Solutions Health Services, LLC/ Dobbs & Associates, Inc

Access Behavioral Health, Inc.

NEW PATIENT PAPERWORK

Thank you for choosing Access Behavioral Health, Inc. for your mental health needs. Attached is paperwork needed before your first appointment. In order to maximize the time you get to spend with your therapist/psychiatrist, please fill out everything completely. New Patient paperwork can be mailed, faxed, or brought in.

YOUR FIRST APPOINTMENT

We suggest you use the “Driving Directions” on our website www.accessabh.com to direct you to our office as GPS/Online maps often lead you to an incorrect location.

After your appointment has been made, please:

 Call your insurance company to obtain pre-certification. To do so, call the number on back of your card to request. You will need to give them the name of the therapist/psychiatrist you are seeing. Write this number as well as the number of visits covered, start and end date. Also verify your co pay. Sometimes mental health services may be different than what shows on your card. If your insurance company tells you that pre-certification is not required, write the name of the person you spoke with as well as the reference number. If your insurance denies a claim due to not having pre-certification, you will be help responsible for payment in full of the services provided.

 Please plan to arrive 10-15 minutes before your scheduled appointment time.

 You must bring your photo ID, insurance card, and any payment. If you have a high deductible insurance plan, and have not met your deductible, you are expected to pay for the appointment prior to seeing the therapist/psychiatrist.

 Please bring a list of your medications, including dose, schedule, and frequency. Previous treatment records that may be important, including hospitalizations, psychological testing results, therapy notes. Access Behavioral Health, Inc.

Clinical Self Assessment

Name: Date:

What concerns do you have for the therapist today? Why are you seeking therapy at this time?

Please circle the description which fits you most:

Your Mood: Very depressed Down/Low Content Happy Very Happy

Your Pleasure and Interest in Activities: None Poor Average Good Excellent

Feelings of Guilt: Excessive Some Little Rare None

Your Energy Level: None Poor Average Good Excellent

Your Concentration: Extremely Poor Poor Average Good Excellent

Your Sleep: Extremely Poor Poor Average Good Excellent

Your Appetite: None Poor Average Good Excellent

Have you experienced any thoughts of hurting yourself or others? (If yes, please explain)

Please list any current medical problems:

Please list any prescription or over the counter medications you are taking, including dosage:

Please list your use of caffeine, alcohol, tobacco and other drugs/ substances in the last month:

Patient or Guardian’s Signature Page 1 of 9 Access Behavioral Health, Inc.

Client Information:

Name: DOB: SSN:

Home Address:

City: State: Zip:

Home Phone: If needed, may we contact you at home? Yes No

Work Phone: If needed, may we contact you at work? Yes No

Cell Phone: ______If needed, may we contact your cell? Yes No

Email Address:______

Responsible Party Information (Please fill out if client is minor)

Name: ______

Mailing Address: ______

City: ______State: ______Zip: ______

Home Phone: If needed, may we contact you at home? Yes No

Work Phone: If needed, may we contact you at work? Yes No

Employer: ______

Cell Phone: ______If needed, may we contact you by cell phone?Yes No

Emergency Contact:

Name: ______Relationship:______Phone:______

POLICY HOLDER INFORMATION:

Insurance Company: Insurance ID # ______

Policy Holder Name: Policy Holder Date of Birth

Policy Holder’s Employer:

Policy Holder address if different than client: ______

Client relationship to insured (please circle one): Self Spouse Child Other How did you hear about us? (check one) { } Physician { } Yellow Pages { } Insurance { } EAP program { } Friend/Relative { } Brochure { } Website { } Other:

Is this appointment for a child custody evaluation? { } Yes { } No

****Please return this form with a copy of your insurance card and driver’s license. Access Behavioral Health, Inc.

of 9 AUTHORIZATIONS TO RELEASE INFORMATION Welcome to Access Behavioral Health, Inc. This packet contains important information about services and business policies as well as information about the Health Insurance Portability and Accountability Act (HIPAA), a new federal law that provides new privacy protections and new patient rights with regards to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment and health care operations. The law protects the privacy of all communications between a patient and a therapist. In most situations, information can only be released to others if you sign a written authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advanced consent.

