Common use of PROFESSIONAL RECORDS Clause in Contracts

PROFESSIONAL RECORDS. The laws and standards of his/her profession require that the therapist keep Protected Health Information about you in your Clinical Record. 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, the therapist recommends that you initially review them in his/her presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, the therapist is allowed to charge a copying fee of $0.25 per page. HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include requesting that the therapist amend your record; requesting restrictions on what information from your Clinical Records 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 his/her policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and his/her privacy policies and procedures. the therapist is happy to discuss any of these rights with you. Patients under 12 years of age and their parents should be aware that the law allows parents to examine their child’s treatment records. Parents of children between 12 and 17 cannot examine their child’s records unless the child consents and unless the therapist finds that there are no compelling reasons for denying the access. Parents are entitled to information concerning their child’s current physical and mental condition, diagnosis, treatment needs, services provided, and services needed. Since parental involvement is often crucial to successful treatment, in most cases, the therapist requires that patients between 12 and 17 years of age and their parents enter into an agreement that allows parents access to certain additional treatment information. If everyone agrees, during treatment, the therapist will provide parents with general information about the progress of their child’s treatment, and his/her attendance at scheduled sessions. The therapist will also provide parents with a verbal summary of treatment when it is complete. Any other communication will require the child’s Authorization, unless the therapist feels that the child is in danger or is a danger to someone else, in which case, the therapist will notify the parents of his/her concern. Before giving parents any information, the therapist will discuss the matter with the child, if possible, and do his/her best to handle any objections he/she may have. 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. The therapist will fill out forms and provide you with whatever assistance the therapist can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of his/her 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, the therapist will provide you with whatever information the therapist can based on his/her experience and will be happy to help you in understanding the information you receive from your insurance company. You should also be aware that your contract with your health insurance company requires that you authorize the therapist to provide it with information relevant to the services that the therapist provides to you. If you are seeking reimbursement for services under your health insurance policy, you will be required to sign an authorization form that allows the therapist to provide such information. The therapist is required to provide a clinical diagnosis. Sometimes the therapist is required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, the therapist 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, the therapist has 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. The therapist will provide you with a copy of any report the therapist submits, if you request it. It is important to remember that you always have the right to pay for his/her services yourself to avoid the problems described above.

PROFESSIONAL RECORDS. The laws and standards of his/her profession our professions require that the therapist we keep Protected Health Information about you in your Clinical Recordclient record. You may have the right to 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 and may be upsetting to untrained readers. For this reason, the therapist recommends we recommend that you initially review them in his/her presence, our presence or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, the therapist is allowed to charge a copying fee of $0.25 per page. HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include requesting that the therapist amend your record; requesting restrictions on what information from your Clinical Records 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 his/her policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and his/her privacy policies and procedures. the therapist is happy to discuss any of these rights with you. Patients Clients under 12 18 years of age who are not emancipated and their parents should be aware that the law allows parents to examine their child’s treatment records. Parents of children between 12 and 17 cannot examine their child’s records unless it is decided that such access is likely to injure the child consents and unless the therapist finds that there are no compelling reasons for denying the accesschild, or we agree otherwise. Parents are entitled to information concerning their child’s current physical and mental condition, diagnosis, treatment needs, services provided, and services needed. Since parental involvement Because privacy in psychotherapy is often crucial to successful treatmentprogress, in most casesparticularly with adolescents, the therapist requires that patients between 12 and 17 years of age and their parents enter into it is often my policy to request an agreement from parents that allows parents they consent to give up their access to certain additional treatment informationtheir child’s records. If everyone agreesthe parents agree, during treatment, the therapist we will provide parents them only with general information about the progress of their child’s treatment, and his/her attendance at scheduled sessionsprogress. The therapist We will also provide parents with a verbal summary of their