indicates that you have read the information in this document and agree to abide by its terms during our professional relationship.
(Parent if under 18)________________________________