Welcome to our practice. This document (the Agreement) contains important information about our professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights about the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations. HIPAA requires that we provide you with a Notice of Privacy Practices (the Notice) for use and disclosure of PHI for treatment, payment and health care operations.
The Notice, which is attached to this Agreement, explains HIPAA and its application to your personal health information in greater detail. The law requires that we obtain your signature acknowledging we provided you with this information at the end of this session. Although these documents are long and sometimes complex, it is very important that you read them carefully before your session. You and Dr. Haugen can discuss any questions you have about the procedures at that time. When you sign this document, it will also represent an agreement between you, ATAGF, and Dr. Haugen.
YOUR PROFESSIONAL
Your professional, Erin Haugen, PhD, LP, CMPC, is a Licensed Psychologist and Certified Mental Performance Consultant ® (CMPC). She has a PhD in Clinical Psychology and completed the requirements for licensure as a psychologist in the state of North Dakota (#402) and Minnesota (#LP6555). Individuals who are Certified Mental Performance Consultants have completed the requirements put forth by the Association for Applied Sport Psychology for this certification. This includes coursework in sport and performance psychology as well as providing sport psychology services under mentorship from another qualified sport psychology professional. She also holds the Authority to Practice Interjurisdictional Telepsychology (APIT) credential (#15738) administered by the PSYPACT Commission. Individuals who hold the APIT credential are approved to practice telepsychology within the limits authorized under the PSYPACT Compact in another Compact state. She is required to complete continuing education credits in psychology and sport psychology to maintain her licenses, certifications, and credentials.
PSYCHOLOGICAL SERVICES
You are likely coming to see Dr. Haugen for mental health therapy (therapy), which can include managing psychological symptoms negatively impacting sport performance. Therapy is not easily described in general statements. It varies depending on the personalities of the professional and patient and the problems you are experiencing. There are many different methods we may use to deal with the problems you hope to address, although Dr. Haugen typically uses evidence-based interventions in cognitive behavioral therapy (CBT) and acceptance and commitment therapy (ACT). Therapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. For your meetings with Dr. Haugen to be most successful, you will have to work on things you and Dr. Haugen talk about during your sessions, at home, and within the performance environment (practice, competition, academics).
The length of a course of therapy varies based upon goals you establish with Dr. Haugen, your symptoms, their severity, frequency of sessions, your motivation to participate in therapy or the evaluation, and your ability to implement learned skills outside of session.
Therapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. On the other hand, they have also been shown to have many benefits. Therapy and often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. Yet, there are no guarantees of what you will experience.
The first few sessions with Dr. Haugen will involve an evaluation of your needs. Part of this evaluation may involve completing psychological inventories to help her better understand your experience. By the end of the evaluation period, Dr. Haugen will be able to offer you some first impressions of what your work together will include. There may also be a treatment plan to follow which may include referrals to other professionals for services (such as psychotherapy and/or other treatment recommendations). You should evaluate this information along with your own opinions of whether you feel comfortable working with these professionals. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the professional(s) you select. If you have questions about our procedures at ATAGF, you should discuss them with Dr. Haugen whenever they arise. If your doubts persist, Dr. Haugen will be happy to help you set up a meeting with another mental health professional for a second opinion.
MULTIPLE RELATIONSIPS IN SPORT PSYCHOLOGY
Dr. Haugen must follow applicable laws and rules as well as the ethics codes within clinical and sport psychology, and she takes this responsibility seriously. Because sport psychology is a specialty area, there are few providers in the region that provide these services. This means Dr. Haugen may be working with individuals that you know, such as teammates or other athletes at your or another institution. Dr. Haugen will take reasonable steps to minimize any conflict of interest prior to working with you. Should a conflict of interest arise during your work with her, she will address this with you in a manner that maintains confidentiality and minimizes harm for all impacted parties. If you have any questions about multiple relationships in sport psychology, please ask Dr. Haugen who is happy to discuss this with you further.
SOCIAL MEDIA
Dr. Haugen maintains various professional social media profiles to share information about psychology, sport psychology, athlete mental health, interprofessional care, and events that individuals may attend to learn more about these topics. Because she is active on social media, she has a Social Media Policy that outlines her office policies related to her use of social media. This policy is available on her website at www.drerinhaugen.com/social-media-policy or by request. You are encouraged to view this policy and discuss any questions you have with Dr. Haugen.