child’s treatment when it is complete. Any other Although we encourage all children to allow parental participation in therapy, any sensitive communication will require the child’s Authorizationauthorization, unless the therapist feels we feel that the child is in danger to himself/herself or is a danger to someone else, in which . In this case, the therapist we will notify the parents of his/her my concern. Before giving parents any information, the therapist we will discuss the matter with the child, if possible, and do his/her our best to handle any objections he/she may have. In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available You will be expected to pay for your treatmenteach session at the time that it is held, unless we agree otherwise. Payment schedules for other professional services will be agreed to when they are requested. We accept payment in the form of cash, check, or credit card. If you your account has not been paid for more than 90 days and arrangements for payments have not been agreed upon, we have the option of using a health insurance policylegal means to secure the payment. This may involve hiring a collection agent or going through small claims court which will require us to disclose otherwise confidential information. In most collection situations, it will usually provide some coverage for mental health treatment. The therapist will fill out forms and provide you with whatever assistance the therapist can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of only information we release regarding a client’s treatment is his/her fees. It is very important that you find out exactly what mental health name, the nature of the services your insurance policy covers. You should carefully read provided (i.e. individual psychotherapy hour), and the section in your insurance coverage booklet that describes mental health servicesamount due. If you have questions about the coverage, call your plan administrator. Of coursesuch legal action becomes necessary, the therapist will provide you with whatever information the therapist can based on his/her experience and costs will be happy to help you included in understanding the information you receive from your insurance company. You should also be aware that your contract with your health insurance company requires that you authorize the therapist to provide it with information relevant to the services that the therapist provides to you. If you are seeking reimbursement for services under your health insurance policy, you will be required to sign an authorization form that allows the therapist to provide such information. The therapist is required to provide a clinical diagnosis. Sometimes the therapist is required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, the therapist 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, the therapist has 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. The therapist will provide you with a copy of any report the therapist submits, if you request it. It is important to remember that you always have the right to pay for his/her services yourself to avoid the problems described aboveclaim.

PROFESSIONAL RECORDS. The laws and standards of his/her our profession require that the therapist we keep Protected Health Information about you in your Clinical Record. You Except in unusual circumstances that involve danger to yourself and/or others or where information has been supplied to us confidentially by others, you may examine and/or receive a copy of your Clinical Record, 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, the therapist recommends we recommend that you initially review them in his/her presence, our presence or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, the therapist is allowed to We will charge a fee for copying fee and certain other expenses, as allowed by law. If we refuse your request for access to your records, you have a right of $0.25 per pagereview, which we will discuss with you upon request. HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include requesting that the therapist we amend your record; requesting restrictions on what information from your Clinical Records 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 his/her our policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice formForm, and his/her our privacy policies and procedures. the therapist is We are happy to discuss any of these rights with you. Patients under 12 18 years of age who are not emancipated and their parents should be aware that the law allows may allow parents to examine their child’s treatment records. Parents of Even where parental consent is given, children between over age 12 may have the right to control access to their treatment records. While privacy in clinical sessions, assessments and 17 cannot examine their child’s records unless the child consents and unless the therapist finds that there are no compelling reasons for denying the access. Parents are entitled to information concerning their child’s current physical and mental conditiontherapeutic, diagnosisis very important, treatment needsparticularly with teenagers, services provided, and services needed. Since parental involvement is often crucial also essential to successful treatment, in most cases, the therapist requires that patients between particularly with younger children. For children age 12 and 17 years of age and their parents enter into over, we request an agreement that allows between our patient and his/her parents access allowing us to certain additional treatment information. If everyone agrees, during treatment, the therapist will provide parents with share general information about the progress of their the child’s treatment, treatment and his/her attendance at scheduled sessions. The therapist We will also provide parents with a verbal summary of their child’s treatment when it is complete. Any other communication will require the child’s Authorization, unless the therapist feels we feel that the child