OUTPATIENT SERVICES AGREEMENT
Welcome to my practice! This document (the Agreement) contains important information about my professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights with regard to the use and disclosure of your Protected Health Information (PHI). HIPAA requires that I provide you with a Notice of Privacy Practices (the Notice) for use and disclosure of PHI for treatment, payment and health care operations. The Notice explains HIPAA and its application to your personal health information in greater detail. The law requires that I obtain your signature acknowledging that I have provided you with this information.
Although documents such as this one are long and sometimes complex, it is very important that you read them carefully. We can discuss any questions you have at any time during the course of your treatment. When you sign this document, it will represent a legally binding agreement between us. You may revoke this Agreement in writing at any time. That revocation will be binding on me unless I have taken action in reliance on it, if there are obligations imposed on me by your health insurer in order to process or substantiate claims made under your policy, or if you have not satisfied financial obligations you have incurred. I will keep the original document and provide a copy for you as well.
SERVICES I OFFER
Psychological and Neuropsychological Assessment
Psychological assessment involves evaluation of both cognitive (intellectual) and emotional functioning. In addition to an interview in which I will be asking you questions about your history and symptoms, I will use different techniques and standardized tests including, but not limited to, asking questions about your knowledge of certain topics, having you read and/or view printed material, and having you manipulate objects. The assessment includes behavioral observations of attitude toward testing, motivation and effort put forth as well. On average, a psychological assessment takes three to four hours of direct contact to complete. It is also necessary for me to review records, score and interpret tests and write a comprehensive report. This takes approximately two to three hours, in addition to the direct contact.
Neuropsychological assessment includes extensive evaluation of multiple cognitive processes such as attention, memory, language and problem-solving, as well as intellectual and emotional functioning. In addition to an interview, in which I will be asking you questions about your history and symptoms, I will use different techniques and standardized tests including, but not limited to, asking questions about your knowledge of certain topics, having you read and/or view printed material, having you draw figures and shapes, having you listen and respond to recorded tapes and having you manipulate objects. The assessment includes behavioral observations of attitude toward testing, motivation and effort put forth as well. A neuropsychological evaluation typically takes four to six hours of direct contact to complete, as well as four to five hours for me to review records, score and interpret tests and write a comprehensive report.
For some individuals, assessments can cause fatigue, frustration and anxiety.
I will make every effort to complete an assessment report within two weeks of the date of evaluation, and will notify you if I anticipate any increase in the time it will take to produce the report. Once the report is complete, I will schedule another appointment in which test results, and recommendations based upon those results, are reviewed with you in detail. Results are typically provided to the individual or agency that requested the evaluation as well. It is important to note that, although I emphasize the confidentiality of results and that results are intended for professional use only, I have no actual control over how results are disseminated or used once they have been delivered to another individual or agency.
Psychotherapy and Neurocognitive Rehabilitation
Psychotherapy and neurocognitive rehabilitation are not easily described in general statements. Treatment varies depending on the expertise of the provider and personality of the patient, and the particular problems you are experiencing. There are many different methods I may use to address the problems that you hope to manage. Psychotherapy and neurocognitive rehabilitation call for a very active effort on your part. In order for the treatment to be most successful, you will have to follow recommendations and work on things we talk about both during our sessions and outside my office.
Psychotherapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. On the other hand, psychotherapy has also been shown to have benefit. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. There are no guarantees as to what you will experience.
Psychotherapy and neurocognitive rehabilitation sessions are typically 45-minutes in length, although some may be longer, and are scheduled on a weekly basis. Our first meeting will involve an evaluation of your needs. Please understand that meeting with me for an initial consultation does not guarantee that I will be able to accept your case. The fields of psychology and neuropsychology are vast, and no one provider can specialize in all aspects of these fields. Upon reviewing your paperwork and meeting with you, I may discover that I do not offer the treatment modality from which I feel you would benefit, or that another local provider would be a better fit for you. Please do not view this as a personal rejection. I simply want you to receive the best available care, even if that is not with me. By the end of the initial consultation appointment, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if we decide to continue with treatment.
Therapy and rehabilitation involve a large commitment of time, money, and energy, so you should be very careful about the provider you select. If you have questions about my procedures, we should discuss them as they arise. If your doubts persist, I will be happy to help you arrange a meeting with another professional for a second opinion.
APPOINTMENTS
If you are fifteen or more minutes late for an appointment, it is considered a missed appointment. Once an appointment is scheduled, you will be expected to pay for it unless you provide 48 hours advance notice of cancellation, or if we both agree that you were unable to attend due to circumstances beyond your control. Under such circumstances, if it is possible, I will try to find time that same week to reschedule the appointment. I cannot bill your insurance company for missed appointments. You are solely responsible for this charge. No appointments will be conducted until this bill is paid in full or a payment plan has been arranged.
PROFESSIONAL FEES
My fee is $200.00 per hour for testing, therapy and other professional services you may need. Other professional services include report writing, completing forms on your behalf, telephone conversations lasting longer than 5 minutes, consultations with other professionals you have authorized, preparation of records or treatment summaries and time spent performing any other service you may request of me.
If, at the time of initial consultation, you are aware of any pending legal matters in which I may become involved, I cannot accept your case. After treatment has been initiated, if you become involved in legal proceedings that require my participation, you will be expected to pay for my professional time, even if the request comes from another party. Because of the complexity of legal matters, I charge $300.00 per hour for preparation, time spent traveling, speaking with attorneys, reviewing and preparing documents, testifying, being in attendance, and any other case-related costs.
BILLING AND PAYMENTS
You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage which requires another arrangement. Payment schedules for other professional services will be agreed upon when they are requested. In circumstances of unusual financial hardship, I may be willing to negotiate a payment installment plan.
If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or filing suit in small claims court. If such legal action is necessary, its costs will be included in the claim. In most collection situations, the only information I will release regarding a patient’s treatment is his/her name, the nature of services provided and the amount due.
INSURANCE REIMBURSEMENT
In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for treatment. In particular, you should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, please call your plan administrator.
Of course, I will provide you with whatever information I can, based upon my experience, and will help you to understand the information you receive from your insurance company. If it is necessary to clear confusion, I am willing to call the company on your behalf as well. I will also fill out required forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. It is very important that you understand that you are financially responsible for any services not covered by your insurance policy.
Some insurance plans are limited to short-term treatment approaches designed to sort out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more treatment after a certain number of sessions have been completed. While a lot 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 me to provide additional services to you once your benefits end. If this is the case, I will do my best to find another provider who will help you continue your treatment.
You should also be aware that most insurance companies require you to authorize me to provide them with a clinical diagnosis. Sometimes I have to provide additional clinical information such as treatment plans or summaries, or copies of the entire clinical record. In such situations, I 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’s files. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. Should you choose to utilize your insurance benefits, your signature on this document authorizes payment to me on your behalf. It further authorizes me to release to any third-party payor any and all information requested.
Once we have all of the information about your insurance coverage, we will discuss what we 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 treatment. It is important to remember that you have the right to pay for my services yourself to avoid the problems described above.
CONTACTING ME
Routine Calls
Typically, I am not immediately available to respond to telephone calls. The telephone is answered during office hours by a receptionist. At times when the office is receiving an unusually high number of telephone calls, your call may be transferred to a secure voice messaging system. Outside of office hours, a secure voice messaging system is available for you to leave a message. If you call during office hours, I will make every effort to ensure that your call is returned on the same day you place it. If you leave a message outside of office hours, your call will be returned the next business day.
Emergency Services
I do not currently provide emergency services. If my receptionist cannot assist you with a particular issue and you need to speak directly with me, you will be asked to schedule a telephone conference. If you feel that you can’t wait for a telephone conference, contact your family physician or the nearest emergency room and ask for the psychologist or psychiatrist on call. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary.
ELECTRONIC COMMUNICATIONS & TELEHEALTH
Definition
Telehealth is the provision of healthcare remotely by means of telecommunications technology. Telehealth includes both clinical and non-clinical services, such as billing and scheduling.
One of the benefits of telehealth is that the patient and health care provider can engage in treatment without being in the same physical location. This can be helpful in ensuring continuity of care under settle in place orders, or if the patient or clinician moves to a different location, takes an extended vacation, or is otherwise unable to continue to meet in person.
Telehealth, however, requires technical competence on both our parts to be beneficial and, although there are benefits of telehealth, there are some differences between in-person and remote treatment, as well as some risks.
Text Messaging
I do not use text messaging services to discuss clinical issues, as they are not secure or HIPAA compliant. If you choose, you can receive appointment reminders and cancellation notifications via text message after you sign a consent form allowing me to send them to you in this fashion.
Email Communications
I only use email communication for administrative purposes, such as sending certain forms. Please do not email the office about scheduling or clinical matters, as your email is likely not secure, and my email accounts are not continuously monitored. If you need to discuss a scheduling or clinical matter, please call the office or utilize the Patient Portal to do so.
Website
I have a professional website, www.doctoremick.com, that I use to provide information to others about me and my practice. You are welcome to access and review the information that I have on my website. If you have questions about that information, please feel free to discuss them with me.
Patient Portal
I offer a Patient Portal on my website solely as a convenient and secure means of communication between patients and my office. Through the Patient Portal you can request an appointment, send a secure message, and submit forms. Your records are not stored in, nor can they be accessed from, the Patient Portal. Any information you submit via the Patient Portal will be added to your actual record in the office. Your choice to use the Patient Portal is entirely voluntary, and you can choose to discontinue use at any time. The Patient Portal is not continuously monitored and is NOT to be used for medical emergencies. Your correspondence will not be reviewed in real time. For example, if you submit a message at 11:30 PM on the evening of a national holiday, it will not be read and reviewed until the office opens after the holiday. I will take every effort to respond to you within two business days of receipt and review of your correspondence.
Telephone and Video Conferences
Although I do not routinely provide treatment via telephone or video conferencing, there are times when it may be appropriate and effective. In such cases, we will decide together which type of technology to use. If telehealth is not appropriate, we will discuss options for referral to another professional in your location who can provide necessary services.
If we agree that telehealth is appropriate, you are solely responsible for any cost to you to obtain necessary equipment, accessories or software to participate in remote communications. While there are benefits to providing services remotely, there are also some risks. For example:
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Risks to confidentiality
. I have a legal and ethical responsibility to attempt to protect all communications between us. However, the current nature of technology is such that I cannot guarantee that our remote communications will be kept confidential, or that other people may not gain access to those communications. I use updated encryption methods, firewalls and HIPAA compliant software to help keep your information secure, but there is a risk that our remote communications may be compromised or accessed by others. For example, numerous prominent organizations have had their entire operational systems “hacked.” Although both my office telephone and video conferencing systems are HIPAA compliant, data collected and stored by your telephone company or internet service provider could be accessed without your authorization.
In addition to confidentiality issues related directly to technology, there is the potential for other people to overhear you if you are not in a private place while speaking to me from a remote location. In order for you to protect your confidentiality when remotely communicating with me, it is important that you find a private place where you will not be interrupted or overheard. It is also important that you protect the privacy of your cell phone or other electronic device by only using secure networks, and by creating passwords to protect the device you use to communicate with me remotely. It is known that many devices such as Siri, Alexa, and Google Home/Google Nest have recorded information without the knowledge or consent of the individuals present in the room. Be sure these devices and apps are turned off before you begin your session. Recording of sessions, by any party, is not allowed.
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Issues related to technology
. There are many ways that technology issues might impact remote communications. For example, devices, software and telephone or internet services may fail during an appointment. If this occurs, disconnect from the telephone call or video conferencing platform and then reconnect. I will wait two minutes before contacting you via telephone or the platform we were using. If that fails, I will attempt to call you at the telephone number you have listed below as the number at which messages can be left. If you do not receive a call from me, or are unable to reconnect to the video conference within two minutes, please call the office directly. In the event that there is a technological failure and we are unable to resume the connection, the charge for the appointment will be prorated to reflect the actual time spent engaged in the appointment.
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risis management and intervention.
Prior to engaging in remote communications, we will develop an emergency response plan to address potential crisis situations that may arise during the course of treatment. Assessing and evaluating threats and other emergencies is much more difficult when done remotely, rather than in my office. For your safety, I will not engage in remote communication with you if you are experiencing a crisis situation requiring high levels of support and intervention. If you are experiencing an emergency, call 911 or go to your nearest emergency room. After you have obtained emergency services, please call the office to schedule an appointment with me.
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Efficacy
. Telehealth is an emerging technology and field of research. Although current research suggests that remote communication can be as effective as in-office treatment, there is debate about a provider’s ability to fully appreciate nonverbal information and communication when working remotely.
Fees
The same private pay fee rates will apply for remote communications as for in-office appointments. Your particular health insurance policy may not cover appointments that are conducted remotely. If it does not, you will be solely responsible for the entire fee for the appointment. Please contact your insurance company prior to engaging in remote communication appointments to determine whether these appointments will be covered.
Records
To preserve confidentiality, I will not record remote communications. I will maintain documentation of the appointment in the same way I maintain records of in-office appointments. Should you choose to engage in telehealth treatment, you also agree not to record your appointments with me in any format.
Web Searches
I will not use web searches to gather information about you as 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 a vast amount of information available about individuals on the internet, some which may be accurate and some which may be false. If you encounter any concerning information about me through web searches, or in any other fashion for that matter, please discuss this with me so that we can effectively address the issue and its potential impact on your treatment.
Social Media
I do not communicate with, follow, or contact any of my patients through social media platforms such as Twitter or Facebook, as I believe that communicating with patients in such a manner has a high potential to compromise the professional relationship. Please do not try to contact me in this way; I will not respond and will terminate any online contact, no matter how accidental.
Online Reviews
Recently it has become fashionable for patients to review their healthcare providers on various websites. Unfortunately, providers cannot respond to negative comments or misstatements of fact due to restrictions involving patient privacy and confidentiality. If you encounter a negative review 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 treatment. Please do not post negative reviews of me on any of these websites while I am treating you, as this has a significant potential to damage our ability to work together. If you have issues with me or your treatment, please discuss them directly with me so that we can effectively address them.
INTERACTIONS WITH STAFF
In this office, we attempt at all times to treat others with dignity and respect, and we expect that in return. Although we realize that, at times, individuals may be frustrated or overwhelmed, while interacting with me or my staff over the telephone, if you become argumentative, use profanity, raise your voice, or threaten or denigrate the person attempting to assist you, you will be given one verbal warning, after which your call will be released. If you engage in these behaviors while interacting with me or my staff in the office, you will be given one verbal warning, after which you will be asked to leave the building. Should you refuse to do so and continue with the aforementioned behavior, the legal authorities will be contacted. I may choose to refer you to another provider/agency if I feel that our professional relationship has been compromised as a result of your behavior.
THERAPY DOGS
Therapy dogs may be present in the office during your scheduled appointment. By signing this document, you acknowledge that you are aware of this and that you expressly and specifically assume any and all known and unknown risks associated with interacting with the dogs, which may include, but are not limited to, licking you, nibbling you, leaning on you, brushing against you, accidentally scratching you, and you having an allergic or other physical reaction to them. You also agree to treat the dogs in a humane manner at all times, regardless of whether they are directly incorporated into your treatment.
PROFESSIONAL RECORDS
The laws and standards of my profession require that I keep protected health information in a clinical record for a period of seven years after termination of services, or for three years after a minor patient reaches the age of majority, whichever is greater. I will maintain your records for that period of time, after which they will be destroyed. Except in unusual circumstances that involve danger to yourself and/or others, you may examine and/or receive a copy of your clinical record if you request it in writing. After I receive your request, I have fifteen days in which to respond. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents.
In most circumstances, the Texas Administrative Code, Title 22, Part 21, Chapter 465, Rule §465.22 (C)(8) allows me to charge a reasonable fee for the cost of reproduction of records, to be paid in advance. I may recoup the cost of postage as well. The current rates for reproduction of records can be found in the Texas Administrative Code, Title 22, Part 9, Chapter 165, Rule §165.2 (e)(1)(B) and §165.2 (c)(5)(C). You agree you will pay, in advance, for the copying cost of the actual record and the time required for the preparation of the documents. This includes providing copies or reports to any court or legal representative or designate. In the event of your death, these requirements will be binding on any heirs, successors or executor(s). If I refuse your request for access to your records, you have a right of review, which I will discuss with you upon your request.
PATIENT RIGHTS
HIPAA provides you with certain rights with regard to your clinical record and disclosures of protected health information. These rights include requesting that I amend your record in the event of inaccuracies; 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 my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the HIPAA Notice form, and my privacy policies and procedures.
LIMITS ON CONFIDENTIALITY
In general, the privacy of all communications between a patient and a psychologist is protected by law, and I can only release information about your treatment to others with your written permission. But there are a few exceptions, and your signature on this Agreement provides consent for those activities, as follows:
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I may occasionally find it helpful to consult with other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my patient. The other professionals are also legally bound to keep the information confidential. If you don’t object, I will not tell you about these consultations unless I feel that it is important to our work together. I will note all consultations in your clinical record.
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You should be aware that I utilize administrative staff. In most cases, I need to share protected information with these individuals for both clinical and administrative purposes, such as scheduling, billing and quality assurance. All staff members have been given training about protecting your privacy and have agreed not to release any information outside of the practice without my permission or that of an “on call” clinician.
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I may share “on call” responsibilities with other clinicians. All of the clinicians are bound by the same rules of confidentiality. My professional records are separately maintained. However, there may be times when I am unavailable and one of these clinicians will need to access your records. They will only do so at your request.
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I also have contracts with attorneys. As required by HIPAA, I have a formal business associate contract with these attorneys, 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, I can provide you with the names of these individuals and/or a blank copy of this contract.
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Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement.
There are some situations in which I am permitted or required to disclose information without either your consent or Authorization:
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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. I cannot provide any information without your (or your legal representative’s) written authorization. However, I must abide by a court order compelling me to release requested information. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information.
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If a government agency is requesting the information for health oversight activities, I may be required to provide it for them.
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If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself.
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If a patient files a worker’s compensation claim, I must, upon appropriate request, provide records relating to treatment or hospitalization for which compensation is being sought.
Although unusual in my practice, there are some situations in which I am legally obligated to take actions which I believe are necessary to attempt to protect others from harm, and I may have to reveal some information about a patient’s treatment:
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If I have cause to believe that a child under 18 has been or may be abused or neglected (including physical injury, substantial threat of harm, mental or emotional injury, or any kind of sexual contact or conduct), that a child is a victim of a sexual offense, or that an elderly or disabled person is in a state of abuse, neglect or exploitation, the law requires that I make a report to the appropriate governmental agency, usually the Department of Protective and Regulatory Services. Once such report is filed, I may be required to provide additional information.
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If I determine that there is a probability that the patient will inflict imminent physical injury on another individual, or that the patient will inflict imminent physical, mental or emotional harm upon him/herself, or others, I may be required to take protective action by disclosing information to medical or law enforcement personnel or by securing hospitalization of the patient.
If such a situation arises, I will make every effort to fully discuss it with you before taking any action, and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. The laws governing confidentiality can be quite complex, and I am not an attorney. In situations in which specific advice is required, formal legal advice may be needed.
TERMINATION OF TREATMENT
The length of time required for treatment will be determined by your personal situation. I will do my best to fulfill your therapeutic needs and provide you with the best professional care. For your part, you agree to participate in the process to the best of your ability. It is intended that, when your treatment goals are met, to the extent that they can be, we will terminate our relationship. There is no guaranty of a cure.
You may terminate treatment at any time. This may be done via written letter, oral communication, canceling two consecutive appointments or three nonconsecutive appointments, failing to attend a scheduled session without giving prior notice, or failing to follow treatment recommendations I may make. I will respect your wishes. If you do terminate treatment with me, it will be my decision as to whether we can re-establish a professional relationship in the future. Keep in mind that your decision to terminate and the method chosen to accomplish this termination will impact any decision regarding whether I will agree to resume a professional relationship with you.
Your signature below indicates that you have read the information in this document and agree to abide by its terms during our professional relationship.
Michelle A. Emick, Ph.D. is a Licensed Psychologist with the Texas State Board of Examiners of Psychologists. Her Texas license number is 30727. For information on how to verify a license or file a complaint, please call (512) 305-7700 or go to www.tsbep.texas.gov.
Dr. Emick has been granted authority to practice interjurisdictional telepsychology by the Association of State and Provincial Psychology Boards. Her APIT mobility number is 6072. For information on how to verify a mobility number, please call (888) 201-6360 or go to www.asppb.net.
Revised and adopted on January 1, 2021