I, authorize

(Client’s name) (Provider’s name) to release and/or obtain the following information related to my treatment: (Check all that apply. Only those listed will be allowed to call or obtain information. If using insurance, this must be checked for billing purposes. )

Insurance Company Name: Phone:

Employer Name: Phone:

Spouse Name: Phone:

______Parent or Guardians:______Phone:______

Other Relationship ______Name: ______Phone:

Primary Care Physician Information:

Check here if you DO NOT have a Primary Care Physician.

Doctor:______Phone: Address: ______

*Please Check One: I give my permission to release any applicable information to the above doctor.

I give my permission to release only medical information to the above doctor.

Do Not release any information to my primary care physician.

Time limitation for this release is: OR ______No limitation I understand I may revoke this authorization at any time.

I further understand that this information will be confidential and cannot be released to any party not named above, including spouses or parents. Federal law prohibits myself or any of the above named individuals/ agency from re- disclosing this information without my signed consent. Due to HIPAA regulations, we usually require the patient to personally pick up copies of documents or confidential information. We do not usually mail or fax confidential information due to HIPAA. We also do not mail confidential information to other parties, such as attorneys, without a court order.

Billing information and statements are not considered confidential medical information and will be sent to the patient’s home address.

_____ Yes, I give permission to call me for reminder appointments. The best number is call is ______

_____ I decline to receive reminders of my appointments. If permission is not given, I understand that it is possible I will not be informed of scheduling changes when the provider is unable to be in the office.

Signature of Patient or Parent or Guardian Date Page 3 of 9 Access Behavioral Health, Inc.

Permission to Treat/ Permission to Render Services

I, , give permission to Patient’s name Therapist’s name and Access Behavioral Health, Inc. to provide me treatment services.

______Signature of the patient Date

OR IF THE PATIENT IS A MINOR:

I, , give permission to Parent’s/ guardian’s name Therapist’s name and Access Behavioral Health, Inc. to render treatment to

, Patient’s name whose relationship to me is child Other (specify)

Signature of the patient

Signature of parent/guardian

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MEDICATION MANGEMENT POLICY Access Behavioral Health, Inc., has formulated the following medication management policy to: Provide additional safety monitoring of patients taking medications

Reduce risk to patients who may abuse medications prescribed

Reduce risk and liability for providers due to patients who do not follow the treatment plan or who abuse medications

In order to be considered an active patient at Access Behavioral Health, Inc., a patient must be seen by either a therapist or a psychiatrist at least every ninety (90) days. Since medication management follow-ups are only 15 minutes, seeing a therapist will provide a safety net to identify any patient who might become suicidal or who may be having reactions to medications.

Medications will not be written for more than 90 days, unless the patient has been treated by the same psychiatrist for at least 3 years and is consistent with the same medication and dosage. This assures that all patients are seen in an attempt to rule out any adverse situations that would create liability for providers or Access Behavioral Health, Inc. Access Behavioral Health does not feel it is prudent to write prescriptions without seeing patients on a regular basis. We understand this may not be convenient for those patients who use mail order services, but this is necessary because of the additional liability for providers and for Access Behavioral Health, Inc.

All medication management patients must have lab tests at least once a year. The psychiatrist will determine if more than one test per year is needed.

If the patient is taking medications for depression or other illnesses that might involve patient safety, we require that the patient also see a therapist on a regular basis. A new patient must be seen at least once by a therapist at Access Behavioral Health, or request copies of their current therapist’s notes to provide a history for the chart.