is in danger or is a danger to someone else, in which case, the therapist case we will notify the parents of his/her our concern. Before giving parents any information, the therapist we will discuss the matter with the child, if possible, and do his/her our best to handle any objections he/she may have. In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available You will be expected to pay for each visit at the time of the visit unless you have insurance coverage that requires another arrangement. Payment can be made by cash, check, VISA, AMEX or MasterCard. Use of credit cards may incur up to a 4% fee as well as tax as allowed for assessments involving non-medical and/or educational techniques. If your treatmentcheck is returned for insufficient funds, we will request immediate payment by cash, credit card, or bank cashier’s check and add an additional $20 “bad check” fee. Additional visits are suspended until you pay for returned checks. Payment schedules for other professional services will be agreed to when they are requested. If your account has not been paid for more than 60 days and arrangements for payment have 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, and this 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. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. The therapist will fill out forms and provide you with whatever assistance the therapist can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of his/her fees. It is very important We recommend that you find out exactly what mental health services your insurance policy covers. You should carefully read Read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, services and call your plan administrator. Of courseIf your plan is one with which we have had experience, our secretary may also be helpful as you try to understand your coverage. Even though your insurance provider may approve your payment for treatment, you are ultimately responsible for all payments. We are on the therapist panel for several insurances such as GHI, Emblem Health, HIP and Empire However, coverage varies depending on plan and individual circumstance. Our office will cooperate with you and work with the insurance company to provide diagnostic and procedural codes to obtain authorization. We are often successful. If you with whatever information are responsible for any of the therapist can based on his/her experience and amount, you will be happy notified PRIOR to help you in understanding the information you receive appointment. Often, if the appointment is needed urgently and coverage or authorization is still pending, which may take a while, we suggest an out of pocket quote which is reimbursable ONLY if the contracted insurance rate is paid at a later time. This initial payment guarantees your evaluation and report without a wait or approval from your insurance company. You should also At this time, you are considered a private pay patient and we will bill the insurance company with your consent and try to obtain part of all monies paid by you, so we can reimburse you. The contracted amount with the insurance company may differ than CCPS’s quoted rate as a private patient. Hence, the insurance company is required to pay out our contracted amount. If the insurance company pays out, you will be aware that reimbursed the amount paid of out of pocket less the difference between the amount billed to the insurance company by CCPS and the amount the amount paid out by the insurance company. For example: If the privately quoted amount is $2500, which you pay, we may bill the insurance $2800 as part of our agreement with them. If they only reimburse, $2500, we will deduct the unpaid $300 from your reimbursement, allowing us to refund you $2200 of your fee. We will complete treatment plans only with you or your representative (if you are a minor) present. All treatment plans must be completed during your visit with us, consequently. As authorizations from insurance companies expire, it is your responsibility to complete your visits and assessments during the time permitted or allow us to obtain new authorizations. The authorizations are generally valid for 90 days, and we can obtain more units after 90 days of the first set of approved visits. If we are participating providers in your health insurance plan, you have already given our secretary permission by phone to contact your insurance company and verify your benefits. The payment you make at the visit, known as a “copayment,” is specified by the insurance or managed care company. Co-payment may be collected for more than one session as neuropsychological evaluations are billed as several units for scoring and report write up, and do not require visits, hence, co-pays are applicable but we cannot procure them at a later time. Therefore, they must be satisfied during your in-office visits. We are responsible for obtaining authorization for your visits and for submitting insurance claims. Your contract with your health insurance company requires that you authorize the therapist to provide it with we disclose information relevant to the services that the therapist provides we provide to you. If you We are seeking reimbursement for services under your health insurance policy, you will be required to sign an authorization form that allows the therapist to provide such information. The therapist is required to provide a clinical diagnosis. Sometimes the therapist is we are required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, the therapist 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, the therapist has 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. The therapist We will provide you with a copy of any report the therapist submitswe submit, if you request it. It is important By signing the Acknowledgement Sheet, you agree that we can provide requested information to remember that you always have the right to pay for his/her services yourself to avoid the problems described aboveyour insurance company.

