Web Searches. I will not use web searches to gather information about you without your permission. I believe that this violates your privacy rights; however, I understand that you might choose to gather information about me in this way. In this day and age there is an incredible amount of information available about individuals on the internet, much of which may actually be known to that person and some of which may be inaccurate or unknown. If you encounter any information about me through web searches, or in any other fashion for that matter, please discuss this with me during our time together so that we can deal with it and its potential impact on your treatment. Recently it has become fashionable for clients to review their health care provider on various websites. Unfortunately, mental health professionals cannot respond to such comments and related errors because of confidentiality restrictions. If you encounter such reviews of me or any professional with whom you are working, please share it with me so we can discuss it and its potential impact on your therapy. Please do not rate my work with you while we are in treatment together on any of these websites. This is because it has a significant potential to damage our ability to work together. I may use a xxxx assistant to generate and track basic billing information. Only the billing assistant and I will have access to your billing records from which invoices are generated. The psychotherapy notes are NOT a part of this record. PATIENT RIGHTS 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 I 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 my policies and procedures recorded in your records; and the right to a paper copy of this Agreement. I am happy to discuss any of these rights with you. This agreement provides that during treatment, I will provide parents with only general information about the progress of the treatment, and the patient’s attendance at scheduled sessions. I will also provide parents with a summary of their child’s treatment when it is complete when requested to do so. Any other communication will require the child’s Authorization, unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have. Your signature below indicates that you have read the information in this document and agree to abide by its terms during our professional relationship.
Appears in 2 contracts
Samples: drdebrakessler.com, drdebrakessler.com
Web Searches. I will not use web searches It is NOT a regular part of our practice to gather information about you without your permissionsearch for patients on Google or Facebook or other search engines. I believe that this violates your privacy rights; however, I understand Extremely rare exceptions may be made during times of crisis. If we have a reason to suspect that you are in danger and you have not been in touch with your clinician via your usual means (coming to appointments, phone, or email) there might choose be an instance in which using a search engine (to gather information about me find you, find someone close to you, or to check on your recent status updates) becomes necessary as part of ensuring your welfare. These are unusual situations and if we ever resort to such means, your clinician will fully document it and discuss it with you when you next meet. Business Review Sites: You may find your clinician or AOBHC on sites such as Yelp, Healthgrades, Yahoo Local, Bing, or other places which list businesses. Some of these sites include forums in this waywhich users rate their providers and add reviews. In this day Many of these sites comb search engines for business listings and age there is an incredible amount automatically add listings regardless of information available about individuals on whether the internet, much of which may actually be known business has added itself to that person and some of which may be inaccurate or unknownthe site. If you encounter should find our listing on any information about me through web searchesof these sites, please know that our listing is NOT due to our request for a testimonial, rating, or in endorsement from you as my patient. The American Psychological Association’s Ethics Code discourages psychologists from soliciting testimonials. Of course, you have a right to express yourself, tell anyone that you are working with one of our therapists, or how you feel about treatment, on any other fashion site or any forum of your choosing. HOWEVER, we urge you to take your own privacy as seriously as we take our commitment of confidentiality to you. If you must disclose personal information on a public forum, we urge you to create a pseudonym that is not linked to your regular email address or friend networks for that matteryour own privacy and protection. Due to confidentiality, please discuss this with me during our time together so that we can deal with it and its potential impact on your treatment. Recently it has become fashionable for clients to review their health care provider on various websites. Unfortunately, mental health professionals cannot respond to such comments and related errors because of confidentiality restrictions. If you encounter such reviews of me or any professional with whom you are working, please share it with me so we can discuss it and its potential impact on your therapy. Please do not rate my work with you while we are in treatment together review on any of these websitessites or forums whether it is positive or negative because we cannot tell