Common use of PATIENT SERVICES AGREEMENT Clause in Contracts

PATIENT SERVICES AGREEMENT. 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 (HIPAA), 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. 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: a) I have taken action in reliance on it; b) there are obligations imposed on me by your health insurer in order to process or substantiate claims made under your policy; c) you have not satisfied any financial obligations that you have incurred. Psychological Services 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.

PATIENT SERVICES AGREEMENT. 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 (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 I provide you with a Notice of Privacy Practices (the Notice) for use and disclosure of PHI for treatment, payment and health care operations. The Notice, which is attached to this Agreement, explains HIPAA and its application to your personal health information in greater detail. The law requires that I obtain your signature acknowledging that I have provided you with this information at the end of this session. Although these documents are long and sometimes complex, it is very important that you read them carefully before our next session. We can discuss any questions you have about the procedures at that time. When you sign 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: a) unless I have taken action in reliance on it; b) if there are obligations imposed on me by your health insurer in order to process or substantiate claims made under your policy; c) or if you have not satisfied any financial obligations that you have incurred. Psychological Services Psychotherapy can have benefits and risksSESSIONS AND FEES Sessions are billed at a 50-minute hour at the rate of $125.00. Since Payment is due at the time of each therapy often involves discussing unpleasant aspects session. Appointment reminders are sent via email and/or text two days prior to your scheduled session via TherapyNotes. If you do not wish receive these reminders contact the practice administrator, Xxxxxxx Xxxxxxx, at 000-000-0000. REQUIREMENT OF A CREDIT/DEBIT CARD ON FILE • A credit/debit card is required to be on file for payments. • The card is used for payments of telemedicine appointments as the client is not physically present. • The credit/debit card is used to process payment if a patient misses or has a late cancellation. • The credit/debit card is used to process payment automatically the day of a client's appointment (unless the client specifies a different arrangement at least the day before the appointment). • The credit/debit card is used to process payments of administrative fees such as letters, forms, administrative documents, etc. at the client's request. TELEPHONE/TELEMEDICINE APPOINTMENTS • If your appointment is conducted via telemedicine, please click the link provided 5-10 minutes before your video appointment. • If your appointment is conducted via a phone call, Xxxxxxx Xxxxxx will call you at the time 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 distressappointment.

PATIENT SERVICES AGREEMENT. Welcome to my practiceWelcome. 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 (HIPAA), a federal law that provides privacy protections and patient rights with regard to the use and disclosure of your Protected Health Information (PHI) ). PHI is 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 separate from this Agreement, explains HIPAA and its application to your personal health information PHI in greater detail. The law requires that I obtain your signature acknowledging that I have provided you with this information at the end of this sessionNotice. Although these documents this document and the Notice are long and sometimes complexlong, it is very important that you read them carefully before our next sessioncarefully. We can discuss any questions you have about the procedures at that timehave. When you sign this document, 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: a) I have taken action in reliance on it; b) there are obligations imposed on me by your health insurer in order to process or substantiate claims made under your policy; c) you have not satisfied any financial obligations that you have incurred. Psychological Services PSYCHOLOGICAL SERVICES 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 or helplessness. On the other hand, psychotherapy has also been shown to have many benefits. Therapy often leads to better relationships, solutions to specific problems, better relationships, and significant reductions reduction in feelings of distress. However, there are no guarantees of what you will experience in terms of outcome. Our first 1-3 sessions will involve an evaluation of your needs. By the end of the evaluation I 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 opinion of whether you think I am the best person to provide the services you need in order to meet your treatment goals. Therapy involves a commitment of time, money, and energy so you should be careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another behavioral healthcare professional for a consultation should you so desire.

PATIENT SERVICES AGREEMENT. Welcome Continued MEETINGS I normally conduct an evaluation that will last from 2 to 4 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 45 or 60 minute session (one appointment hour of 45 or 60 minutes duration) per week at a time we agree on, although some sessions may be longer or more frequent. Once an appointment is scheduled, you will be expected to pay $100 unless you provide 24 hours advance notice of cancellation [unless we both agree that you were unable to attend due to circumstances beyond your control]. It is important to note that insurance companies do not provide reimbursement for cancelled sessions. I will try to find another time to reschedule the appointment. PROFESSIONAL FEES My hourly fee is $200 for an initial session and $150 for subsequent sessions. In addition to weekly appointments, I 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 with your permis- sion, preparation of records or treatment summaries, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Because of the difficulty of legal involvement, I charge $200 per hour for preparation and attendance at any legal proceeding. CONTACTING ME (000) 000-0000 Due to my work schedule, I am often not immediately available by telephone. While I am usually in my office between 9 AM and 7 PM, I probably will not answer the phone when I am with a patient. When I am unavailable, my telephone is answered by voice mail that I monitor frequently, or by my secretary who knows where to reach me. I will make every effort to return your call within 24 hours, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. In emergencies, if you are unable to reach me and feel that you can’t wait for me to return your call, contact your family physician, the nearest emergency room or call 911. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a patient and a psychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA and/or Illinois law. However, in the following situations, no authorization is required:: • I may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my patient. The other professionals are also legally bound to keep the information confidential. If you don’t object, I will not tell you about these consultations unless I feel that it is important to our work together. I will note all consultations in your Clinical Record. LICENSED PROFESSIONAL COUNSELOR-PATIENT SERVICES AGREEMENT – Continued • You should be aware that I practice with other mental health professionals and that I employ administrative staff. In most cases, I 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. • Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement. • 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 LPC-patient privilege law. I cannot disclose any information without 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 me to disclose information. • If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. • If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself. • If you file a worker’s compensation claim, and I rendering treatment or services in accordance with the provisions of Illinois Workers’ Compensation law, I must, upon appropriate request, provide a copy of your record to your employer or his/her appropriate designee. There are some situations in which I am legally obligated to take actions, which I believe are necessary to attempt to protect others from harm and I may have to reveal some information about a patient’s treat- ment. These situations are unusual in my practice. This document (the Agreement) contains important information about • If I have reasonable cause to believe that a child under 18 known to me in my professional services and business policies. It also contains summary information about capacity may be an abused child or a neglected child, the Health Insurance Portability and Accountability Act (HIPAA), 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. The law requires that I obtain your signature acknowledging file a report with the local office of the Department of Children and Family Services. Once such a report is filed, I may be required to provide additional information. • If I have reason to believe that an adult over the age of 60 living in a domestic situation has been abused or neglected in the preceding 12 months, the law requires that I file a report with the agency designated to receive such reports by the Department of Aging. Once such a report is filed, I may be required to provide additional information. • If you have provided you with this information at the end made a specific threat of this session. Although these documents are long and sometimes complex, it is very important violence against another or if I believe 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 documentpresent a clear, it will also represent an agreement between us. You imminent risk of serious physical harm to another, I may revoke this Agreement in writing at any time. That revocation will be binding on me unless: a) I have taken action in reliance on it; b) there are obligations imposed on me by your health insurer required disclose information in order to process take protective actions. These actions may include notifying the potential victim, contacting the police, or substantiate claims made under seeking your policy; c) you have not satisfied any financial obligations that you have incurred. Psychological Services 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 distresshospitalization.