PROFESSIONAL RECORDS. The laws law requires that psychologists maintain a record of the evaluation conducted. This record will contain the information that will allow the psychologist to generate diagnostic conclusions and standards recommendations. The records will only be used for that purpose. The psychologist will provide the patient with a synopsis of his/her profession require that the therapist keep Protected Health Information about you data contained in your Clinical Recordthe record in a report format. You may examine and/or receive should be aware that pursuant to Texas law, psychological test data (raw data) are not part of a copy of your Clinical Record, if you request it in writingpatient's record. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, the therapist recommends we recommend that you initially review them in his/her my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, the therapist is we are allowed to charge a copying fee of $0.25 5 per pagepage (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If we refuse your request for access to your Clinical Record, you have a right of review, which we will discuss with you upon your request. HIPAA provides you with several new or expanded rights with regard to your Clinical Records Record and disclosures of protected health information. These rights include requesting that the therapist your doctor amend your record; requesting restrictions on what information from your Clinical Records 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 his/her our policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and his/her our privacy policies and procedures. the therapist is happy to discuss any of these rights with you. Patients under 12 18 years of age who are not emancipated and their parents should be aware that the law allows may allow parents to examine their child’s 's treatment records. Parents of children between 12 and 17 cannot examine their child’s records unless the child consents and unless the therapist finds that there are no compelling reasons for denying the access. Parents are entitled to information concerning their child’s current physical and mental condition, diagnosis, treatment needs, services provided, and services needed. Since parental involvement is often crucial to successful treatment, in most cases, the therapist requires that patients between 12 and 17 years of age and their parents enter into an agreement that allows parents access to certain additional treatment information. If everyone agrees, during treatment, the therapist will provide parents with general information about the progress of their child’s treatment, and his/her attendance at scheduled sessions. The therapist will also provide parents with a verbal summary of treatment when it is complete. Any other communication will require the child’s Authorization, unless the therapist feels that the child is in danger or is a danger to someone else, in which case, the therapist will notify the parents of his/her concern. Before giving parents any information, the therapist will discuss the matter with the child, if possible, and do his/her best to handle any objections he/she may have. 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. The therapist will fill out forms and provide you with whatever assistance the therapist can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of his/her 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, the therapist will provide you with whatever information the therapist can based on his/her experience and will be happy to help you in understanding the information you receive from your insurance company. You should also be aware that your contract with your health insurance company requires that you authorize the therapist to provide it with information relevant to the services that the therapist provides to you. If you are seeking reimbursement for services under your health insurance policy, you will be required to sign an authorization form that allows the therapist to provide such information. The therapist is required to provide a clinical diagnosis. Sometimes the therapist is required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, the therapist 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, the therapist has 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. The therapist will provide you with a copy of any report the therapist submits, if you request it. It is important to remember that you always have the right to pay for his/her services yourself to avoid the problems described above.

PROFESSIONAL RECORDS. The laws and standards of his/her profession mental health professions require that the therapist keep Protected Health Information about you is kept in your Clinical Record. 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, the therapist recommends we recommend that you initially review them with your therapist or accept a written treatment summary. If you want a copy of your medical record, you must pick it up in his/her presenceperson at the clinic to ensure security of the record. MINORS: Clients under 12 years of age and their parents should be aware that the law allows parents to examine their child’s treatment records. Parents of children between the ages of 12 and 17 cannot examine their child’s record unless the child consents and unless the therapist finds that there are no compelling reasons for denying any access. Parents have a right to information concerning their child’s current physical and mental condition, diagnosis, treatment needs, services provided, progress updates and services needed. Any other communication will require the child’s (ages 12-17) Authorization, unless the therapist feels that the child is in danger or have them forwarded is a danger to another mental health professional so you can discuss the contents. In most circumstancessomeone else, in which case, the therapist will notify the parents of the concern. Before giving parents any information, the