people that you are one of our patients. You should also be aware that if you are using these sites to communicate indirectly with us about your feelings about our therapy, there is a good possibility that we may never see it. We hope that you will bring your feelings and reactions directly to our therapy sessions. This is because it has a significant potential to damage our ability to work together. I may use a xxxx assistant to generate and track basic billing information. Only the billing assistant and I will have access to your billing records from which invoices are generated. The psychotherapy notes are NOT a can be an important part of therapy, even if you decide we are not a good fit. If you feel we have done something harmful or unethical and you do not feel comfortable discussing it with us, you can always contact the Board of Psychology, which oversees licensing, and they will review the services we have provided. Professional Licensing Agency Illinois Psychologist Licensing and (Attn: Indiana State Psychology Board) Disciplinary Board 000 X. Xxxxxxxxxx St., Room W072 000 Xxxx Xxxxxxxxxx Xx., 0xx Xxx Indianapolis, Indiana 46204 Springfield, IL 62786 Phone: 000-000-0000 Phone: (000) 000-0000 Email: xxx0@xxx.xx.xxx Location-Based Services (LBS): If you used location-based services on your mobile phone, you may wish to be aware of the privacy issues related to using these services. However, if you have GPS tracking enabled on your device, it is possible that others may surmise that you are a patient due to regular check-ins at the office on a weekly basis. Please be aware of this record. PATIENT RIGHTS HIPAA provides risk if you with several new are intentionally “checking in,” from our office or expanded rights with regard to if you have a passive LBS app enabled on your Clinical Records and disclosures phone Acknowledgement of protected health information. These rights include requesting Agreement I acknowledge that I 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 my policies and procedures recorded in your records; and the right to a paper copy of this Agreement. I am happy to discuss any of these rights with you. This agreement provides that during treatmentread, I will provide parents with only general information about the progress of the treatmentunderstand, and the patient’s attendance at scheduled sessions. I will also provide parents with a summary of their child’s treatment when it is complete when requested to do so. Any other communication will require the child’s Authorization, unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have. Your signature below indicates that you have read the information in this document and agree to abide by its terms during our professional relationshipthe clinic policies described above. I have reviewed this sheet with a staff member, had all of my questions fully answered, and am being given a copy for my records. My signature below shows that I understand and agree with all of these statements Patient Date Parent or Legal Guardian (if patient is age 18 and below) Date I, the therapist, have discussed the issues above with the client (and/or his or her parent, guardian, or other representative). My observations of this person's behavior and responses give me no reason to believe that this person is not fully competent to give informed and willing consent. Signature of Clinician Date ☐ A copy of this agreement has been given to the client.
Appears in 1 contract
Samples: Service Agreement
Web Searches. I will not use web searches to gather information about you without your permission. I believe that this violates your privacy rights; however. However, I understand that you might choose to gather information about me in this way. In this day and age there is an incredible amount of information available about individuals on the internet, much of which may actually be known to that person and some of which may be inaccurate or unknown. If you encounter any information about me through web searches, or in any other fashion for that matter, please feel free to discuss this with me during our time together so that we can deal with it and its potential impact on your treatmentwork with me. Recently it has become fashionable for clients to review their health care provider on various websites. Unfortunately, mental health professionals cannot respond to such comments and related errors because of confidentiality restrictions. If you encounter such reviews of me or any professional with whom you are working, please share it with me so we can discuss it and its potential impact on your counseling and therapy. For example, I do considerable evaluation work for disability claimants. It is not unusual that individuals who are denied disability benefits after seeing me might attribute that denial to my report, and, therefore, write a negative review. Please do not rate my work with you while we are in treatment together on any of these websiteswebsites while we work together. This is because it has a significant potential to damage our ability to work together. I Changes to this Policy From time to time, it may use a xxxx assistant be necessary to generate and track basic billing information. Only update the billing assistant and I will have access to your billing records from which invoices are generated. The psychotherapy notes are NOT a part text of this recordpolicy. PATIENT RIGHTS You will find the current version on my website (xxxxx://xxx.xxxxxxxxxxxx.xxx/), or a