MEETINGS
Dr. Haugen normally conducts an evaluation during the first session that typically consists of answering questions. During this time, you and Dr. Haugen can both decide if she is the best person to provide the services you need to meet your treatment goals. If mental health therapy or sport performance sessions begin, Dr. Haugen will usually schedule one, 45-minute session (one appointment hour of 45 minutes duration) per week at a time you agree on, although some sessions may be shorter/longer or more/less frequent. If you complete any psychological inventories, this may be done over the course of several different sessions. Dr. Haugen will be able to discuss any plan for your work with her during the initial session.
Once an appointment hour is scheduled, you are asked to provide 24 hours [1 day] advance notice of cancellation if you are unable to make it to your appointment. Although ATAGF provides reminder calls, SMS (text) messages, or emails for appointment times as a courtesy, it is your responsibility to know when you are scheduled to meet with Dr. Haugen. Given reminder calls/SMS (text)/email messages can be made less than 24 hours in advance, if you cancel when you get your reminder, it is likely your cancellation will be considered a late cancellation/no-show. After two late cancellations and/or no-shows, Dr. Haugen reserves the right to remove you from a regular spot in her schedule and speak with you prior to scheduling additional appointments to determine your commitment to therapy, sport performance enhancement, evaluation, or combination of these. She maintains a strict attendance policy; if you are unable to regularly attend your sessions with her, she may discuss referring you to another professional for ongoing work.
PROFESSIONAL FEES
The fees involved for services at ATAGF depend upon the service involved. Please contact ATAGF administrative staff or speak with Dr. Haugen for more information about fees for the services provided to you. In addition to regularly scheduled appointments, Dr. Haugen may charge for other professional services you may need, although she will break down the hourly cost if she works for periods of less than one hour. Other services may include but are not limited to telephone conversations lasting longer than 5 minutes, consulting with other professionals with your permission, preparation of records or treatment summaries, and the time spent performing any other service you may request of her. If you become involved in legal proceedings that require Dr. Haugen’s participation, you will be expected to pay for all of her professional time, including preparation and transportation costs, even if she is called to testify by another party. Because of the difficulty of legal involvement, she charges more than the hourly rate for preparation and attendance at any legal proceeding. You are encouraged to discuss this fee with Dr. Haugen prior to any legal involvement.
CONTACTING DR. HAUGEN
Due to the work schedule of Dr. Haugen, she is often not immediately available by telephone. She is usually in the office Monday through Thursday, although her hours in the office vary each day; please discuss office hours directly with Dr. Haugen or her administrative staff. She probably will not be available when she is with a patient. The ATAGF telephone is answered by an administrative assistant 8am to 8pm Monday through Thursday and from 8am to 5pm on Friday. These administrative assistants know where to reach Dr. Haugen and may inform you when she is available to speak with you. Dr. Haugen will make every effort to return your call on the same day you make it, except for evenings, weekends (Friday through Sunday), and holidays. If you are difficult to reach, please inform ATAGF administrative assistants of times when you will be available.
If you are unable to reach Dr. Haugen and feel that you cannot wait for her to return your call, it is advised you utilize these emergency services:
- Call 911;
- Call the National Suicide Prevention Lifeline at 988;
- Go to your local Emergency Room;
- Call the 24-hour crisis line at Northeast Human Service Center at (701) 775-0525; or
- If you are a student at the University of North Dakota (UND) contact the University Counseling Center (UCC) at (701) 777-2127 (press “1” if you call after 4:30pm CT).
If Dr. Haugen will be unavailable for an extended time, she will provide you with the name of a colleague to contact, if necessary. PLEASE NOTE: ATAGF professionals, including Dr. Haugen, do not carry a pager and are not available 24 hours a day. If you believe you may need such crisis services, ATAGF and Dr. Haugen are not the best practice for you.
LIMITS ON CONFIDENTIALITY
The law protects the privacy of all communications between a patient and a provider. In most situations, we can only release information about your treatment to others if you sign a written authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only you provide written, advance consent. Your signature on this Agreement provides consent for those activities, as follows:
- Dr. Haugen may occasionally find it helpful to consult other medical and mental health professionals about a case. During a consultation, she makes every effort to avoid revealing the identity of the patient. The other professionals are also legally bound to keep the information confidential. If you do not object, she will not tell you about these consultations unless she feels it is important to your work together. She will note consultations in your Clinical Record (which is called “PHI” in our Notice of Privacy Practices attached to this Agreement).