therapist will discuss the matter with the child, if possible, and, to the best of the therapist’s ability, handle any objections the child may have. Regardless of a child’s legal age, we take the confidentiality of a minor’s record seriously. Without confidentiality, children have difficulty trusting, which can interfere with treatment progress. Therefore, whenever possible, we encourage parents to accept a brief written therapy progress update (for no charge) or an in-person meeting that can answer the questions they have in place of a copy of the child’s record. We believe this meets the needs of the parents and other providers, while also protecting very private information for the child and ensuring that the record is allowed kept safe. Further, treatment progress summaries are often times more helpful to charge parents because it provides a copying fee comprehensive description and overview of $0.25 per pagethe child’s treatment progress. In the event that a parent still requests a record, we ask that the parent come in person to the clinic to pick up the record to protect the confidentiality of the record. HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include requesting that the your therapist amend your record; requesting restrictions on what information from your Clinical Records 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 his/her our policies and procedures recorded in your records; and the right to . HIPAA requires that we give you a paper copy of this Agreement, the attached Notice formform for use and disclosure of PHI for treatment, payment and health care operations, and his/her our privacy policies and procedures. the therapist is We are happy to discuss any of these rights with you. Patients under 12 years of age and their parents should be aware that the law allows parents to examine their child’s treatment records. Parents of children between 12 and 17 cannot examine their child’s records unless the child consents and unless the therapist finds that there are no compelling reasons for denying the access. Parents are entitled to information concerning their child’s current physical and mental condition, diagnosis, treatment needs, services provided, and services needed. Since parental involvement is often crucial to successful treatment, in most cases, the therapist requires that patients between 12 and 17 years of age and their parents enter into an agreement that allows parents access to certain additional treatment information. If everyone agrees, during treatment, the therapist will provide parents with general information about the progress of their child’s treatment, and his/her attendance at scheduled sessions. The therapist will also provide parents with a verbal summary of treatment when it is complete. Any other communication will require the child’s Authorization, unless the therapist feels that the child is in danger or is a danger to someone else, in which case, the therapist will notify the parents of his/her concern. Before giving parents any information, the therapist will discuss the matter with the child, if possible, and do his/her best to handle any objections he/she may have. 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. The therapist will fill out forms and provide you with whatever assistance the therapist can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of his/her 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, the therapist will provide you with whatever information the therapist can based on his/her experience and will be happy to help you in understanding the information you receive from your insurance company. You should also be aware that your contract with your health insurance company requires that you authorize the therapist to provide it with information relevant to the services that the therapist provides to you. If you are seeking reimbursement for services under your health insurance policy, you will be required to sign an authorization form that allows the therapist to provide such information. The therapist is required to provide a clinical diagnosis. Sometimes the therapist is required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, the therapist 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, the therapist has 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. The therapist will provide you with a copy of any report the therapist submits, if you request it. It is important to remember that you always have the right to pay for his/her services yourself to avoid the problems described above.

PROFESSIONAL RECORDS. The laws and standards of his/her profession require Except in unusual circumstances that the therapist keep Protected Health Information about involve danger to yourself and/or others, you in your Clinical Record. You may examine and/or receive a copy of your Clinical Record, Record if you request it in writing. Because these You should be aware that pursuant to Texas law, psychological test data are professional not part of a patient’s record. If I refuse your request of records, they can be misinterpreted and/or upsetting to untrained readers. For this reasonyou have a right of review, the therapist recommends that which I will discuss with you initially review them in his/her presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, the therapist is allowed to charge a copying fee of $0.25 per pageupon your request. HIPAA provides you with several new or expanded rights with regard to your Clinical Records Record and disclosures of protected health information. These rights include requesting that the therapist I amend your record; requesting restrictions on what information from your Clinical Records 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 his/her my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and his/her my privacy policies and procedures. the therapist is happy to discuss any of these rights with you. Patients under 12 18 years of age who are not emancipated and their parents