Although the psychiatrist will try to return phone calls and process medication refill requests as soon as possible, there is THREE-DAY notice required for refill requests. PRESCRIPTIONS WILL NOT BE FILLED ON FRIDAYS. If the patient feels it is a medical emergency, the patient should immediately go to the nearest emergency room. The psychiatrist will be called by the emergency room if needed.

If a patient requesting a medication refill has a balance, our policy is to fill the prescription for only seven days at a time until the balance is cleared. A patient must have a follow-up appointment scheduled before a refill request will be processed.

I have read and agree to follow this policy:

______Date ______Patient/ Parent or Guardian’s signature Page 5 of 9 Access Behavioral Health, Inc.

Patient Bill of Rights

Statement of Patients’ Rights

Patients have the right to be treated with dignity and respect.

Patients have the right to fair treatment. This is regardless of their race, religion, gender, ethnicity, age, disability, or source of payment.

Patients have the right to have their treatment and other patient information kept private.

Patient records cannot be released without patient permission except as required by law or in accordance with HIPAA regulations.

Patients have the right to information from staff/providers in a language they can understand.

Patients have the right to have an “easy to understand” explanation of their condition and treatment.

Patients have the right to know about their treatment choices, regardless of the cost or whether or not they are covered by insurance.

Patients have the right to get information about Access Behavioral Health, Inc. services and role in the treatment process.

Patients have the right to professional information about providers.

Patients have the right to know the clinical guidelines used in providing and/or managing their care.

Patients have the right to file a complaint or grievance with the administration of Access Behavioral Health, Inc.

Patients have the right to know about State and Federal laws that relate to their rights and responsibilities.

Patients have the right to know of their rights and responsibilities in the treatment process.

Statement of Patients’ Responsibilities

Patients have the responsibility to give providers information they need. This is so the provider can deliver the best possible care.

Patients have the responsibility to let their provider know when the treatment plan no longer works for them.

Patients have the responsibility to follow their medication plan. They must tell their provider about medication changes, including medications given to them by other providers.

Patients have the responsibility to treat those giving them care with dignity and respect. This includes any support staff, such as people who make appointments.

Patients should not take actions that could harm the lives of Access Behavioral Health, Inc., employees, providers, or other patients.

Patients have the responsibility to keep their appointments. Patients should call their providers as soon as possible if they need to cancel visits. A fee of $35 is charged if the patient does not show or if the cancellation is made in less than 24 hours of the appointment time. Reminder phone calls may be made by our office. This is only a courtesy to our patients. The patient is ultimately responsible for tracking their appointment day and time.

Patients have the responsibility to ask their providers questions about their care. This is so they can understand their care and their role in that care.

Patients have the responsibility to meet their financial obligations for their services. Should a problem arise with meeting this obligation, patients must communicate with their provider to resolve the problem.

Patients have the responsibility to follow the plans and instructions for their care. The care is to be agreed upon by the member and provider.

I have read and understand my Patient Rights and Responsibilities

______Date: ______Patient or Guardian Signature Page 6 of 9 Access Behavioral Health, Inc.

Fees and Collections Policy I understand that I am fully responsible for payment of services rendered to me, by the above practice, BEFORE the session begins. It is company policy to collect all co-payments BEFORE each session with a therapist or doctor. I realize that my mental health benefits have been determined prior to this appointment and that all co-payments and co-insurance payments are due at the time of service. I understand that I am financially responsible for charges not covered and agree to guarantee payment for any balance due in excess of any amount paid by individuals, agencies, and/or insurance companies. In the event of default, I agree to pay all costs of collections including court costs and reasonable attorney’s fees. I understand that if the insurance policy that is being used is out-of-state that Access Behavioral Health, Inc. reserves the right to collect fees when services are rendered and reimburse me when the insurance company makes payment.