copy can be provided upon request. YOUR SIGNATURE ON THE NEXT PAGE INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS AND ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPAA provides you with several new or expanded rights with regard to your Clinical Records NOTICE FORM DESCRIBED ABOVE Rev. 01/22 I have read and disclosures of protected health information. These rights include requesting that I 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 acknowledge the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; Psychotherapist-Client Services Agreement and the right Missouri Notice Form to Protect the Privacy of Client Health Information. A credit card is required to insure financial responsibility for services rendered. Cardholder name: Credit Card (please circle): Visa MasterCard Discover American Express # Exp. Date Card verification value (CVV; three or four numbers on the back of the card): Billing address for the credit card: Street City, State, Zip Phone Email: Date of Birth: Payment is expected at the time of service. By my signature below I agree to charges to my credit card for the any balances once a paper copy of this Agreementservice is provided. I am happy to discuss any of these rights with you. This agreement provides that during treatment, I will provide parents with only general information about the progress of the treatment, and the patient’s attendance at scheduled sessions. I will also provide parents with a summary of their child’s treatment when it is complete when requested to do so. Any other communication will require the child’s Authorization, unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have. Your signature below indicates that you have read the information in this document and agree to abide by its terms during our professional relationship.these documents. Name Date Name Date
Appears in 1 contract
Samples: Client Services Agreement
Web Searches. I will not use web searches to gather information about you without your permission. I believe that this violates your privacy rights; howeverHowever, I understand that you might choose to gather information about me in this way. In this day and age there is an incredible amount of information available about individuals on the internet, much ; some of which may actually be known to that person us and some of which may be inaccurate or unknown. If you encounter are concerned about any information you encounter about me through web searches, or in any other fashion for that mattermanner, please discuss this with me during our time together so that we can deal with it and its potential impact on your treatment. Recently it has become fashionable for clients to review their health care provider on various websites. Unfortunately, mental health professionals cannot respond to such comments and related errors because of confidentiality restrictions. If you encounter such reviews of me or any professional with whom you are working, please share it with me so we can discuss it and its potential impact on your therapy. Please do not rate my work with you while we are in treatment together on any of these websites. This is because it has a significant potential to damage our ability to work together. PROFESSIONAL RECORDS The laws and standards of my profession require that I may use keep treatment records. You are entitled to request that I provide a xxxx assistant copy of the records to generate you, or to another health care provider that you specify. You must sign a written authorization for release of confidential information in order for me to fulfill requests for records. If you would like a copy of your records I recommend that you schedule a session to review them together so we can discuss the contents. Also, you should be aware that because these are professional records they can be misinterpreted and/or upsetting to untrained readers. I am n o t r eq u i r ed t o r el e as e p sychotherapy notes, which are personal notes documenting or analyzing the contents of sessions to help me provide better treatment to you. PLEASE NOTE, If you choose to keep a copy of your records I am no longer able to guarantee the confidentiality of the record once it leaves my office and track basic billing information. Only the billing assistant and I will have access to your billing records from which invoices are generated. The psychotherapy notes are NOT a part of this record. PATIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your Clinical Records and cannot be responsible for any disclosures of protected health information. These rights include requesting that I 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 records that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about not in my policies possession and procedures recorded in your records; and the right to a paper copy of this Agreement. I am happy to discuss any of these rights with you. This agreement provides that during treatment, I will provide parents with only general information about the progress of the treatment, and the patient’s attendance at scheduled sessions. I will also provide parents with a summary of their child’s treatment when it is complete when requested to do so. Any other communication will require the child’s Authorization, unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have. Your signature below indicates that you have read the information in this document and agree to abide by its terms during our professional relationshipcontrol.