- You should be aware Dr. Haugen practices with other mental health professionals, and we employ administrative staff. In most cases, we need to share protected health information with these individuals for both clinical and administrative purposes, such as scheduling, billing, and quality assurance. All mental health professionals are bound by the same rules of confidentiality. All staff members have been given training about protecting your privacy and have agreed not to release any information outside of the practice without the permission of the professional staff member involved in your care.
- ATAGF also has contracts with various entities that enable us to perform treatment, billing, and practice management operations. As required by HIPAA, we have formal business associate contracts 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, Dr. Haugen 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 a patient threatens to seriously harm himself/herself/themself or someone else, Dr. Haugen or ATAGF staff may take actions to prevent this, including seeking hospitalization for him/her/them, notifying law enforcement, or contacting family members or others who can help provide protection.
There are some situations where ATAGF and/or Dr. Haugen is permitted or required to disclose information without either your consent or authorization:
- If you are involved in a court proceeding and a request is made for information concerning your evaluation, diagnosis, and treatment, such information is protected by the provider-patient privilege law. ATAGF providers cannot provide any information without your 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 your provider to disclose information.
- If a government agency is requesting the information for health oversight activities, Dr. Haugen may be required to provide it for them.
- If a patient files a complaint or lawsuit against an employee of ATAGF, the ATAGF employee may disclose relevant information regarding that patient to defend him or herself.
- If a patient files a worker’s compensation claim, ATAGF must, upon appropriate request, provide appropriate information including a copy of the patient’s record or other information concerning mental health care services, to the North Dakota Worker's Compensation Bureau.
There are some situations in which an ATAGF professional is legally obligated to take actions, which we believe are necessary to attempt to protect others from harm and we may have to reveal some information about a patient’s treatment.
- If we have reason to suspect that a child is abused or neglected, the law requires that we file a report with the Department of Human Services. Once such a report is filed, we may be required to provide additional information.
- If we have knowledge of or reasonable cause to suspect that an adult with developmental disabilities or mental illness is abused, neglected, or exploited, the law requires that we report such information to the Protection and Advocacy Project. Once such a report is filed, we may be required to provide additional information.
- If a patient threatens serious physical harm to an identifiable victim, we may take actions to protect the victim. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the patient.
If such a situation arises, Dr. Haugen will make every effort to fully discuss it with you before taking any action and will limit my disclosure to what is necessary.
Although this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important you and Dr. Haugen discuss any questions or concerns you may have now or in the future. The laws governing confidentiality can be complex, and Dr. Haugen is not an attorney. In situations where specific advice is required, formal legal advice may be needed.
PROFESSIONAL RECORDS
The laws and standards of Dr. Haugen’s profession require that she keep Protected Health Information about you in your Clinical Record. You may examine and/or receive a copy of your Clinical Record (or a summary or explanation of the information contained in your Clinical Record if agreed by you in advance), if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, Dr. Haugen recommends that you initially review them in her presence or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, ATAGF can charge a copying fee of $20 per page for the first 25 pages, 75 cents per page for any pages beyond twenty-five and includes administrative, document retrieval, and postage charges. There may be instances in which Dr. Haugen does not believe reviewing your record is in your best interest, and this will be discussed with you should this occur.
PATIENT RIGHTS
HIPAA provides you with several new or expanded rights regarding your Clinical Record and disclosures of protected health information. These rights include requesting that ATAGF amends your record; requesting restrictions on what information from your Clinical 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 ATAGF policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and ATAGF privacy policies and procedures. Dr. Haugen or an ATAGF administrative assistant is happy to discuss any rights with you.
MINORS & PARENTS
Patients under 18 years of age who are not emancipated and their guardians should be aware the law may allow guardians to examine their child’s treatment records unless Dr. Haugen decides that such access is likely to injure the child or the legal guardian and the child’s provider agree otherwise. Because privacy in psychotherapy and sport performance consulting is often crucial to successful progress, particularly with teenagers, it is sometimes ATAGF’s policy to request an agreement from guardians that they consent to give up their access to the child’s records. If they agree, during treatment, Dr. Haugen will provide them only with general information about the progress of the child’s treatment, and his/her/their attendance at scheduled sessions. Dr. Haugen may also provide guardians with a summary of their child’s treatment when it is complete. Any other communication will require the child’s Authorization, unless Dr. Haugen feels the child is in danger or is a danger to someone else, in which case, Dr. Haugen will notify the guardians of her concern. Before giving guardians any information, Dr. Haugen will discuss the matter with the child, if possible, and do her best to handle any objections the child may have.