**PLEASE TAKE NOTICE** NO-SHOW / LATE CANCELLATION FEES A fee of $35.00 will be added to the account of any patient failing to cancel an appointment 24 hours prior to appointment time. A patient is considered a “no-show” if the appointment is not kept and not canceled 24 hours prior to the scheduled time. These charges are not covered by health insurance benefits and are the responsibility of the patient/responsible party. Patients with no-show fees must clear the charge PRIOR to the next scheduled appointment. Unpaid past-due charges will be turned over to a collection agency. THERE WILL BE NO EXCEPTIONS.

Dedication to mental health treatment involves a commitment from your clinician to reserve time and be prepared for your session. Your commitment is to attend all scheduled appointments and follow through with all treatment recommendations. Consistency in keeping appointments is important to the patient’s treatment plan. In addition, multiple cancellations, even with advance notice, do not reflect patient commitment to the treatment plan and may also result in the patient being referred to another agency. Three cancellations in a row, or five cancellations within a six-month period (even if appropriate 24 hour notice is given) are considered a lack of investment in treatment.

Below is a list of our standard charges, which you will be responsible for paying if your insurance company denies a claim: Initial Visit for a DIAGNOSTIC INTERVIEW, with MD $160.00 Initial visit for a DIAGNOSTIC INTERVIEW, with Psychologist $150.00 Initial visit for a DIAGNOSTIC INTERVIEW, with Social Worker $125.00 Visit for a FOLLOW-UP SESSION, with MD $ 65.00 Visit for a FOLLOW-UP SESSION, with Psychologist $125.00 Visit for a FOLLOW-UP SESSION, with Social Worker $100.00 Hypnosis session with Ronald D. Dobbs, LCSW, NBCDCH $125.00

CUSTODY EVALUATIONS: (In the event that you are here for a custody evaluation) I understand that Access Behavioral Health, Inc. will perform a custody evaluation based on a court order that designates the psychologist appointed by the court for such purposes. Custody evaluations will not be billed to my insurance carrier. I understand that a minimum retainer of $1,750 per adult named in the court order will be due prior to the evaluation. In the case that the order is cancelled, the retainer will be billed at $200.00 per hour for services rendered on the case. I understand that additional retainer amounts may apply in atypical cases. Costs for court appearances and depositions are additional to the retainer for the custody evaluation and must also be paid prior to the court or deposition date. PSYCHOLOGICAL TESTING All psychological testing must be pre-authorized prior to the date of testing by insurance company. Please be advised that MOST insurance plans EXCLUDE COVERAGE for assessment of learning disabilities, educational testing and IQ testing. Payment for psychological testing MUST BE MADE PRIOR to date of testing . I understand that I am fully responsible for PAYMENT IN FULL for any professional services excluded by my insurance plan. The office will provide a Testing Services Agreement form documenting the type and amount charged for testing that is not covered by insurance.

Other Fees

Legal Fees for Court Appearance (per hour)………………………….…varies by therapist Legal Fees for Deposition (per hour)………………….…………………varies by therapist Legal Letters……………………………………………….………………… $125.00 * All other Letters……………………………………………………………… $ 75.00 * Disability/FMLA Forms.……………………………………………………. $ 75.00 * Off Site visits/consultation on School Premises (per hour)………..………. $105.00 No Show Fee (due at next appt.)………………………………………….. $ 35.00 Cancellation < 24 hours…………………………………………………… $ 35.00 Returned check fees ………………………………………………………… $ 35.00 * Fee could change based on extensiveness of report Miscellaneous Copies of chart information or notes: patient receives first copy free. Additional requests are $.50 per page for patients. Requests for copies for legal purposes varies based on time element required.

PLEASE MAKE A REQUEST FOR A RECEIPT OR COPY OF YOUR STATEMENT WHILE YOU ARE IN THE OFFICE. WE WILL DO OUR BEST TO GIVE THEM TO YOU BEFORE YOU LEAVE THE OFFICE.

A therapy hour is 45 minutes in length, based on standards in mental health practices. After the initial 45 min. evaluation, a medication follow-up with a psychiatrist is 15 minutes.