Appears in 1 contract
Samples: Outpatient Services Agreement
Web Searches. I will not use web searches to gather information about you without your permission. I believe that this violates your privacy rights; however, I understand that you might choose to gather information about me in this way. In this day and age there is an incredible amount of information available about individuals on the internet, much of which may actually be known to that person and some of which may be inaccurate or unknown. If you encounter any information about me through web searches, or in any other fashion for that matter, please discuss this with me during our time together so that we can deal with it and its potential impact on your treatment. Recently it has become fashionable for clients to review their health care provider on various websites. Unfortunately, mental health professionals cannot respond to such comments and related errors because of confidentiality restrictions. If you encounter such reviews of me or any professional with whom you are working, please share it with me so we can discuss it and its potential impact on your therapy. Please do not rate my work with you while we are in treatment together on any of these websites. This is because it has a significant potential to damage our ability to work together. I may use a xxxx assistant to generate and track basic billing information. Only the billing assistant and I will have access to your billing records from which invoices are generated. The psychotherapy notes are NOT a part of this record. PATIENT RIGHTS 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 I 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 my policies and procedures recorded in your records; and the right to a paper copy of this Agreement. I am happy to discuss any of these rights with you. This agreement provides that during treatment, I will provide parents with only general information about the progress of the treatment, and the patient’s attendance at scheduled sessions. I will also provide parents with a summary of their child’s treatment when it is complete when requested to do so. Any other communication will require the child’s Authorization, unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have. Your signature below indicates that you have read the information in this document and agree to abide by its terms during our professional relationship. ACKNOWLDGING SIGNATURES ___________________________________ __________________________ Patient Signature Date ___________________________________ __________________________ Therapist Signature Date Xxxxx Xxxxxxx, Psy.D., R.N.,M.N. Clinical Psychologist LIC. PSY 00000 (000)000-0000 PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENT SIGNITURE PAGE ADULT Your signature below indicates that you have read the information in the Psychotherapist-Patient Agreement and agree to abide by its terms during our professional relationship. ACKNOWLEDGING SIGNATURES: Patient Signature Date
Appears in 1 contract
Samples: Patient Services Agreement
Web Searches. I will not use web searches to gather information about you without your permission. I believe that this violates your privacy rights; however. However, I understand that you might choose to gather information about me in this way. In this day and age there is an incredible amount of information available about individuals on the internet, much of which may actually be known to that person and some of which may be inaccurate or unknown. If you encounter any information about me through web searches, or in any other fashion for that matter, please feel free to discuss this with me during our time together so that we can deal with it and its potential impact on your treatmentwork with me. Recently it has become fashionable for clients to review their health care provider on various websites. Unfortunately, mental health professionals cannot respond to such comments and related errors because of confidentiality restrictions. If you encounter such reviews of me or any professional with whom you are working, please share it with me so we can discuss it and its potential impact on your counseling and therapy. For example, I do considerable evaluation work for disability claimants. It is not unusual that individuals who are denied disability benefits after seeing me might attribute that denial to my report, and, therefore, write a negative review. Please do not rate my work with you while we are in treatment together on any of these websiteswebsites while we work together. This is because it has a significant potential to damage our ability to work together. I Changes to this Policy From time to time, it may use a xxxx assistant be necessary to generate and track basic billing information. Only update the billing assistant and I will have access to your billing records from which invoices are generated. The psychotherapy notes are NOT a part text of this recordpolicy. PATIENT RIGHTS You will find the current version on my website (xxxxx://xxx.xxxxxxxxxxxx.xxx/), or a copy can be provided upon request. YOUR SIGNATURE ON THE NEXT PAGE INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS AND ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPAA provides you with several new or expanded rights with regard to your Clinical Records NOTICE FORM DESCRIBED ABOVE Rev. 05/20 I have read and disclosures of protected health information. These rights include requesting that I 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 acknowledge the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; Psychotherapist-Client Services Agreement and the right Missouri Notice Form to Protect the Privacy of Client Health Information. A credit card is required to insure financial responsibility for services rendered. Cardholder name: Credit Card (please circle): Visa MasterCard Discover American Express # Exp. Date Card verification value (CVV; three or four numbers on the back of the card): Billing address for the credit card: Street City, State, Zip Phone Email: Date of Birth: Payment is expected at the time of service. By my signature below I agree to charges to my credit card for the any balances once a paper copy of this Agreementservice is provided. I am happy to discuss any of these rights with you. This agreement provides that during treatment, I will provide parents with only general information about the progress of the treatment, and the patient’s attendance at scheduled sessions. I will also provide parents with a summary of their child’s treatment when it is complete when requested to do so. Any other communication will require the child’s Authorization, unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have. Your signature below indicates that you have read the information in this document and agree to abide by its terms during our professional relationship.these documents. Name Date Name Date