RECORDING
Your sessions with Dr. Haugen may not be recorded in any way by any party unless agreed to in writing by mutual consent (between you/your guardian and Dr. Haugen). The end date of this mutual consent will be included in the written agreement. A copy of this written agreement will be maintained in your medical record.
APPOINTMENT REMINDERS
ATAGF utilizes electronic SMS messaging (texting) for appointment reminders which may include phone calls with voicemail or emails. It is your responsibility to ensure that contact information (phone number, email) is updated with ATAGF staff and that failure to do so may result in someone other than yourself receiving the appointment reminder. You may also choose to opt out of text messaging and/or email reminders or to receive them in an alternative format, such as a phone call with voicemail. To do so, please submit the request to ATAGF staff in writing and appointment reminders will be handled accordingly.
BILLING AND PAYMENTS
You will be expected to pay for each session at the time it is held, unless you have insurance coverage that requires another arrangement, or you and Dr. Haugen agree otherwise. Credit card payments and similar arrangements are more confidential than checks (with names on them), as we deposit these checks into our banking account. Payment schedules for other professional services will be agreed to when they are requested. In circumstances of unusual financial hardship, Dr. Haugen may be willing to negotiate a fee adjustment (if allowed by managed care contracts) or payment plan.
If you would like someone other than yourself to pay your bill at ATAGF (such as parent of someone over the age of 18 or your institution’s athletic department), we need additional information from you. We ask you provide contact information for the individual or entity responsible for the account and provide your written authorization for us to speak with them about matters pertaining to your bill. This authorization does not mean they have access to your medical record unless you explicitly authorize this access on the release of information. Additional information is included in the form Payment of Outstanding Balances attached to this Agreement.
If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, ATAGF has the option of using legal means to secure the payment. This may involve hiring a collection agency (i.e., United Accounts) or going through small claims court which will require Dr. Haugen to disclose otherwise confidential information. In most collection situations, the only information ATAGF releases regarding a patient’s treatment is his/her/their 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 your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon or if the arrangements have not been followed, Dr. Haugen may speak with you about a referral to another agency or professional who is able to provide more cost-effective services to you.
INSURANCE REIMBURSEMENT
For you and Dr. Haugen 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. ATAGF administrative assistants and Dr. Haugen will fill out forms and provide you with whatever assistance they can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of Dr. Haugen’s 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, ATAGF administrative staff will provide you with whatever information they can based on their experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, ATAGF administrative staff will be willing to call the company on your behalf.
Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. Although much can be accomplished in short-term therapy, some patients feel that they need more services after insurance benefits end. Some managed care plans will not allow professionals to provide services to you once your benefits end. If this is the case, Dr. Haugen will do her best to find another professional who will help you continue your psychotherapy.
You should also be aware that your contract with your health insurance company requires that ATAGF provides it with information relevant to the services that your provider provides to you. Dr. Haugen is required to provide a clinical diagnosis when using insurance. Sometimes Dr. Haugen is required to provide additional clinical information such as treatment plans, summaries, or copies of your entire clinical record. In such situations, Dr. Haugen 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. Although all insurance companies claim to keep such information confidential, ATAGF 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. Dr. Haugen will provide you with a copy of any report she submits, if you request it in writing. By signing this Agreement, you agree that ATAGF can provide requested information to your carrier.
An Explanation of Benefits (EOB) is typically sent by your insurance company to the primary policy holder (e.g., a parent). EOBs generally include dates of service, the type of service provided (e.g., 45-minute individual therapy), and whom provided the service (Dr. Haugen). if you do not want this information sent by your insurance company to the primary policy holder, using insurance may not be the best option for you. If this is a concern, please contact ATAGF staff at (701) 780-6821 to discuss alternative options.
Once we have all information about your insurance coverage, you and Dr. Haugen will discuss what you can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your sessions. It is important to remember that you always have the right to pay for your sessions with Dr. Haugen yourself to avoid the problems described above unless prohibited by contract.
CONSENT FOR RELEASE OF PROTECTED HEALTH INFORMATION TO INSURANCE COMPANY
You authorize Assessment and Therapy Associates of Grand Forks, PLLC to disclose to your current insurance carrier past and present information that is necessary to prepare an insurance claim. The insurance company will use this information to process claims for benefits. You authorize all insurance payable on claims originating from Assessment and Therapy Associates of Grand Forks, PLLC to be paid directly to Assessment and Therapy Associates of Grand Forks, PLLC. You understand that no other use will be made of this information except for that otherwise authorized by law.
EMAIL INFORMED CONSENT
Email can be a useful method of correspondence for clients. Transmitting confidential information by email can create several risks, both general and specific that clients need to be aware of if they choose this method of correspondence.
General email risks include but are not limited to the following:
- Email can be immediately broadcasted worldwide and received by many intended and unintended recipients;
- Recipients can forward email messages to other recipients without the original sender’s permission or knowledge;
- Users can easily send an email to the incorrect address;
- Email is easier to falsify than handwritten or signed documents;
- Backup copies of email may exist even after the sender or recipient has deleted his or her copy; and
- Without the benefit of face-to-face interaction, emails can be misinterpreted in tone and meaning.
Specific email risks include but are not limited to the following:
- Email containing information pertaining to a client’s diagnosis and/or treatment must be included in the client’s medical record. Thus, all individuals who have access to the medical record will have access to the email messages;
- If you are sending your emails from your employer’s and/or educational institution’s computer and/or email account, they do have access to your emails;
- While it is against the law to discriminate, an employer who has access to your email could use the information to discriminate against the employee. Additionally, the employee could suffer social stigma from a workplace disclosure;
- Insurance companies who learn of your PHI information could deny you coverage; and
- Although therapists and ATAGF staff will endeavor to read and respond to email correspondence promptly, they cannot guarantee that any particular email message will be read and responded to within any particular time frame.
Conditions for use of email:
All email messages sent or received that concern your diagnosis or treatment or that are a part of your medical record will be treated as part of your PHI. Reasonable means will be used to protect the security and confidentiality of the email. Because of the risk outlined above, the security and confidentiality of email cannot be guaranteed.
Your consent to email correspondence includes your understanding of the following conditions:
- All emails to and from you concerning your protected health information (PHI) will be a part of your file and can be viewed by health care, insurance providers, and ATAGF office support staff.
- Your email messages may be forwarded within ATAGF as necessary for diagnosis, treatment, and reimbursement. However, they will not be forwarded outside the office without your consent or as required by law.
- Though all efforts will be made to respond promptly, this may not be the case. Because the response cannot be guaranteed do not use email in a medical or mental health emergency.
- You are responsible for following up with the therapist or support staff if you have not received a response.
- Medical information is sensitive and unauthorized disclosure can be damaging. You should not use email for communications concerning diagnosis or treatment of AIDS/HIV infection, other sexually transmittable diseases, mental health, developmental disability, or substance abuse issues. It is your right, however, to choose to communicate about this information if you desire.
- Since employers and educational institutions do not observe an employee’s or student's right to privacy in their email system, you should not use their employer’s or educational institution's email system to transmit or receive confidential emails.
- ATAGF will take reasonable steps to ensure that all information shared through emails is kept private and confidential. However, ATAGF is not liable for improper disclosure of confidential information that is not a result of our negligence or misconduct.
- If you consent to the use of email, you are responsible for informing your therapist of any type of information that you do not want sent to you by email.
- It is your responsibility to update your email address with ATAGF staff members and clinicians if it changes.
- You are responsible for protecting your password and access to your email account and any email you send or receive from ATAGF to ensure your confidentiality. Your ATAGF and its staff members cannot be held liable if there is a breach of confidentiality caused by a breach in your account security.
- Any email that you send that discusses your diagnosis or treatment constitutes informed consent to the information being transmitted. If you wish to discontinue emailing information, you must submit a written notification that you wish to discontinue or an email informing your therapist that you are withdrawing consent to email information.
Signing this does not mean Dr. Haugen will use email for communication. Specific terms will be discussed with you directly, as she utilizes email on a case-by-case basis for specific reasons.