All fees for services are due BEFORE your session begins. We accept cash, personal checks, money orders, Visa, and MasterCard. Under no circumstances do we accept post-dated checks. We do not extend credit for any reason.

COLLECTION PROCEDURES Our office reserves the right to place all accounts 30 days PAST DUE into collection procedures even if only one statement has been sent. Returned Checks / Checks on Closed Accounts There is a $35 fee for checks returned for insufficient funds. The patient will then be required to use cash, money order, or credit card for all future transactions. A letter will be mailed, giving the patient 10 days to redeem the check and pay the fee in cash or money order. After 10 days, the check will be handed over to the Jefferson County Attorney’s Office for collection and/or prosecution.

I have read, understand and agree to the above policy also acknowledge that by signing this Policy I am solely responsible to pay ALL non-covered services charged by Access Behavioral Health, Inc. regardless of Divorce Decrees and outside Agreements with other parties. The adult who accompanies a dependent is responsible for paying for services due BEFORE the session. We DO NOT BILL other parties, regardless of custody agreements. I UNDERSTAND THAT ADDITIONAL SERVICES DEEMED NECESSARY BY MY CLINICIAN WILL PRODUCE ADDITIONAL CHARGES, AND I AGREE TO BE RESPONSIBLE FOR THE FULL AMOUNT OF THESE CHARGES IF THEY ARE NOT COVERED BY INSURANCE.

______Patient or Parent/Guardian Signature Date

PATIENT RIGHTS

Health Insurance Portability and Accountability Act (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 the therapist’s policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and privacy policies and procedures. The therapist is happy to discuss any of these rights with you.

MINORS & PARENTS

For patients under 16 years of age who are not emancipated, their parents should be aware that the law may allow parents to examine their child’s treatment records. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is sometimes the policy to request an agreement from parents that they consent to give up their access to their child’s records. If they agree, during treatment, the therapist will provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. The therapist will also provide parents with a summary of their child’s 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 the concern. Before giving parents any information, the therapist will discuss the matter with the child, if possible, and attempt to handle any objections he/she may have.

I, ______understand the office policies and procedures of Access (Patient’s Name) Behavioral Health, Inc. I understand that Access Behavioral Health, Inc. is in compliance with the Health Insurance Portability and Accountability Act (HIPAA) guidelines. I also understand my patient Bill of Rights. The therapist may use or disclose my protected health information, for treatment, payment, and health care operation purposes.

I understand I may request a copy of the above policies at any time.

I decline a copy of the Health Insurance Portability and Accountability Act (HIPAA)

______Date:______Patient or Parent / Guardian Signature

OFFICE POLICIES

Insurance and co payment agreement: All co pays, co insurance, or self-payment amounts are DUE BEFORE the session begins. If your insurance does not pay, FOR ANY REASON then you are responsible for the charges. The individual therapist will determine separate fees for psychological testing and custody/ divorce procedures.

Fees and Cancellation policy: If you do not cancel an appointment 24 HOURS BEFORE time, you will be charged $35 and it must be paid before your next appointment. If you forget an appointment this is called a “no show”, and you will be charged $35. You can call after office hours and the answering service will record the time and date so that your 24-hour time limit can be determined. The answering service does not have the authorization to waive charges or tell you that you will not be charged. The number to call is 502- 394-0101.

FEE SCHEDULE

Initial Psychiatric Evaluation……………………………………….…. $160.00 Subsequent Medication Check………………………….………...…… $ 65.00 Initial Psychological Evaluation………………………………….…… $150.00 Subsequent Psychological Sessions……………………………….….. $125.00 Initial Assessment LCSW…………….………………………….…… $125.00 Subsequent Sessions LCSW………….………………………………. $100.00 Hypnosis – Initial...…………………………………………..……….. $125.00 Hypnosis Follow-up sessions……………………….………………… $100.00

Other Fees

Legal Fees for Court Appearance (per hour)………………………….…varies by therapist Legal Fees for Deposition (per hour)………………….…………………varies by therapist Legal Letters……………………………………………….………………… $125.00 * All other Letters……………………………………………………………… $ 75.00 * Disability/FMLA Forms.……………………………………………………. $ 75.00 * Off Site visits/consultation on School Premises (per hour)………..………. $105.00 No Show Fee (due at next appt.)………………………………………….. $ 35.00 Cancellation < 24 hours…………………………………………………… $ 35.00 Returned check fees ………………………………………………………… $ 35.00 * Fee could change based on extensiveness of report Miscellaneous Copies of Chart information or notes: patient receives first copy free. Additional requests are $.50 per page for patients. Requests for copies for legal purposes vary based on time element required.

PLEASE MAKE A REQUEST FOR A RECEIPT OR COPY OF YOUR STATEMENT WHILE YOU ARE IN THE OFFICE. WE WILL DO OUR BEST TO GIVE THEM TO YOU BEFORE YOU LEAVE THE OFFICE. THIS OFFICE WILL NOT BILL YOUR INSURANCE COMPANY FOR NO-SHOW OR LATE CANCELLATION FEES.

A therapy hour is 45 minutes in length, based on standards in mental health practices. After the initial 45 min. evaluation, a medication follow-up with a psychiatrist is 15 minutes.

All fees for services are due BEFORE your session begins. We accept cash, personal checks, money orders, Visa, and MasterCard. Under no circumstances do we accept post-dated checks. We do not extend credit for any reason. Page 1 of 5 Patient Copy Access Behavioral Health, Inc.

KENTUCKY NOTICE FORM

Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information

THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

USES AND DISCLOSURES REQUIRING AUTHORIZATION Therapists may use or disclose PHI for purposes outside of treatment, payment, or health care operations when your appropriate authorization is obtained. An “authorization” is written permission above and beyond the general consent that permits only specific disclosures. In those instances when a therapist is asked for information for purposes outside of treatment, payment or health care operations, the therapist will obtain an authorization from you before releasing this information. The therapist will also need to obtain an authorization before releasing your psychotherapy notes. “Psychotherapy notes” are notes the therapist has made about conversations during a private, group, joint, or family counseling session, which the therapist has kept separate from the rest of your medical record. These notes are given a greater degree of protection than PHI.

You may revoke all such authorizations (of PHI or psychotherapy notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) the therapist has relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, and the law provides the insurer the right to contest the claim under the policy.

Uses and Disclosures with Neither Consent nor Authorization The therapist may use or disclose PHI without your consent or authorization in the following circumstances:

Child Abuse: If the therapist has reasonable cause to believe that a dependent child is neglected or abused, the therapist must report this belief to the appropriate authorities, which may include the Kentucky Cabinet for Families and Children or its designated representative, the commonwealth's attorney or the county attorney, or local law enforcement agency or the Kentucky state police.

Adult and Domestic Abuse: If the therapist has reasonable cause to believe that an adult has suffered abuse, neglect, or exploitation, the therapist must report this belief to the Kentucky Cabinet for Families and Children.

Health Oversight Activities: The Kentucky Board of Examiners of Psychology may subpoena records from the therapist relevant to its disciplinary proceedings and investigations.

Judicial and Administrative Proceedings: If you are involved in a court proceeding and a request is made for information about your diagnosis and treatment and records thereof, such information is privileged under state law, and the therapist will not release information without the written authorization of you or your personal or legally- appointed representative, or a court order. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court-ordered. You will be informed in advance if this is the case.

Serious Threat to Health or Safety: If you communicate an actual threat of physical violence against a clearly identified or reasonably identifiable victim or an actual threat of some specific violent act, the therapist has a duty to notify the victim and law enforcement authorities.

Workers’ Compensation: If you file a claim for workers’ compensation, you waive the psychotherapist- patient privilege and consent to disclosure of your health information reasonably related to your injury or disease to your employer, workers’ compensation insurer, special fund, uninsured employers’ fund or the administrative law judge.

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PSYCHOLOGIST’S DUTIES  The therapist is required by law to maintain the privacy of PHI and to provide you with a notice of the therapist’s legal duties and privacy practices with respect to PHI.

 The therapist reserves the right to change the privacy policies and practices described in this notice. Unless the therapist notifies you of such changes, however, the therapist is required to abide by the terms currently in effect.

 If the therapist revises the therapist’s policies and procedures, the therapist will provide individuals with a revised notice by mail.

Complaints If you are concerned that the therapist has violated your privacy rights, or you disagree with a decision the therapist made about access to your records, you may contact Dr. Ronda Mancini, Access Behavioral Health, Inc., Partner. You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. The person listed above can provide you with the appropriate address upon request.

THERAPIST-PATIENT AGREEMENT

Limits on Confidentiality The law protects the privacy of all communications between a patient and a therapist. In most situations, information can only be released to others if you sign a written authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advanced consent. Your signature on this agreement provides consent for those activities, as follows:

* The therapist may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, every effort is made to avoid revealing the identity of the patient. These other professionals are also legally bound to keep the information confidential. If you don’t object, the therapist will not tell you about these consultations unless the therapist feels that it is important to work together. The therapist will note all consultations in your Clinical Record (PHI).

* As a group practice, it may be necessary to share information with other mental health professionals or with the administrative staff for the purposes of billing, scheduling and quality assurance, etc. All of the staff and therapists are bound by the same confidentiality rules. All staff has been trained about protecting your privacy and will not release any information without prior permission from the patient.

* The therapist also has contracts with various other businesses. As required by HIPAA, the therapist has a formal business associate contract with these businesses, in which they promise to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, the therapist can provide you with the names of these organizations and/or a blank copy of this contract.

* Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement.

* If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the psychologist-patient privilege law. The therapist cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order the therapist to disclose information.

* If a government agency is requesting the information for health oversight activities, the therapist may be required to provide it for them.

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PROFESSIONAL RECORDS The laws and standards of the therapist’s profession require that the therapist keep Protected Health Information about you in your Clinical Record. Except in unusual circumstances where disclosure would physically endanger you and/or others or makes reference to another person (unless such other person is a health care provider) and the therapist believes that access is reasonably likely to cause substantial harm to such other person, 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 the therapist’s presence, or have them forwarded to another mental health professional so you can discuss the contents. You are entitled to a free copy of your records. However, the therapist is allowed to charge a copying fee of $0.50 per page (and for certain other expenses) for any subsequent copies. If the therapist refuses your request for access to your records, you have a right of review, which the therapist will discuss with you upon request.

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 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 the therapist’s policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and privacy policies and procedures. The therapist is happy to discuss any of these rights with you.

MINORS & PARENTS For patients under 16 years of age who are not emancipated, their parents should be aware that the law may allow parents to examine their child’s treatment records. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is sometimes the policy to request an agreement from parents that they consent to give up their access to their child’s records. If they agree, during treatment, the therapist will provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. The therapist will also provide parents with a summary of their child’s 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 the concern. Before giving parents any information, the therapist will discuss the matter with the child, if possible, and attempt to handle any objections he/she may have.

AFTER HOURS

Office telephones are rolled over at 5:00 pm. Calling the office after regular business hours, weekends, or holidays are answered by an answering service. The answering service will phone the on-call therapist/psychiatrist, which may not be your therapist/psychiatrist. This service should only be utilized for urgent matters that cannot wait until the next business day. Calls place for non-emergency issues such as medication refills, scheduling or billing issues, may result in being charged for that call. If your call is an emergency, please dial 911 to receive immediate medical/psychological help.

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Access Behavioral Health, Inc.

MEDICATION MANGEMENT POLICY

Access Behavioral Health, Inc., has formulated the following medication management policy to: Provide additional safety monitoring of patients taking medications