Appears in 1 contract
Samples: Client Services Agreement
Web Searches. I will not use web searches to gather information about you without your permission. I believe that this violates your privacy rights; howeverHowever, I understand that you might choose to gather information about me in this way. In this day and age there is an incredible amount of information available about individuals on the internet, much some of which may actually be known to that person us and some of which may be inaccurate or unknown. If you encounter are concerned about any information you encounter about me through web searches, or in any other fashion for that mattermanner, please discuss this with me during our time together so that we can deal with it and its potential impact on your treatment. Recently it has become fashionable for clients to review their health care provider on various websites. Unfortunately, mental health professionals cannot respond to such comments and related errors because of confidentiality restrictions. If you encounter such reviews of me or any professional with whom you are working, please share it with me so we can discuss it and its potential impact on your therapy. Please do not rate my work with you while we are in treatment together on any of these websites. This is because it has a significant potential to damage our ability to work together. PROFESSIONAL RECORDS The laws and standards of my profession require that I keep treatment records. You are entitled to request that I provide a copy of the records to you, or to another health care provider that you specify. You must sign a written authorization for release of confidential information in order for me to fulfill requests for records. If you would like a copy of your records I recommend that you schedule a session to review them together so we can discuss the contents. Also, you should be aware that because these are professional records they can be misinterpreted and/or upsetting to untrained readers. If I believe that providing your records to you would be emotionally damaging or harmful, I may use deny access. My fee for records requests is $15. PLEASE NOTE, If you choose to keep a xxxx assistant copy of your records I am no longer able to generate guarantee the confidentiality of the record once it leaves my office and track basic billing information. Only the billing assistant and I will have access to your billing records from which invoices are generated. The psychotherapy notes are NOT a part of this record. PATIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your Clinical Records and cannot be responsible for any disclosures of protected health information. These rights include requesting that I 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 records that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about not in my policies possession and procedures recorded in your records; and the right to a paper copy of this Agreement. I am happy to discuss any of these rights with you. This agreement provides that during treatment, I will provide parents with only general information about the progress of the treatment, and the patient’s attendance at scheduled sessions. I will also provide parents with a summary of their child’s treatment when it is complete when requested to do so. Any other communication will require the child’s Authorization, unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have. Your signature below indicates that you have read the information in this document and agree to abide by its terms during our professional relationshipcontrol.
Appears in 1 contract
Samples: Outpatient Services Agreement
Web Searches. I will not use web searches to gather information about you without your permission. I believe that this violates your privacy rights; however, I understand that you might choose to gather information about me in this way. In this day and age there is an incredible amount of information available about individuals on the internet, much of which may actually be known to that person and some of which may be inaccurate or unknown. If you encounter any information about me through web searches, or in any other fashion for that matter, please discuss this with me during our time together so that we can deal with it and its potential impact on your treatment. Recently it It has become fashionable increasingly common for clients to review their health care provider on various websites. Unfortunately, mental health professionals cannot respond to such comments and related errors because of confidentiality restrictions. If you encounter such reviews of me or any professional with whom you are working, please share it with me so we can discuss it and its potential impact on your therapy. Please do not rate my work with you while we are in treatment together on any of these websites. This is because it has a significant potential to damage our ability to work together. I may use a xxxx assistant Once you have read and understood this agreement, please sign in the space immediately below indicating that you are agreeing to generate the terms of this agreement and track basic billing informationauthorizing me to provide psychotherapy, consultation, and/or assessment services for you. Only the billing assistant and I will have access to your billing records from which invoices are generated. The psychotherapy notes are NOT a If there is any part of this record. PATIENT RIGHTS 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 I 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 agreement that you have neither consented do not understand, please discuss it with me prior to nor authorized; determining the location signing it. Informed consent for psychotherapy: I hereby authorize Xxxxx Xxxxxx, PsyD to which protected information disclosures are sent; having any complaints you make about my policies render counseling, consultation, and procedures recorded in your records; psychotherapy services for me. This authorization constitutes informed consent without exception and the right agreement to a paper copy of this Agreementpay all applicable fees. I am happy to discuss any of these rights with you. This agreement provides that during treatment, I will provide parents with only general information about the progress of the treatment, and the patient’s attendance at scheduled sessions. I will also provide parents with a summary of their child’s treatment when it is complete when requested to do so. Any other communication will require the child’s Authorization, unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have. Your signature below indicates that you have read the information in and understood this document agreement and agree to abide by its terms during our professional relationship.have received a copy for myself. Signed: Date: If under age 18 parent or legal guardian must sign. Signed: Date:
Appears in 1 contract