should be aware that the law allows may allow parents to examine their child’s treatment records. Parents of children between 12 and 17 canHowever, if treatment is for suicide prevention, chemical addiction or dependency, or sexual, physical or emotional abuse, the law provides that parents may not examine access their child’s records unless the child consents records. For children between 13 and unless the therapist finds that there are no compelling reasons for denying the access. Parents are entitled to information concerning their child’s current physical and mental condition17, diagnosis, treatment needs, services provided, and services needed. Since parental involvement because privacy in psychotherapy is often crucial to successful treatmentprogress, in most cases, the therapist requires that patients between 12 and 17 years of age and their parents enter into it is my policy to request an agreement that allows parents access to certain additional treatment information. If everyone agrees, during treatment, from the therapist will provide parents with general information about the progress of their child’s treatment, patient and his/her attendance at scheduled sessions. The therapist parents as to what information from the therapy sessions will also provide parents with a verbal summary of treatment when it is completebe disclosed to parents. Any other communication will require the child’s Authorizationauthorization, unless the therapist feels I feel that the child is in danger or is a danger to someone else, in which case, the therapist I will notify the parents of his/her my concern. Before giving parents any information, the therapist I will discuss the matter with the child, if possible, and do his/her my best to handle any objections he/she may have. In order Most major insurance companies will pay a portion of the cost of psychotherapy after you have satisfied the deductible. If we have established a relationship with your insurance company, we will collect your deductible or co-pays and bill the insurance company. Otherwise, your insurance payments go directly to you. An itemized statement will be provided at your request so that you can submit claims. Payment is always required at the time of service, even when using insurance. All session times not covered by insurance will be charged at the regular fee for us to set realistic treatment goals and prioritiesservice rate. When anticipating a change in insurance coverage, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policydiscuss this with me ahead of time, it will usually provide some coverage for mental health treatment. The therapist will fill out forms and provide you with whatever assistance the therapist can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment as this may affect continuity of his/her 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, the therapist will provide you with whatever information the therapist can based on his/her experience and will be happy to help you in understanding the information you receive from your insurance companycare. You should also be aware that your contract with your health insurance company requires that you authorize the therapist to I provide it with information relevant to the services that the therapist provides I provide to you. If you are seeking reimbursement for services under your health insurance policy, you will be required to sign an authorization form that allows the therapist to provide such information. The therapist is required to provide a clinical diagnosis. Sometimes the therapist is I am required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, the therapist I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This By signing this Agreement, you agree that I can provide requested information to your carrier. A copy of a valid credit card, front and back, must be provided prior to beginning service. If insurance does not reimburse for any reason: I will become part of bill your credit card and notify you immediately. I am happy to arrange a payment plan if the amount is large (over $250.00). I will also be happy to provide any statements you may need to seek reimbursement from your insurance company files and will probably be stored in a computercompany. Though all insurance companies claim If you do not wish to keep such information confidential, the therapist has 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. The therapist will provide you with a copy of any report a valid credit card: payment in full at the therapist submitscontracted rate I have with your insurance company is due at the time of each service and a statement will be provided to you to seek reimbursement from your insurance company. Finally, if you request itpaying utilizing a credit card, I bill the amount plus the cost per credit card transaction. It For example, a $20.00 dollar copay would be charged as $20.40 via credit card. There is important no additional fee for paying with cash or check. I have read and understand the above information and agree to remember that you always have these conditions. Signature of Client/Guardian/Personal Representative Date Please print name of Client/Guardian/Personal Representative Date 01/31/2014 XXXXXXX X. XXXXXX, PH.D., ABPP / FAACP 0000 Xxxxxxxxx Xxxxxxx Xx., 0-200 Office (512) 767 -5539 Austin, Texas 78759 Fax (512) 467 - 8658 Name: Date: I am providing the following credit card information to Xx. Xxxxxxx X. Turner to keep on file: Select One: VISA MASTERCARD Signature: Card No.: Expiration date: Card Security Code (3 digit code on far right to pay for his/her services yourself to avoid on back of card): Name on Card: Credit Card billing address: City: State: Zip Code: Card Holder’s phone number: XXXXXXX X. XXXXXX, PH.D., ABPP / FAACP 0000 Xxxxxxxxx Xxxxxxx Xx., 0-200 Office (512) 767 -5539 Austin, Texas 78759 Fax (512) 467 - 8658 Call your insurance company and acquire the problems described above.following information BEFORE meeting with Xx. Xxxxxx: