Patient Privilege. The information disclosed by Patient, as well as any records created, is subject to the psychotherapist patient privilege. The psychotherapist-‐patient privilege results from the special relationship between Therapist and Patient in the eyes of the law. It is akin to the attorney-‐client privilege or the doctor-‐patient privilege. Typically, the patient is the holder of the psychotherapist-‐patient privilege. If Therapist received a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-‐patient privilege on Patient’s behalf until instructed, in writing, to do otherwise by Patient or Patient’s representative. Patient should be aware that he/she might be waiving the psychotherapist-‐ patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Patient should address any concerns he/she might have regarding the psychotherapist-‐patient privilege with his/her attorney. The usual and customary fee for service is per 50-‐minute session. Sessions longer than 50-‐minutes are charged for the additional time pro rata. Therapist reserves the right to periodically adjust this fee. Patient will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with other third-‐party payors, or by agreement with Therapist. The agreed upon fee between Therapist and Patient is _. Therapist reserves the right to A Patient’s appointment is reserved exclusively for the Patient. Patient will be charged the full fee per session for any missed or cancelled appointments unless Patient provides Xxxxxx Xxxxxxxx, MA, LMFT, with at least 24 hours notice. Unless you have made special arrangements with Therapist, if Patient misses two or more appointments in a row Therapist may not be able to hold the appointment time and Patient may lose their time slot. From time-‐to-‐time, Therapist may engage in telephone contact with Patient for purposes other than scheduling sessions. Patient is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. In addition, from time-‐to-‐time, Therapist may engage in telephone contact with third parties at Patient’s request and with Patient’s advance written authorization. Patient is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. All past due accounts which have not had payment ac...
Patient Privilege. The information disclosed by Patient, as well as any records created, is subject to the psychotherapist-patient privilege. The psychotherapist-patient privilege results from the special relationship between Therapist and Patient in the eyes of the law. Typically, the patient is the holder of the psychotherapist-patient privilege. If Therapist received a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-patient privilege on Patient’s behalf until instructed, in writing, to do otherwise by Patient or Patient’s representative. Patient should be aware that he/she might be waiving the psychotherapist-patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Patient should address any concerns he/she might have regarding the psychotherapist-patient privilege with his/her attorney. The usual and customary fee for service is $165 per 55-minute session. This fee is increased by $5 on the first of each year. At times, Therapist may suggest sessions of other lengths, and if accepted by Patient, these are billed at $225 for 85 minutes or $285 for 115 minutes. Special extended sessions beyond two hours are billed at the hourly session fee. Patient will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with insurance companies, managed care organizations, or other third-party payors, or by agreement with Therapist. If Patient wishes to use insurance benefits, a separate insurance fee consent will outline the fees specific to the individual’s plan. If Patient does not wish to use insurance benefits, Patient may choose to begin using benefits, if available, at any time in the future. Benefits utilization will begin at the time Therapist is provided policy information; no back-billing will be done. Therapist will xxxx primary insurance when the therapist is contracted with the insurance panel. For out of network and secondary insurance benefits, Therapist will provide a superbill that Patient can use for reimbursement. From time-to-time, Therapist may engage in telephone contact with Patient for purposes other than scheduling sessions. Patient is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. In addition, from time-to-time, Therapist may engage in telephone contact with third parties at Patient’s request and with Patient’s advance written authorizati...
Patient Privilege. The information disclosed by Patient, as well as any records created, is subject to the psychotherapist-patient privilege. The psychotherapist-patient privilege results from the special relationship between Therapist and Patient in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient privilege. Typically, the patient is the holder of the psychotherapist-patient privilege. If Therapist received a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-patient privilege on Patient’s behalf until instructed, in writing, to do otherwise by Patient or Patient’s representative. Patient should be aware that he/she might be waiving the psychotherapist-patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Patient should address any concerns he/she might have regarding the psychotherapist-patient privilege with his/her attorney.
Patient Privilege. The information disclosed by Client, as well as any records created, is subject to the psychotherapist-client privilege. The psychotherapist-client privilege results from the special relationship between Therapist and Client in the eyes of the law. It is akin to the attorney-client privilege or the doctor-client privilege. Typically, the patient is the holder of the psychotherapist- patient privilege. If Kairos Counseling Inc or Therapist received a subpoena for records, deposition testimony, or testimony in a court of law, Kairos Counseling Inc. and Therapist will assert the psychotherapist-patient privilege on Client’s behalf until instructed, in writing, to do otherwise by Client or Client’s representative. Client should be aware that he/she might be waiving the psychotherapist-client privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Client should address any concerns he/she might have regarding the psychotherapist-client privilege with his/her attorney. F ee and Fee Arrangements The usual and customary fee for service is $160 per 50-minute session. Sessions longer than 50- minutes are charged for the additional time pro rata. Kairos Counseling Inc. reserves the right to periodically adjust this fee. Client will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with insurance companies, managed care organizations, or other third-party payors, or by agreement with Therapist. The agreed upon fee between Kairos Counseling Inc. and Client is $160/hr. Kairos Counseling Inc. reserves the right to periodically adjust fee. Client will be notified of any fee adjustment in advance. From time-to-time, Therapist may engage in telephone contact with Client for purposes other than scheduling sessions. Client is responsible for payment for any telephone calls at the same rate as a regular therapy session. In addition, from time-to-time, Therapist may engage in telephone contact with third parties at Client’s request and with Client’s advance written authorization. Client is responsible for payment for any telephone calls. Therapist may also engage in correspondence with third parties in the form of letters, emails, text messages, and voicemails. Client is also responsible for the therapist time spent on such communication on the same rate charged for therapy sessions. Clients are expected to pay for services at the time services are rendered. Kairos Counseling Inc. accepts cash and...
Patient Privilege. The information disclosed by Patient, as well as any records created, is subject to the psychotherapist-patient privilege. The psychotherapist-patient privilege results from the special relationship between Therapist and Patient in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient privilege. Typically, the patient is the holder of the psychotherapist-patient privilege. If Therapist received a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-patient privilege on Patient’s behalf until instructed, in writing, to do
Patient Privilege. The information disclosed by client, as well as any records created, is subject to the psychotherapist-patient privilege. The psychotherapist-patient privilege results from the special relationship between Therapist and client in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient privilege. If I received a subpoena for records, deposition testimony, or testimony in a court of law, I will assert the psychotherapist-patient privilege on client’s behalf until instructed, in writing, to do otherwise by client or client’s representative. Client should be aware that he/she might be waiving the psychotherapist-patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Client should address any concerns he/she might have regarding the psychotherapist-patient privilege with his/her attorney. _______ Initial Notice of Privacy Practices: This practice is HIPAA compliant. Please indicate that you have received and signed the document named “Notice of Privacy Practices.” _______ Initial
Patient Privilege. The information disclosed by Patient, as well as any records created, is subject to the psychotherapist-patient privilege. The psychotherapist-patient privilege results from the special relationship between Therapist and Patient in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient privilege. Typically, the patient is the holder of the psychotherapist-patient privilege. If Therapist received a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-patient privilege on Patient’s behalf until instructed, in writing, to do otherwise by Patient or Patient’s representative. Patient should be aware that he/she might be waiving the psychotherapist-patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Patient should address any concerns he/she might have regarding the psychotherapist-patient privilege with his/her attorney. By signing below, each Patient acknowledges that he/she has reviewed and fully understands the terms and conditions of this Agreement. Patient has discussed such terms and conditions with Therapist and has had any questions with regard to its terms and conditions answered to Patient’s satisfaction. Patient agrees to abide by the terms and conditions of this Agreement and consents to participate in psychotherapy with Therapist. Moreover, Patient agrees to hold Therapist free and harmless from any claims, demands, or suits for damages from any injury or complications whatsoever, save negligence, that may result from such treatment.
Patient Privilege. The information disclosed by Patient, as well as any records created, is subject to the psychotherapist‐ patient privilege. The psychotherapist‐patient privilege results from the special relationship between Therapist and Patient in the eyes of the law. It is akin to the attorney‐client privilege or the doctor‐ the psychotherapist‐patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Patient should address any concerns he/she might have regarding the psychotherapist‐patient privilege with his/her attorney. The usual and customary fee for service is $125.00 per 50‐minute session. Sessions longer than 50I minutes are charged for the additional time pro rata. Therapist reserves the right to periodically adjust this fee. Patient will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with insurance companies, managed care organizations, or other third‐party payors, or by agreement with Therapist. The agreed upon fee between Therapist and Patient is what their insurance allows plus any copayments and deductibles. Therapist reserves the right to periodically adjust fee. Patient will be notified of a fee adjustment in advance. From time‐to‐time, Therapist may engage in telephone contact with Patient for purposes other than scheduling sessions. Patient is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. In addition, from time‐to‐time, Therapist may engage in telephone contact with third parties at Patient’s request and with Patient’s advance written authorization. Patient is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. Patients are expected to pay for services at the time services are rendered. Therapist accepts cash and checks.
Patient Privilege. The information disclosed by you, as well as any records created, is subject to the psychotherapist-patient privilege. The patient is the holder of the psychotherapist-patient privilege. If you are concerned about waiving the psychotherapist-patient privilege in a legal proceeding, you should consult an attorney. Xxxxx Xxxxx Psychological Group, LLC and your therapist cannot give you legal advice.
Patient Privilege. The information disclosed by Patient, as well as any records created, is subject to the psychotherapist- patient privilege. The psychotherapist-patient privilege results from the special relationship between Therapist and Patient in the eyes of the law. If Therapist receives a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-patient privilege on Patient’s behalf until instructed, in writing, to do otherwise by a person with the authority to waive the privilege on Patient’s behalf. When a patient is a minor child, the holder of the psychotherapist-patient privilege is either the minor, a court appointed guardian, or minor’s counsel. Parents typically do not have the authority to waive the psychotherapist-patient privilege for their minor children, unless given such authority by a court of law. Representative is encouraged to discuss any concerns regarding the psychotherapist-patient privilege with his/her attorney. Patient, or Representative, should be aware that he/she might be waiving the psychotherapist- patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Professional consultation is an important component of a healthy psychotherapy practice. Therapist regularly participates in clinical, ethical, and legal consultation with appropriate professionals. Therapist will not reveal any identifying information regarding Patient or Patient’s family members or caregivers.
